Enhanced Recovery in NSQIP (ERIN): an update on the collaborative. Julie Thacker, LianeFeldman, and Julia Berian ACS NSQIP National Conference 2015
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1 Enhanced Recovery in NSQIP (ERIN): an update on the collaborative Julie Thacker, LianeFeldman, and Julia Berian ACS NSQIP National Conference 2015
2 No disclosures
3 ERIN, ERAS, and ERP ERIN-Enhanced Recovery in NSQIP ERAS-Enhanced Recovery after Surgery ERP-Enhanced Recovery Program
4 Enhanced Recovery Multimodal, interdisciplinary Targeted interventions along the continuum of surgical care Decreases surgical stress Improves outcomes Decreases variability of care Decreases costs
5 Enhanced Recovery Evidence based perioperative care PREOP Defined expectations Liberalized preop fluid intake Optimized medical state INTRAOP Intentional fluid management Minimized surgical trauma POSTOP Aggressive adherence to best practices Food, walks, minimal drains and lines, defined goals
6 ERIN Enhanced Recovery in NSQIP collaborative Nationwide, opt in, additional variables Unique collaborative Guided and audited implementation Individual surgeon, site improvement
7 ERIN Goals Quality improvement Individual surgeon and NSQIP site level Guided implementation On-going NSQIP auditing Specific collaborative variables Impact study of high level, multifactorial outcomes under directed change plan
8 ERIN objective Guided implementation of Enhanced Recovery principles to decrease LOS in colon operations
9 ERIN outcomes of interest Decrease LOS after colon resection Secondary Pneumonia VTE UTI SSI readmissions
10 ERIN collaborative creation Solicit sites Define outcome/s of interest Create implementation strategy model Define variables
11 ERIN collaborative auditing Unique variables Process Outcomes
12 ERIN Collaborative-details 17 hospitals and health systems 13 process variables 3 specific outcomes variables
13 Site # beds/hospitals ERIN Collaborative #surgeons Participant #cases/yr Demographics lap reason / LOS, SSI % LOS (7.4d) 3 793/ Readmissions, (9 th decile) / % LOS (10d) Readmissions 20% /1 1.5of 4 82 LOS, (9 th decile) / % SSI, UTI, Pneumonia, LOS % Ileus, readmissions, LOS (5d) % SSI, VTE, pneumonia, LOS (7d) % LOS (7d) % Pneumonia, (LOS 3.8) SSI % LOS (6-10d) % System spread, (LOS 4d) % LOS(7.5d) /4 groups % LOS (6d)
14 ERIN Collaborative Process Variables Preadmission counseling Preoperative clears until 3 hours before induction Epidural anesthesia for open resections Multi-modal pain management Normothermia on arrival to recovery room Intraoperative goal directed IVF therapy PONV assessment and prophylaxis Mobilization, POD 0-1, POD 1-2, and POD 2-3 Clear liquids provided in the first 24 hours postop Solids provided in hours postop Foley removed on or before POD 1 IVF discontinued POD 0-1
15 ERIN Collaborative-outcome variables Return of bowel function, (date) Tolerating diet, (date) Pain managed with PO medication, (date)
16 ERIN collaborative timeline, expected NSQIP COLON PROCEDURE SPECIFIC DATA COLLECTION October 2014 ERIN VARIABLE COLLECTION AND START-UP January 2015 ERIN COLLABORATIVE STUDY PERIOD
17 ERIN Collaborative Site selection Variables LIVE START-UP CALLS meeting Preop variables Site team creation Implementation plans and supporting materials distributed RAMP-UP, directed site protocol implementation GO-LIVE plans shared CALLS Intraop variables Postop variables UPDATES NSQIP planning July 24 th, 2015 NSQIP Meeting
18 ERIN collaborative timeline, expected NSQIP COLON PROCEDURE SPECIFIC DATA COLLECTION October 2014 ERIN VARIABLE COLLECTION AND START-UP January 2015 ERIN COLLABORATIVE STUDY PERIOD
19 ERIN collaborative timeline, expected NSQIP COLON PROCEDURE SPECIFIC DATA COLLECTION October 2014 ERIN VARIABLE COLLECTION AND START-UP January 2015 ERIN COLLABORATIVE STUDY PERIOD
20 Completeness ERIN-early review Difficult variables Early data
21 Data Collection 17 ERIN sites 15 collecting ERIN variables 15 sites accomplishing over 65% complete records 3 consistently incomplete fields
22 14 ERIN Pilot Hospitals Data Completeness Pre & Intra-operative Elements Number of Hospitals % complete 11-89% complete % complete 0 preop counseling allow CLD preop (3h) thor-epidural antiemetic prophy goal directed therapy normothermia PACU multipain management ERIN Variable
23 12 ERIN Pilot Hospitals Data Completeness Postoperative Elements Number of hospitals % complete 11-89% complete % complete 0 POD0 mobilization POD0 Clear liquids POD1 IV fluid discontinued POD1 foley removal POD1 mobilization POD1 solid diet ERIN Variables POD2 mobilization date pain control on PO meds date return bowel fxn date tolerate diet
24 Not just ERIN sites 239 sites contributing Data Collection June 2014 July 2015 Number of cases entered/site: Mean: 51 / Median 13 (SD 143) 95%: 171, highest values:
25 All hospitals entering ERIN data: Completeness of entry Preoperative & Intraoperative Elements 250 Number hospitals % complete 34-66% complete % complete 0 preop counseling allow CLD preop (3h) thor-epidural antiemetic prophy goal directed therapy normothermia PACU multipain management ERIN Variables 74 (31.3%)
26 Number of Hospitals All hospitals entering ERIN data: completeness of entry Postoperative Elements 0-33% complete 34-66% complete % complete ERIN Variables
27 ERIN Collaborative, preliminary content 17 ERIN Pilot sites N=1764 cases Baseline data process measure compliance
28 Pre-Admission ERIN Variable Counseling (62%) Number of cases (2%) 647 (37%) Missing No Yes
29 Allow Clears till 3h Preop (60%) (25%) 221 (13%) 38 (2%) Missing No No - high risk patient Yes
30 Goal-Directed Intraoperative Fluid Therapy (43%) 850 (48%) (9%) Missing No Yes
31 Mobilization POD (62%) (15%) 415 (24%) 0 Missing No Yes
32 Clear Liquids POD (53%) (39%) (8%) Missing No Yes
33 Solids POD (67%) (8%) 426 (24%) 0 Missing No Yes
34 IV Fluids Discontinued POD (84%) (8%) 146 (8%) 0 Missing No Yes
35 ERIN Collaborative Site Reports All 17 sites multi-disciplinary team 7 sites working groups Pre, intra, postoperative focus Interdisciplinary work with anesthesia 4 sites early working group spin-outs None reported AE s or attrition All reported Building enthusiasm and buy in
36 ERIN-early site data LOS N Days Pre ERIN Average of 3 years 7.3 Post ERIN 179 / 6 months 4.8 LOS N Days non ERIN ERIN SSI N % Pre ERIN or SSIB 800 /yr 10, 11, 12: 20 Post ERIN 247 6
37 Enhanced Recovery in NSQIP-Conclusions Collaborative ACTIVE Early successes Pilot of guiding and auditing process change for better outcomes
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