9/29/2017. Enhanced Recovery After Surgery at the University of Virginia Medical Center. Disclosures. Objectives. None

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1 Enhanced Recovery After Surgery at the University of Virginia Medical Center Bethany Sarosiek, RN, MSN, MPH, CNL University of Virginia Health System Charlottesville, VA Disclosures None Objectives Provide background and rationale behind implementing an ERAS program Describe the key steps for implementation of an interdisciplinary ERAS program Identify potential barriers to ERAS program implementation and ways to overcome them 1

2 Why ERAS in Colorectal Surgery? 2012 NSQIP data revealed discouraging trends starting in 2008 when outcomes at UVA were better than average: Morbidity: 1.35 (from 0.99) LOS: 0.79 (from 0.99) UTI: 1.95 (not tracked in 2008) SSI: 1.37 (from 0.99) What is ERAS? A multimodal approach to perioperative care designed to decrease the time required to recover from surgery Major components include: Not starving patients before surgery Intraoperative goal-directed therapy (GDT) using advanced hemodynamic monitors to only give IV fluids when they are needed Adequate pain control with minimal opioid use Early ambulation Patients take ownership of their care Our Objective Recognizing the need for improvement, we implemented an Enhanced Recovery After Surgery (ERAS) protocol for all patients undergoing elective colorectal surgery at an academic institution. Provide quality care at reduced costs Inter-disciplinary effort to standardize care 2

3 The Preoperative Phase Perioperative teaching Surgery Handbook Setting realistic goals and expectations The Intraoperative Phase Goal-directed fluid therapy (GDT) Vasopressors for hypotension Long acting intrathecal opioid Ketamine and lidocaine infusion Standardized protocol Pleth Variability Index monitors fluid responsiveness continuously based on the pulse oximeter waveform The Postoperative Phase Clears and OOB in PACU Elimination of IV opioids from order set Lidocaine drip for 48 hours IVF at 40 cc/hr for 24 hours only Checklists for nursing staff to complete WITH patient Discharge criteria IDENTICAL Discharge goal POD 3 Ordersets and checklists help to drive care! 3

4 Inter-disciplinary Partnership Core Team Surgeon Anesthesia RN champion Partners Pharmacy/Pain Management Registered Dieticians Participating staff from Clinic, Preop, OR, PACU, Postop Informatics Widespread systems changes (EPIC, OR, checklists, pathway) Ongoing education prior to implementation Colorectal Data Comparison ERAS implemented August 1, 2013 All patients undergoing elective abdominal surgery on colorectal service enrolled in protocol regardless of procedure or medical comorbidities Compared pre/post data pre ERAS (08/ /2013) post ERAS (08/ /2014) 4

5 LOS relative to Medical Center 5

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7 Financial Impact of ERAS $30, $25, $20, $15, $10, $5, $6,567/pt $7,129/pt $0.00 Mean Total Cost Mean Direct Cost Pre ERAS 25,344 20,435 Post ERAS 18,777 13,306 Financial Impact of ERAS 25,000 20,000 15,000 + $6,836/pt $898/pt $746,231 in cost savings 10,000 5,000 0 Pre ERAS Post ERAS Expected Direct Costs 13, Actual Direct Costs The Business Case for Expansion Decision pack in 2014 (>$700,000 investment): Clinicians RN champion to lead effort 2 LIPs for outpatient and inpatient support Medical directors - salary support Data analyst Equipment (OR and post-op monitoring) 7

8 Expansion Timeline to Date Colorectal ERAS Aug 2013 Thoracic ERAS March 2016 GYN ERAS March 2015 Whipple ERAS Jan 2017 Barriers Changing deep-rooted, traditional practices Electronic Medical Record Process Additional (unforeseen) costs Academic medical center w/ rotating staff Ongoing iterative process From a Systems Perspective: Communication is key! Comprehensive patient educational materials Checklists for staff AND patients EPIC (EMR) support ERAS indication in ALL phases of care Frequent compliance audits/data collection Frequent feedback to providers Make it as easy as possible to do the right thing! Ongoing protocol revisions to ensure application of latest evidence 8

9 Success Stories Ever-growing interest from add l surgical services Successful implementation of electronic checklist ERAS app Expanded institutional support What does ERAS implementation require? Multidisciplinary effort Buy-in from everyone to standardize care Will be different at each institution, individual elements not as important as adhering to 5 main ERAS concepts Dedicated surgeon, anesthesiologist, nurse champions Strict monitoring of compliance Constant feedback and iteration Plans for Expansion Ortho Joint Spine (Ortho and Neurosurgery) General Surgery Thoracic (Esophagectomy) Hepatic Resection Breast Surgery Neurosurgery Vascular Surgery Pediatric Surgery Donor Kidney (Transplant) Urology Bottom Line: Our GOAL is to expand these principles to every patient undergoing surgery at UVA ERAS should be the standard of care - providing quality surgical care at reduced cost with a focus on improving patient outcomes 30 9

10 Expanded ERAS Program Organizational Chart Self Assessment Question 1 Which of the following is not a key concept of an ERAS program: 1. Early ambulation 2. Opioid-sparing multimodal pain management 3. Preoperative fasting 4. Patient education and expectation management Self Assessment Question 2 Name three key members of a inter-disciplinary ERAS team. 10

11 Self Assessment Question 3 Which of the following could be considered a barrier to ERAS implementation: 1. Remarkable change from traditional practices 2. Cost 3. Continuous change in staff 4. All of the above E R A S = 1) Protocolized care 2) Opioid minimization 3) Focus on mobilization 4) Patient empowerment 5) Reduced healthcare costs 6) More efficient use of scarce resources 33 Thank you! 11

12 References 1. Kehlet, H. Multimodal Approach to Control Postoperative Pathophysiology and Rehabilitation. Br J Anaesth 1997;78: Zhuang, CL et al. Enhanced Recovery After Surgery Programs versus Traditional Care for Colorectal Surgery: A Meta-analysis of Randomized Control Trials. Dis Colon Rectum 2013;56: Brandstrup, B et al. Effects of Intravenous Fluid Restriction on Postoperative Complications: Comparison of Two Perioperative Fluid Regimens: A Randomized Assessor-Blinded Multicenter Trial. Ann Surg 2003; 238: Gan, TJ et al. Goal-directed Intraoperative Fluid Administration Reduces Length of Hospital Stay After Major Surgery. Anesthesiology 2002;97: Barreveld, A et al. Preventive Analgesia by Local Anesthetics: the Reduction of Postoperative Pain by Peripheral Nerve Blocks and Intravenous Drugs. Anesth Analg 2013;116: Thiele, R et al. Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery. J Amer Coll Surg 2015; 220(4): Modesitt, S et al. Enhanced Recovery Implementation in Major Gynecologic Surgeries: Effect of Care Standardization. Ob & Gyn 2016;128(3): Roulin, D et al. Cost-effectiveness of the Implementation of an Enhanced Recovery Protocol for Colorectal Surgery. Br J Surg 2013;100: