Standardizing for Efficiency: Enhanced Recovery Lillian S. Kao, MD, MS, CMQ July 23, 2018
Disclosures Small intestine section editor for UpToDate.
ERAS Preoperative Intraoperative Postoperative Enhanced Recovery after Surgery
Preoperative Optimization Consider prehab Selective bowel prep Carb drink No long acting sedatives Reduce preop fasting https://www.sages.org/smart-enhanced-recovery-program/
Intraoperative Lap surgery Fluid balance No tubes, drains, lines Nerve blocks Prevent PONV Normothermia Anesthesia protocol https://www.sages.org/smart-enhanced-recovery-program/
Postoperative Diet ASAP No Foley MMP regimen No ileus HL IV Mobilize ASAP Daily care maps https://www.sages.org/smart-enhanced-recovery-program/
? Clinical Practice Guideline Standardized Pathway
? Clinical Practice Guidelines Standardized Pathways
Enhanced Recovery EQUIFINALITY Standardized Pathways
? My Hospital Clinical Practice Guidelines Our Standardized Pathway
Cookbook Analogy GOALS/ METRICS Are you hoping just to make a cake that looks good? is edible? that family/ guests will eat? EVIDENCE Is the recipe from a reputable chef/cookbook? What do reviews say about the recipe? Do you plan to use the recipe as is? make some modifications? make a recipe up from scratch? TEAM Who is making the cake? Do you bake frequently? Have you ever made a cake before?
Cookbook Analogy STRATEGIES & TOOLS Can anything be bought premade? Should you take a baking class? CONTEXT Is the kitchen prepared for you to succeed with the recipe? What kind of ingredients/ equipment are needed? Are they in the pantry? Are they easily obtained? STANDARDIZATION What worked well? What did not work well? Will you make the cake again? How will you modify the recipe for next time?
Strategies & Tools Evidence Team
Compliance Complications Readmissions Ljungqvist O et al. JAMA Surg, 2017. (Overview) Stone AB et al. J Am Coll Surg, 2016. (Costs) Etc. Length of stay Costs Satisfaction
Strategies & Tools Evidence Context Team Goals/ Metrics
Influence-Importance Chart High Importance Low Importance High Influence Essential to the project; collaborate High risk; involve to increase interest Low Influence Protect and defend; strengthen influence Do not spend resources Surgeons Anesthesiologists Nurses QI personnel Nutritionists Pharmacists PT/OT Administrators Patients Adapted from Tague NR, The Quality Toolbox, 2nd edition
Strategies & Tools Evidence Context Team Goals/ Metrics
Search & screen Review & evaluate Select Adopt or adapt
Search and Screen
Review and Evaluate Strength of recs Disease prevalence Currency of evidence Quality of evidence Quality of guideline Context Values & preferences Wang Z, Norris SL, Bero L. Implementation Science, 2018.
GRADE Implication Preoperative Intraoperative Postoperative 1A/ 1B Strong recommendation, can apply to most patients in most circumstances without reservation 1C Strong recommendation but may change when higher quality evidence becomes available 2A/ 2B Weak recommendation, best action may differ depending on circumstances or patients or societal values 2C Very weak recommendations; other alternatives may be reasonable 2 8 6 1 1 1 3 1 0 1 0 0 Carmichael JC et al. Dis Colon Rectum, 2017.
Multimodal Pain Management Plan Acetaminophen Celecoxib Gabapentin Do epidurals improve outcome? Borzellino G et al. Surg Res Pract, 2016. Ketamine Lidocaine Magnesium Ketorolac Helander EM. J Laparoendosc Adv Surg Tech A, 2017 Do NSAIDs increase anastomotic leak rate? Modasi A et al, Surg Endosc. 2018.
Select GRADE: 1A EVIDENCE COSTS STAKEHOLDER BUY-IN DIFFICULTY OF IMPLEMENTATION
Adopt, adapt, or not 1. Adopt recommendations without modification 2. Adapt recommendations to the new context 3. Develop recommendations de novo based on existing reviews of evidence 4. Develop recommendations de novo based on new evidence synthesis CONSENSUS
Strategies & Tools Evidence Context Team Goals/ Metrics
CONTEXT Patient Safety Practices Effectiveness & Harms Implementation Adoption & Spread
External factors Teamwork, leadership, and patient safety culture Organizational structural characteristics Management tools
Hospital: Safety-net hospital ~200 beds 60% patients uninsured External factors Disproportionate penalties with healthcare reform programs (HRRP, VBP) Organizational structural characteristics Decreased financial strength Teamwork, leadership, and patient safety culture Need for improvement in patient safety culture Supportive leadership Management tools Limited resources for collecting process measure (and outcome) data for ERAS Limited number of QI professionals
Strategies & Tools Evidence Context Team Goals/ Metrics
Tailor strategies Develop relationships Train and educate Engage patients Change structure Evaluate Incentivize financially Support clinicians IMPLEMENTATION STRATEGIES Waltz et al. Implementation Science, 2015.
Strategies and Tools Strategy Use evaluative and iterative strategies Provide interactive assistance Adapt and tailor to context Develop stakeholder interrelationships Train and educate stakeholders Support clinicians Engage consumers (patients) Utilize financial strategies Change infrastructure Tool Provider report card Help desk Generic alternative Interdisciplinary task force Seminar Checklist Computer decision support Patient education pamphlet Disincentive for lack of compliance Anesthesia preop clinic
Strategies & Tools Evidence Team
Conclusions There are multiple standardized clinical pathways that result in improved outcomes due to enhanced recovery after surgery (ERAS). Standardization should be tailored to the stakeholder team, the interpretation of the evidence, the context, and the desired goals.
Questions? Lillian.S.Kao@uth.tmc.edu Tweet me: @LillianKao1
Tools & Strategies Evidence Context Team Goals/ Metrics