Implementing an Enhanced Recovery Program for Surgery. Michael F. McGee, MD, FACS, FASCRS September 21, 2017

Transcription

1 Implementing an Enhanced Recovery Program for Surgery Michael F. McGee, MD, FACS, FASCRS September 21, 2017

2 Continuing Education Disclosures Commercial Support or Sponsorship None Speaker or planner relationships with commercial interests None For CME credit or attendance certificate: Full-session attendance + Completion of on-line evaluation. Evaluation link available at the end of the session.

3 Implementing an Enhanced Recovery Program for Surgery Michael F. McGee, MD, FACS, FASCRS September 21, 2017

4 Conflicts None relevant to this presentation I am a surgeon Pictures/videos Lunch meeting?

5 Overview Detail conventional surgical care and motivate rational of enhanced recovery protocols (ERP) Contrast ERP with conventional surgical management Describe ERP design and implementation at a tertiary care academic medical center Detail ERP expansion to other service lines, health care system, and to Illinois hospitals

6 Learning Objectives Detail basic tenets of surgically enhanced recovery protocols Recognize barriers to implementing a large quality improvement (QI) project Develop strategies to overcome barriers to implementing a large QI project Develop audit and feedback programs to enhance performance of existing QI projects Apply this information to professional practice

7 Colon Hepatic Flexure Transverse Colon Splenic Flexure Ascending Colon Descending Colon Cecum Rectum Sigmoid Colon Appendix

8 Colectomy

9 Colectomy Anastomosis ( hook-up )

10 Colectomy Stoma (colostomy, ileostomy)

11 Colorectal Surgery at Northwestern Memorial Hospital Over 300 patients undergo colon resection at NMH annually for Cancer and pre-cancer Inflammatory bowel disease Crohn s disease Ulcerative colitis Diverticulitis On average, colectomy patients: Stay in the hospital for 6 days 13% are re-admitted with 30 days after surgery Will experience complications 14% of the time 9% surgical site infection Recent advances in pre-, intra-, and post-operative management of surgery patients can improve patient outcomes. Enhanced recovery protocols or ERP represent substantial changes in knowledge, work-flow, and culture from all providers

12 Current management of colon resection patients Pros Cons IV Fluids Replace fluid losses Edema Ileus Normal saline Commonly available May prolong ileus Narcotics Pain control Lethargy Limit activity Prolong ileus Graduated diet Avoid emesis May prolong ileus Foley catheter Accurate urine output Avoid urinary retention Limits ambulation Infection risk NG tubes Avoid emesis Prolong ileus Limit ambulation JP drains Remove unwanted fluid collections Limit ambulation

13 Enhanced Recovery Protocols Focus on minimizing physiologic trauma of surgery: Minimally invasive techniques Limit fasting before and after surgery Minimization of tubes and drains Minimize opioids in lieu of opioid-sparing pain medications Minimize IV fluids Early and frequent ambulation and return to normal activity Better education and management of patient expectations ERP significantly shorten length of stay, complications, and costs of surgery while improving patient satisfaction.

14 Enhanced Recovery Protocols (ERP) 1) Patient education/activation 2) Preoperative physical therapy 3) Minimally invasive surgical approaches 4) Opioid-sparing anesthesia/analgesia 5) Intravenous fluid minimization 6) Tube and drain minimization 7) Early return to diet, fast minimization 8) Early ambulation 9) Surgery-specific complication prevention

15 Surgical Patient Education and Clinical Outcomes Patient Activation: understanding one s own role in the care process and having the knowledge, skill, and confidence to assume that role Author (Year) Surgery Intervention Outcome Lubbeke (2009) Goodman (2008) Hip Replacement Pre-Op Classes Decreased post-op dislocations by 62% CABG Pre-Op Classes Decreased post-op costs via re-admissions Reading (1982) Open GYN 15 minute preop discussion Decreased post-op narcotics, earlier work return

16 Surgical Patient Education and Clinical Outcomes Author (Year) Blay (2005) Hathaway (1986) Surgery Intervention Outcome Laparoscopic Cholecystecto my Meta-analysis* Pre-operative educational program 86 Pre-Op Educational Programs Decreased postoperative pain 20% improvement in various post-op outcome metrics Managing patient expectations is a major part of ERP

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18 Early postoperative feeding benefits Increased anastomotic collagen (healing) Increased anastomotic burst strength Decreased mucosal atrophy Decreased enterocyte inflammation Improved splanchnic blood flow Improved absorptive capacity Improved barrier functioning Improved enterocyte immunologic functioning Greatest clinical benefit in the critically ill Severe trauma, burn Early feeding associated with less morbidity Warren, et al. Postoperative Diet Advancement: Surgical Dogma vs Evidence-Based Medicine Nutrition in Clinical Practice / Vol. 26, No. 2, April 2011

19 Opioid sparing anesthesia and analgesia Neuraxial blockade Epidural Spinal Transversus abdominis plane (TAP) Regional (e.g. femoral, intercostal) Acetaminophen NSAIDs ibuprofen celecoxib (Celebrex ) ketorolac (Toradol ) Antiepileptics (e.g. gabapentin)

20 Opioid sparing analgesia

21 IV fluid management 70 kg male, NPO for 8 hours, 3 hour operation, 200 ml EBL, 4 day stay OR 3070ml 125 ml/hr x 18 hr 2250ml 75 ml/hr x 24 hrs 1800ml KVO (30 ml/hr) x 24hrs x 2d Total IVF (4 days) 1440ml 11,590 ml

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23 Out of bed and ambulate

24 Avoidance of tubes and drains

25 Barriers to ERP The 4 P s Provider Patient Policy Procurement Programmer (IT)

26 Provider barriers Figure from How to Change Practice National Institute for Health and Clinical Excellence, December 2007.

27 Provider barriers to ERP Awareness and knowledge New processes, meds, rules Educational programs Skills Surgeons, anesthesiologists, nurses Acceptance and beliefs Leaving the comfort zone Applicability: Will this work here? Safety: Seems dangerous to me Practicalities Burden: Seems like more work for me! Motivation Job security Doctors just making nurses do more

28 Patient barriers to ERP Health literacy Following medication instructions Making pre-op appointments, testing Patient activation Monitoring for signs and symptoms post-discharge Learning necessary skills prior to discharge Social Home support structures lacking Misperception: Longer hospital stays prevent problems Financial Nutrition drinks Home care costs Co-pays

29 Policy Barriers to ERP Old policies grow roots Old policies have owners (and sentiment) New policies take time ERP involve all care phases and providers Operating room Anesthesiology Nursing Outpatient/clinic Pre-operative inpatient Post-anesthesia care unit (PACU) Ward Pharmacy

30 Procurement barriers to ERP Devices Goal directed IV fluid monitors Medications Acetaminophen IV (Ofirmev ) Alvimopan (Entereg ) Liposomal bupivicane (Exparel ) Nutritional supplements Personnel Nurse navigators Pre-operative clinic development

31 Programming (IT) Barriers to ERP Process measure monitoring Automated data extraction Discrete fields in EMR Data collection integrated with work flow Multiple EMR Dashboard Audit capabilities in (near) realtime Robust outcomes analysis National Surgical Quality Improvement Program (NSQIP)

32 Putting it all together colorectal enhanced recovery University of Virginia, elective colorectal cases (n=109) Gatorade 2 hours prior to surgery Mechanical bowel prep and oral antibiotics Alvimopan (Entereg ), Celecoxib (Celebrex ), acetaminophen, gabapentin Morphine spinal Goal-directed IV fluids, IV stopped POD#1 Lidocaine infusion Clear liquids POD#0, regular diet on POD #1 Ambulation Thiele, et al Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery. J Am Coll Surg 2015;220:430e443

33 Colorectal Enhanced Recovery ERP: The University of Virginia Colorectal Experience mg 64 mg Total morphine equivalents (mg) Standard ERP Thiele, et al Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery. J Am Coll Surg 2015;220:430e443

34 Colorectal Enhanced Recovery ERP: The University of Virginia Colorectal Experience 4409 ml Total IVF (ml) Standard ERP 64 mg -182 ml Thiele, et al Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery. J Am Coll Surg 2015;220:430e443

35 Colorectal Enhanced Recovery 8 ERP: The University of Virginia Colorectal Experience days 4.6 days 0 LOS(days) Standard ERP Thiele, et al Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery. J Am Coll Surg 2015;220:430e443

36 Colorectal Enhanced Recovery 30% 20% ERP: The University of Virginia Colorectal Experience 30% 20% 17% 10% 9% 6.8 days 7% 15% 0% Re-Admit Any SSI Any Complication Standard ERP Thiele, et al Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery. J Am Coll Surg 2015;220:430e443

37 Colorectal Enhanced Recovery ERP: The University of Virginia Colorectal Experience $20,435 $13,306 0 Total costs (USD) Standard ERP Thiele, et al Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery. J Am Coll Surg 2015;220:430e443

38 Colorectal Enhanced Recovery 100% 80% 60% 40% 20% 0% ERP: The University of Virginia Colorectal Experience 43% 98% 32% 6.8 days 89% 17% 85% Pain control LTR Overal Standard ERP satisfaction Thiele, et al Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery. J Am Coll Surg 2015;220:430e443

39 NMH Colorectal ERP June 2015 Commissioned July 2015 Support building

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41 Team Building Anesthesiology Surgeon Nursing ERP

42 Team Building Pharmacy Nursing IT Anesthesiology Quality Surgeon ERP Administration Quality

43 NMH Colorectal ERP Experience

44 Ward PACU Inpatient Outpatient Nursing Pharmacy IT EPIC PowerChart Surginet E D W OR Anesthesiology Quality Services Surgeon ERP Administration Nutrition PT Case/Social Management

45 Literature Review

46 Best Practices Site Visit Dave Larson,MD, MBA Jenna Lovely, PharmD

47 Unofficial guiding principles Goal: suitable for 80% of patients Cutting edge, evidence-based Make it easy to do the right thing (hard to do the wrong thing) Easier for everyone to execute, not harder Integrated into existing work flow Respect colleague s roles Lowest common denominator theory Minimize variation, options, thinking Cost-conscious Discrete data elements

48 Modular for expansion Non-colorectal services Non-GI services NMHC hospitals Statewide Can the smallest hospital in Illinois run this efficiently?

49 Strategies for Overcoming Barriers Provider Knowledge: ERP specific training for every provider Practicality: Address concerns of more work Acceptance & Beliefs: Early data feedback Motivation: Engagement and ownership from all providers Patient Patient education program Provider messaging needed to be consistent with patient education Policy Time and patience Armed with evidence, clear plan, demonstrate provider Safety monitoring, early data feedback

50 Strategies for Overcoming Barriers Procurement Utilitarian and evidence based approach Can t have everything Spend money where most effective Programing (IT) Discrete fields in EMR, automated data acquisition Dashboard Screenshots, clear understanding of IT needs and variable definitions

51 NMH Colorectal ERP 93 steps 20% new 80% current practice, just scripted Discrete steps, data Binary compliance, when possible

52 Enhanced Recovery at NM (Colorectal) Pt education/ activation Expectation mgmt. Pre-op clinic Tele visits Outpatient Perioperative Intake assessment Glucose load Sign/Time In/Outs Anesthesia Low IVF and opioids Surgeon SSI bundle PACU Recovery Rapid diet Narcotic sparing Anti-emetics Laxatives IVF minimization Minimal labs Ambulation / OOB Inpatient

53 Colorectal ERP Novel Highlights At the first surgical visit, all ERP patients are: Educated about ERP Review their own ERP book What/when to complete ERP elements at home Provided all pre-operative medicines Undergo perioperative medicine evaluation Smoking and alcohol cessation Stoma care Postoperative expectations Why wait until after the surgery?

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57 Colorectal ERP Novel Highlights Tele-Clinics Pre-op phone call 1 business day before surgery Medications Logistics Post-op phone call 4 business days after surgery Pre-empting ER visits Pre-empting re-admissions Actual EPIC appointment Time, date Robo-Call

58 Colorectal ERP Novel Highlights

59 Colorectal ERP Novel Highlights Standardized Anesthetic Minimized inhaled agents Opioid-sparing Ketamine Lidocaine Euvolemia IVF restriction GDT esophageal Doppler

60 Colorectal ERP Novel Highlights Surgical Site Infection Reduction Bundle: Bowel preparation, oral antibiotics CHG before, during, after incision Standardized peri-op IV ABX Standardized skin preparation Wound protectors Closing tray, glove/gown changes Euglycemia Normothermia Wound infection bundles decrease risks of preventable wound infections with resultant impact on LOS.

61 Colorectal ERP Novel Highlights Lidocaine infusion Poor man s epidural Low dose local anesthetic given systemically for first 48 hours Set it and forget it, floor based protocols No routine level checking No cardiac monitoring Cheap, non-invasive, little fuss Education, provider assessments New process

62 Colorectal ERP Highlights NSAIDS pre-op (ibuprofen), post-op (ketorolac), gabapentin Gatorade (20 oz) pre-op 75 ml, heplocked 8 AM on POD#1 GI Soft (low residue) diet on POD#0 CBC, chemistry on POD#1, PRN thereafter Foley removed POD#1 MOM 30 ml BID until BM Post-op 3T Tylenol, Toradol, Tramadol Encourage oral pain meds from POD#0 Oxycodone, Dilaudid IV PRN 4 walks/day, OOB 8 hours/day All elements are discrete EMR fields

63 ERP Provider Education New orders, forms, work flow 4 intensive months, > 300 providers Speaking the same language Providers Phases of care Care venues Sharing the same goals Common messaging to patients Breaking dogma, culture change Making a new normal Dozens of providers care for our patients, one mixed message can derail a post-operative experience

64 Process Measure and Outcomes Assessment

65 Launch and Implementation August 31, 2016 Bi-Weekly Meetings All care areas Leader + Bring a friend Duplexed communication structure Responsive to problems Squish the bugs before they lay eggs Respect work flow & culture

66 Qualitative implementation interviews Organized interviews Anonymous and impartial More than numbers Hidden barriers and problems Rich data guided implementation Molly Wasserman Meyers, MD Resident

67 Results

68 ERP Case Request Bookings, ERP Anesthetic Performed, Total Elective Outpatient Colorectal Cases 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 ERP Case Bookings ERP Anesthetic Performed Total Cases % ERP Case Booking 0% % ERP Anesthetic Performed Privileged and Confidential Under the Illinois Medical Studies Act

69 NSQIP Length of Stay and Readmissions Pre ERP 6/1/14 to 8/30/16 Post ERP 8/31/16 to 3/19/17 LOS (Mean) Pre ERP (n = 399) Post ERP (n = 113) Absolute Δ Relative Δ All patients 5.9 d 5.1 d -0.8 d -14% Laparoscopic 4.3 d 4.2 d -0.1 d -2% ns Open 7.6 d 6.4 d -1.2 d -16% 0.12 p 30 d Re-admit Pre ERP (n = 399) Post ERP (n = 113) Absolute Δ Relative Δ p All patients 12.5% 7.1% -5.4% -43% 0.09 Privileged and Confidential Under the Illinois Medical Studies Act

70 NSQIP Surgical Site Infections (SSI) Pre ERP 6/1/14 to 8/30/16 Post ERP 8/31/16 to 3/19/17 Pre ERP (n = 399) Post ERP (n = 113) Absolute Δ Relative Δ Superficial SSI 4% 0% -4% Deep SSI 0.5% 0% -0.5% -- ns Organ Space SSI 5% 4.2% -0.8% -16% ns All SSI* 9.2% 4.4% -4.8% -52% 0.09 *Patients may have multiple levels (deep, superficial, organ space) SSI Corresponding decrease in NHSN-defined colorectal SSIs 13 FY17 YTD compared to 28 in FY16 Privileged and Confidential Under the Illinois Medical Studies Act p

71 Opioid Use and Pain Burden September 2016 February 2017 No Postop Lidocaine (n=34) Postop Lidocaine (n=61) Data presented as median (IQR) or n (%). PACU Morphine Eq. 7 mg 0 mg h Morphine Eq. 12 mg 7 mg h Morphine Eq. 31 mg 14 mg h Pain Burden h Pain Burden Decreased opioid use with similar or improved pain burden. Privileged and Confidential Under the Illinois Medical Studies Act p

72 Feeding Data Back to Drive Change

73 NMH ERP Steering Committee Help disseminate ERP to other surgical services Experiential guidance from ERP leaders Develop resource repository Patient educational documents Provider educational resources Coordinate IT efforts Minimize redundancy Maximize shared EMR elements Develop data monitoring strategy Process measure compliance Clinical outcomes

74 Expanding ERP at NMH Each Surgical Service Surgical champion Anesthesiologist champion Nursing unit champion Outpatient nursing champion Other key stakeholders PI leader Develop DMAIC Charter Identify baseline data Identify goals, action plan, targets and dates Complete a Readiness Assessment Identify existing resources for ERP implementation (i.e. EMR orders, forms, patient/provider educational materials) Identify modifications that need to be made to existing ERP resources Identify new resources that need to be developed

75 Ongoing work NMH Colorectal Pilot Process measure data analysis ongoing NSQIP Outcomes (Crude & Risk Adjusted) Qualitative provider and patient interviews Patient experience Total charges ERP modifications NMH Expansion Gynecology/Oncology Urology Surgical oncology NMHC Expansion 6 affiliate hospitals Colorectal pilot first Non-colorectal ISQIC 55 hospitals, state-wide In conjunction with ACS

76 Questions? Thank You!

77 Continuing Education Certificate For CME credit or attendance certificate - Full session attendance and completion of on-line evaluation: Patient-Engagement-Implementing-an-Enhanced-Recovery-Programfor-Surgery OR Thank you!