Enhanced Recovery After Surgery

Transcription

1 Enhanced Recovery After Surgery Thomas Aloia, MD, FACS and Vijaya Gottumukkala, MB, BS, MD (Anes), FRCA The University of Texas MD Anderson Cancer Center March 7 8, 2017

2 Welcome Ask a question using the Skype Q&A box at the top right To see all questions click on all An orange dot next to all means a new question has been asked As many questions as possible will be answered at the end of the presentation A list of Q&A s from all sessions will be sent after March 8 th 2

3 Confirm Your Attendance Physicians and Non-Physicians All Skype participants Enter your name in the Skype Q&A box at the top right and click ask All Telepresence participants Send an to Carol Rizzie at This is to confirm your attendance 3

4 Education Credit for Tue, Mar 7 Physicians Only Go to activity.credit (www or http not necessary) Input code BXCRHB into the box Sign in, verify profile, choose password and click Save Follow remaining steps CODE EXPIRES IN 30 DAYS BEING LOGGED ON OR IN ATTENDANCE DOES NOT TRACK CME Non-physicians Certificate of attendance will be sent after March 8 th Contact Carol Rizzie with questions carol.rizzie@advocatehealth.com 4

5 Disclosures Thomas Aloia, Faculty Nothing to disclose Charles Derus, Planner / Faculty Nothing to disclose Vijaya Gottumukkala, Faculty Pacira: Consultant Carol Rizzie, Planner Nothing to disclose Michelle Ruther, Planner Nothing to disclose 5

6 Enhanced Surgical Recovery Program Vijaya Gottumukkala M.B;B.S, M.D (Anes), F.R.C.A Professor Deputy Chairman & Clinical Director Director, Cancer Anesthesia Fellowship Program Department of Anesthesiology & Perioperative Medicine The University of Texas MD Anderson Cancer Center Houston, Texas- U.S.A

7 Enhanced Surgical Recovery Program PACIRA MEDTRONIC INC.

8 Enhanced Surgical Recovery Program online-metrics.com Objectives:

9 Enhanced Surgical Recovery Program FUNCTIONAL AND DISABILITY FREE SURVIVAL

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11 RISING HEALTH CARE COSTS IN THE US 2015: $ 9, PP; 17.8% GDP

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13 Value Proposition in Health Care Safe Surgery And Anesthetic Care JAMA 2012; 307:

14 ACUTE SURGICAL CARE IN THE USA

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16 Transforming health care delivery in the US

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18 What do Consumers Want from Surgical Care? Source: Market Innovation Center 2015 Surgical Care Consumer Choice Survey The Advisory Board Company

19 Bending the cost curve Improving surgical outcomes Traditional Care Models are not conducive for delivery of value based surgical care and helping bend the cost curve

20 Transforming Perioperative Care of the surgical patient

21 Enhanced Surgical Recovery Program

22 Improve Surgical Outcomes TRANSFORMING PERIOPERATIVE CARE Building Blocks - MDACC ESRP Deliver High Value Care Surgeon factors: Approach, surgical skill, extent of resection Patient Factors: Disease burden, Medical Optimization, functional status

23 Enhanced Surgical Recovery Program Not a technique Philosophy of care Perioperative continuum Multidisciplinary Minimize symptom burden and complications Enhance Functional Recovery Effective care transitions Reduce/minimize readmissions Track outcomes and HRQoL measures Improve population health Reduce cost of care delivery

24 MINIMIZING VARIATION IN PROCESSES OF CARE DELIVERY

25 Setting up an Enhanced Recovery Program

26 Setting up an Enhanced Recovery Program Fearon KCH, et al. Clinical Nutrition 2005; 24:

27 Setting up an Enhanced Recovery Program

28 MDACC Enhanced Recovery Pathway Choose Wisely Campaign Optimize patients condition Patient and care-giver education and engagement MINIMIZE SURGICAL STRESS (MIS) Procedure specific opioid sparing analgesia strategies Minimize oxygen debt (fluids therapy-hemodynamic optimizationblood management) Optimal Anesthetic Care Pathway based postoperative care Early DRinking Eating AMbulating Early diagnosis and rapid response to manage postop complications Post discharge care (transitions) FUNCTIONAL AND DISABILITY FREE SURVIVAL

29 MDACC Enhanced Recovery Pathway PATIENT EDUCATION, ENGAGEMENT AND EMPOWERMENT

30 MDACC Enhanced Recovery Pathway Preoperative Maneuvers Clear liquids up to 2 hours prior to reporting for surgery Preventive analgesia X Tramadol ER Oral Acetaminophen Pregabalin/Gabapentin X Celecoxib Image modified from aafp.org

31 Enhanced Recovery Pathway Intraoperative Opioid Sparing Strategies Wound Infiltration Dexmedetomidine TAP Block PIC Block PVB X X X x Ketamine Or N 2 O Lidocaine infusion IV Acetaminophen Epidural

32 Immediate Postoperative care: PACU and POD 0 Rapid Emergence from Anesthesia Dynamic Pain Control Opioid Sparing Strategies

33 MDACC Enhanced Recovery Pathway Choose Wisely Campaign Optimize patients condition Patient and care-giver education and engagement MINIMIZE SURGICAL STRESS (MIS) Procedure specific opioid sparing analgesia strategies Minimize oxygen debt (fluids therapy-hemodynamic optimization-blood management) Optimal Anesthetic Care Pathway based postoperative care Early DRinking Eating AMbulating Early diagnosis and rapid response to manage postop complications FUNCTIONAL AND DISABILITY FREE SURVIVAL

34 GDT vs. Conventional A= PNEUMONIA; B= RENAL COMPLICATIONS MORTALITY Anesth Analg 2012;114:640 51

35 Variability in practice and factors predictive of total crystalloid administration during abdominal surgery: retrospective two-centre analysis BJA 114 (5): (2015)

36 Monitoring Needs and Goal-directed Fluid Therapy Within an Enhanced Recovery Program Anesthesiology Clin 33 (2015) 35 49

37 Monitoring Needs and Goal-directed Fluid Therapy Within an Enhanced Recovery Program Anesthesiology Clin 33 (2015) 35 49

38 PERIOPERATIVE ANESTHETIC STRATEGIES AT MDACC MAINTAINING TISSUE PERFUSION AVOIDING OXYGEN DEBT AVOIDING DEEP ANESTHESIA ANESTHESIOLOGY 2015; 123:307-19

39 Meta-analysis of RCT assessing use of intraoperative BIS and risk for POD Avidan MS. IARS 2013 REVIEW COURSE LECTURES

40 Atelectasis and perioperative pulmonary complications in high-risk patients Curr Opin Anesthesiol 2012, 25:1-10

41 Curr Opin Anesthesiol 2012, 25:1-10 Atelectasis and perioperative pulmonary complications in high-risk patients

42 Neuromuscular Reversal and Monitoring Anesthesiology 2017; 126 (1): 1-4

43 Postoperative Care In The Hospital Get Back on Track Ambulation Pulmonary Rehab Balanced Enteral Diet Dynamic Pain Control Opioids: Good, Bad and The Ugly Optimal Fluid Therapy

44 Improving Postoperative Care Need Rapid Diagnosis, Response And Rescue

45 Burden of Postoperative Complications After Major Surgery

46 Burden of Postoperative Complications After Major Surgery

47 Effect of Postoperative Complications Am J Med Qual. 2012; 27:

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49 Improving Postoperative Care Discharge Planning and Post discharge Care

50 PERIOPERATIVE CARE OF THE CANCER PATIENT IMPROVING ONCOLOGICAL OUTCOMES-OUR VISION AT MDACC Preoperative: Preventive Analgesia (Oral Pregabalin, Celecoxib, Tramadol ER) and PONV prophylaxis Intraoperative: Regional Block: PVB/Epidural/TAP Block/Wound infiltration, Opioid sparing strategies Steroids, IV Tylenol,Dexmedetomidine, IV Lidocaine and Ketamine infusions TIVA Propofol Optimal anesthetic plan: Normothermia, Euglycemia, Goal directed Fluid therapy, Hemodynamic optimization, Permissive hypercapnia, LPV strategies, Blood management protocol, Avoid deep anesthesia Complete rversal of NMB ostoperative: Opioid sparing strategies Early DRinking Eating AMbulating Early diagnosis and rapid response Transition of care planning Tracking measures and outcomes (RIOT)

51 Enhanced Surgical Recovery Program

52 MDACC ENHANCED SURGICAL RECOVERY PROGRAM

53 MDASI Life Interference Scores *Aloia/Gottumukkala, JACS, 2015

54 MDACC Liver Surgery Traditional vs. ERLS Traditional Recovery-43 Early pain control Enhanced Recovery-75 Complications Mortality LOS *Aloia/Gottumukkala, JACS, 2015

55 Enhanced Recovery In Liver Surgery Factors for Recovery Factor No RTB Int RTB Int Uni p- value Age >=65 22 (32) 17 (35) Male 35 (51) 30 (61) Preop Chemotherapy 51 (74) 39 (80) Multi p- value Minimally Invasive 14 (20) 17 (34) Major Hepatectomy 26 (38) 11 (22) Operation Time >= 300 m 30 (45) 16 (33) Epidural 35 (51) 28 (57) OR (95% CI) ERLS 38 (55) 37 (76) ( ) LOS > 5 Days 34 (49) 19 (39) Any Complication 35 (51) 19 (39) Major Complication 9 (13) 7 (14) *Aloia/Gottumukkala, JACS, 2015

56 ESRP- GYN Preliminary Impact on LOS/Complications and RIOT Variable Pre-ERP Post-ERP p-value Length of Stay 4 days (2-27) 3 days (1-11) Readmissions 11.7% 12% 1.00 GI complications 24% 15% 0.26 GU Complications Neurologic Complications Hematologic Complications 6% 13% % 0.02% % 14% 0.13 RIOT* 30 (15-52) 22 (20-41) 0.08

57 LOS Days Enhanced Recovery In Liver Surgery Approach Over Incision 8 7 p< Trad ERAS Open MIS *Aloia/Gottumukkala, JACS, 2015

58 ERILS Readmissions % High Risk Patients Readmitted

59 Time to Return to Intended Oncologic Therapy ERILS Baseline 95% 87% Next Step: Can Surgical Recovery Impact Cancer- Specific Survivals? Enhance Recovery RIOT Decrease Postop Days Recurrence Improve Survivals *Aloia/Gottumukkala, JSO, 2014

60 OSJ Prevents Poor Recovery Primary outcome: Poor Recovery Composite endpoint (LOS > 7 or readmission w/in 30 days) Odds Ratio 95% CI P-value Diversion type Operation length Opioid use # Complications < OSJ (yes vs. no) Predictors of poor recovery Every 1 complication increases risk of poor recovery 2.4-fold Use of the OSJ decreases risk of poor recovery 8-fold Shah & Cata et al- Unpublished data

61 Impact on PRO s, Opioid Consumption, PACU pain scores MDASI-OC: Significant decrease in severity of nausea, sleep disturbance, constipation, urinary urgency and difficulty with memory during the hospitalization period 70% reduction in intra-operative morphine equivalents (P<0.001) Pre-ERP median 151 mg (25-263) Post-ERP median 45 mg ( ) 34% reduction in PACU pain scores (p=0.01) Pre-ERP mean 6.04 Post-ERP mean 3.98

62 Ann Thorac Surg 2015;99: Enhanced Recovery After Thoracic Surgery

63 MDACC ERP Teams 2012 to 2017 H&N Surgery Breast Surgery Liver Surgery GIM HIPEC Surgery Anesthesiology Surgery Bladder Surgery Nursing Colorectal Surgery Pharmacy Nutrition GYN Surgery SCT Neuro Surgery Spine Surgery Thoracic Surgery

64 Understanding Process- Measuring Outcomes

65 Enhanced Surgical Recovery Program planzsolutions.com

66 Enhanced Surgical Recovery Program What elements should be routine care? What are core elements of ERP? How do we define core elements? How do we track compliance? What outcomes do we measure? What tools do we use to measure outcomes? How do we normalize elements of care?

67 Enhanced Surgical Recovery Program Patient Reported Outcomes Procedure specific perioperative symptom burden Postoperative morbidity (symptom burden and functional interference) Return to baseline functional status Clinical Outcomes Post operative complications Medical readiness for discharge (MRD) and Return to Intended oncological therapy (RIOT) All Readmissions Frequency/Definition MDASI Symptom Severity (validated 13 core items, plus procedure specific module items) Pre-op; Daily until discharge; Weekly for up to 3 months postop Postop days 1,3,5,7 and at discharge and first postoperative follow-up Days from surgery to return to baseline functional status Frequency/Definition Count, frequency, grade Days from surgery to MRD and RIOT 30, 60 and 90 Day Business Outcomes Length of hospital stay Episode or total TDABC cost for patient Frequency/Definition Days from surgery to discharge Total true MDACC costs / total patient costs Modified from John Calhoun- ICCI, MDACC

68 7.2 d 5.1d 4.7 d

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70 Enhanced Surgical Recovery Program CHANGE IS HARD AT THE BEGINNING MESSY IN THE MIDDLE GORGEOUS AT THE END Marlosneoldeous.com

71 PERIOPERATIVE CARE OF THE CANCER PATIENT IMPROVING ONCOLOGICAL OUTCOMES-OUR VISION AT MDACC

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74 Enhanced Surgical Recovery Program Thank you for your attention

75 How to Build the ERAS Team Thomas A. Aloia, MD Associate Professor of Surgical Oncology Division Director of Quality and Outcomes Deputy Department Chair for Education Associate Head, Institute for Cancer Care Innovation Advocate MDs

76 Disclosures Financial: None Personal: Recovering Transplant Surgeon

77 Agenda/Challenges Why do you want to do ER? Issues Trainee Patient Anesthesia/Surgery Nursing Hospital Administration Teamwork

78 I can t tell you how to build an ER program unless you tell me why you want to do ER

79 Why Do You Want to Do ER? What Is Your Vision/Goal?? ERP Elements?? Anesthesia-Surgery-Nursing

80 What is the Goal? More Than LOS? Morbidity LOS MD Centric Mortality Readmission Bowel Function Quality of Life Pain Med Usage Immunologic Factors Patient Satisfaction Cost Physical Performance Tests Patient Centric % of Papers *Day & Aloia, BJS, 2015

81 What Is Your ER Goal? A. Reduce complications Enhanced Safety Program B. Save the hospital money Enhanced Finance Program C. Lower length of stay Enhanced Discharge Program D. Make them to poop faster (see answer C.) Enhanced BM Program E. Help patients recover faster Enhanced Recovery Program

82 Agenda/Challenges Why do you want to do ER? Issues Trainee Patient Anesthesia/Surgery Nursing Hospital Administration Teamwork

83 Surgeon/Trainee Issues Single largest impediment to LOS reduction is unwillingness to advance diet Eliminate from ordersets and vocabulary Sips of Clears ADAT Full Liquid Diet POD0-1 Clears ad lib POD2 Regular or ADA Diet Second largest impediment to LOS is excessive fluid administration post op SL at 600 ml PO intake UO 50cc/2 hrs acceptable

84 LOS in Days Intervention Intervention Intervention Intervention Mayo Clinic Colectomy LOS Intervention 0 #4: No fluid bolus without attending approval

85 Agenda/Challenges Why do you want to do ER? Issues Trainee Patient Anesthesia/Surgery Nursing Hospital Administration

86 Patient Recovery is the Goal Crossing the Quality Chasm Health Care Goals Aim 1: Safe Aim 2: Effective Aim 3: Patient-Centered Aim 4: Timely Aim 5: Efficient Aim 6: Equitable Patient Goals Don t Hurt me Cure me Recover me See me quickly Avoid unnecessary tests Don t Bankrupt me The Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21 st Century, 2001

87 Agenda/Challenges Why do you want to do ER? Issues Trainee Patient Anesthesia/Surgery Nursing Hospital Administration

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89 Setting up an Enhanced Recovery Program Elements, Buy-in, Hurdles, and Conflict Resolution Lesson 1: It s Not Personal, So Don t Make It Personal People don't resist change. They resist being changed -Peter Senge

90 Non-Narcotic Analgesia Control: Surgeon Surg/Anesth Anesthesia MIS Preop (Limited bowel prep) Intraop Antiemetics Small Incisions Local Analgesia Postop Minimized Tubes and Drains Early Feeding Early Mobilization MIS + ER Preop Education Prehabilitation Premedication Diet Intraop Steroids PROMPT Anesthesia Regional Blocks Fluid Limitation Postop Non-Narcotic Analgesia Immediate Feeding SL IVF -Many more elements -Much more

91 Communication Keys Long before the case Premeds Regional blocks Fluids Narcotics Night before case Next day s plan After the case Share successes If the metric of success is patient recovery and surgeons never show anesthesiology providers an early recovered patient they should not expect buy-in

92 The Best Part of ERAS Implementation Bringing Together Surgery and Anesthesia

93 Agenda/Challenges Why do you want to do ER? Issues Trainee Patient Anesthesia/Surgery Nursing Hospital Administration Teamwork

94 Nursing Concerns Patients are moving too fast Diet intolerance Foley removal failures Discharge planning Concern for inadequate pain control Stairstep prn regimen Mild pain (1-4)=Tylenol Moderate pain (5-7)=Tramadol Severe pain (8-10) (low dose dilaudid and call) Remember Very low the dose Goal: Dilaudid PCA Patient Experience NOT Patient Torture in A Quest to Reduce LOS

95 Epidurals and Foleys Women foley out when independent to the bathroom Men <30 no help Automatic foley ambulate Anyone to bathroom=foley who removal removal >50 orders premed advocates with Flomax for and Foley remove are associated removal on a set with a 17% day or time has not replacement rate had one replaced while awake ~TAA

96 Agenda/Challenges Why do you want to do ER? Issues Trainee Patient Anesthesia/Surgery Nursing Hospital Administration Teamwork

97 To the C-Suite: 1. Join the Team 2. Resource the Team 3. Let doctors be doctors and nurses be nurses 4. The ROI will come LOS reduction is the residue of a high-quality ERP

98 ESRP Annual $ Impact 7.2 d THE FORMULA (Total OR/1000) X days reduced LOS =$millions to margin per yr 4.7 d (13,000 inpt operations/1000 x 2.5 days LOS) 13 x 2.5=$32.5 million per year

99 Agenda/Challenges Why do you want to do ER? Issues Trainee Patient Anesthesia/Surgery Nursing Hospital Administration Teamwork

100 ER Team Set-up Plan 1. Determine the Why 2. Form the Team Punch tickets Meet weekly 3. Revise/Develop ordersets and pathways 4. Develop compliance metrics Measure and Report 5. Develop outcome metrics (PRO) Measure and Report

101 ER Team Set-up Plan 1. Determine the Why 2. Form the Team Punch tickets Meet weekly 3. Revise/Develop ordersets and pathways 4. Develop compliance metrics Measure and Report 5. Develop outcome metrics (PRO) Measure and Report

102 Simon Sinek: Start with Why People do not buy WHAT you do, they buy WHY you do it. Team members don t buy-in to the product or change they are working on, they buy-in to why the team is making the product or change.

103 Setting up an Enhanced Recovery Program Elements, Buy-in, Hurdles, and Conflict Resolution There are only two ways to influence human behavior: you can manipulate it or you can inspire it. Patient-centered care is inspirational.

104 Setting up an Enhanced Recovery Program Elements, Buy-in, Hurdles, and Conflict Resolution Catherinescareercorner.com

105 ER Team Set-up Plan 1. Determine the Why 2. Form the Team Punch tickets Meet weekly 3. Revise/Develop ordersets and pathways 4. Develop compliance metrics Measure and Report 5. Develop outcome metrics (PRO) Measure and Report

106 Early vs. Late Adopters

107 The Team Anesthesia/Surgery Nursing Clinic Periop Inpatient

108 The (Super) Team Anesthesia/Surgery Nursing Clinic Periop Inpatient Pharmacy Nutrition Patient Education PMNR Coordinator IT

109 ER Team Set-up Plan 1. Determine the Why 2. Form the Team Punch tickets Meet weekly 3. Revise/Develop ordersets and pathways 4. Develop compliance metrics Measure and Report 5. Develop outcome metrics (PRO) Measure and Report

110 Brent James It s more important that you do it the same way than what you think is the right way.

111 Brent James It s more important that you [organization] do it the same way than what you [individual] think is the right way. Think globally (patient-centric), then act locally

112 Ordersets and Pathways

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114 ER Team Set-up Plan 1. Determine the Why 2. Form the Team Punch tickets Meet weekly 3. Revise/Develop ordersets and pathways 4. Develop compliance metrics Measure and Report 5. Develop outcome metrics (PRO) Measure and Report

115 Early postoperative diet Early postoperative mobilisation* NGT presence/management* Urinary catheter Postoperative fluid restriction* Epidural analgesia* Preoperative fasting* Preoperative education Mechanical bowel preparation* Narcotic limitation* Carbohydrate loading Intraabdominal drain Routine laxative use Intraoperative fluid restriction* Intraoperative thermal regulation* Postoperative protein supplements MIS/Incision type Withholding sedative medications PONV ppx* High inspired FiO2 Premedication Postoperative carboydrate Colorectal ERAS Studies Elements Reporting Named Element Explained Element Compliance Reported *Day, Gottumukkala & Aloia, BJS, 2015

116 ER Team Set-up Plan 1. Determine the Why 2. Form the Team Punch tickets Meet weekly 3. Revise/Develop ordersets and pathways 4. Develop compliance metrics Measure and Report 5. Develop outcome metrics (PRO) Measure and Report

117 Setting up an Enhanced Recovery Program Elements, Buy-in, Hurdles, and Conflict Resolution windsonline.com

118 ERAS Plan PROs: Symptom Interference Return to Normal Function ASAP If your focus is the patient s recovery experience, your program will be successful. Reduce Anxiety, Narcotics, and Fluids ERP Elements Anesthesia-Surgery-Nursing

119 Thank You! MDACC VM-Many Thanks Steven Swisher/Thomas Feeley Vijay Gottumukkala/Thomas Rahlfs/Carin Hagberg John Calhoun Clinical Teams HPB Anesthesia/CRNAs Surgical Oncology and HPB Surgery Fellows Sharon Fielder/Whitney Dewhurst/Leigh Samp Research Teams Charles Cleeland/Shelley Wang Ryan Day, MD, Bradford Kim, MD, MPH, Catherine Hambleton, MD Pharmacy/Nutrition Support Thomas A. Aloia, M.D., F.A.C.S. MD Anderson Cancer taaloia@mdanderson.org

120 Early Feeding Goal Directed Fluid Therapy Non-narcotic analgesia Ambulation What Areas Need Most Work? Enhanced Recovery Patient Education and Engagement

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