Enhanced Recovery Principles and Practice. Disclosures

Transcription

1 Enhanced Recovery Principles and Practice Julie Marosky Thacker, MD, FACS, FASCRS ASER-EPBOM, April 2016 Disclosures Merck Edwards LifeScience Cheetah Medical Covidien- Medtronic Premier AbboD NutriFonal 1

2 2007à

3 Response Scotland Netherlands Sweden Norway Denmark Range NG is removed in OR % Epidural analgesia is used roufnely on general ward Resume clear fluids day of surgery Resume oral intake at will by POD % % % Lassen, BMJ 2005 Enhanced Recovery Publica>ons- SOURCE 2010 Other 2% UK 18% Scandanavia 80% Thacker, ACS NSQIP

4 Enhanced Recovery Publica>ons- TOPIC 2010 Anesthesia/ other 9% CRS- lap 12% CRS- open 79% Thacker, ACS NSQIP 2015 Enhanced Recovery Publica>ons- SOURCE 2015 CAN 11% ASIA 9% US 38% EUR 20% UK 22% Thacker, ACS NSQIP

5 US Enhanced Recovery Publica>ons- Combined Effort, 2015 US mul>na>onal 22% US mul> ins>tu>on 11% US single ins>tu>on 67% Thacker, ACS NSQIP 2015 Enhanced Recovery Publica>ons- TOPIC 2015 CRS 6% PerioperaFve Medicine 26% Economics 11% Ortho 10% Anesth 12% Systems 10% ENT 2% Uro 7% Breast 2% Gyn 4% Thoracic 3% HPB 4% Gastric 3% Thacker, ACS NSQIP

6 Response Scotland Netherlands Sweden Norway Denmark Range NG is removed in OR % Epidural analgesia is used roufnely on general ward Resume clear fluids day of surgery Resume oral intake at will by POD % % % Lassen, BMJ 2005 Gustaffson, WJS

7 Principles and PracFce, 2016 Differen'ate Care ELEMENTS PRINCIPLES of enhanced recovery Discuss US perioperafve medicine in pracfce Elements and Principles 7 ELEMENTS of ART 7 PRINCIPLES of DESIGN Line Shape Form Color Value Texture Space Balance Movement Rhythm Contrast Emphasis PaDern Unity 7

8 Elements and Principles 7 ELEMENTS of Care 7 PRINCIPLES of Enhanced Recovery EducaFon Preop Fluids Analgesia GDIVF PONV prophylaxis MIS Order set Engaged Euvolemic Euglycemic Drinking EaFng Sleeping SaFsfied Elements and Principles 7 ELEMENTS of ART 7 PRINCIPLES of DESIGN Line Shape Form Color Value Texture Space Balance Movement Rhythm Contrast Emphasis PaDern Unity 8

9 4/25/16 Elements and Principles 7 ELEMENTS of Care 7 PRINCIPLES of Enhanced Recovery EducaFon Preop Fluids Analgesia GDIVF PONV prophylaxis MIS Order set Engaged Euvolemic Euglycemic Drinking EaFng Sleeping SaFsfied Elements and Principles 7 ELEMENTS of Care 7 PRINCIPLES of Enhanced Recovery EducaFon Preop Fluids Analgesia GDIVF PONV prophylaxis MIS Order set Engaged Euvolemic Euglycemic Drinking EaFng Sleeping SaFsfied 9

10 The elements of design, The principle into pracfce Always wonder is every little thing you do or don t do for your patient, the right thing for that person at that time? Principle of Enhanced Recovery Consider EACH care point, from diagnosis to full recovery Implement the evidence for best outcomes If there is inadequate evidence, study it. 10

11 Common elements to mulfple pafent populafons and operafons PREOP EducaFon OpFmizaFon Specialty Teaching Liberal Preop Fluid INTRAOP PONV prevenfon Opioid sparing, MulFmodal analgesia CogniFve protecfon IntenFonal Fluid Use POSTOP Judicious IVF MulFmodal analgesia Food Exercise Progress audits and teaching Defined discharge criteria serge de Nîmes 11

12 What US perioperafve medicine currently is Limited by specialty and surgeon specifics Being adapted to local environments Limited by fee for service, breakdown of fee for service, and by divisive sociefes and goals Variably used to improve surgical outcomes What enhanced recovery in the US is becoming PaFent centric CollaboraFve Uniquely implemented for each system Expansive by principle, rather than elements 12

13 ASER MISSION Advance enhanced recovery perioperafve medicine Foster educafon Fund and lead research ParFcipate in public policy creafon Build relafonships with pafents and providers Qu a Pe l i r i Ope t y I n r a t i ve i t i a t i ve ASER-EPBOM ASER- ASA_ACS- NSQIP IHI, CMS, BXBS 13