Enhanced Recovery After Surgery (ERAS) for Elective Colon Resection Surgery at Vancouver General Hospital What is Possible? BC Provincial Collaborative November 25, 2014
Disclosure Statement I do not have any affiliation (financial or otherwise) with a commercial organization that may have a direct or indirect connection to this initiative or the content of this presentation.
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Background The risk-adjusted reports from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) demonstrate that patients at Vancouver General Hospital undergoing colorectal surgery have a high odds ratio of postoperative morbidity (1.50-1.54). o Odds ratio >1.0 indicates hospital is performing worse than expected Morbidity impacts patients safety and experience, increases length of stay and health care costs.
True North Goals
ERAS Steering Committee Dr. Neely Panton Dr. Garth Warnock Dr. Andrzei Buczkowski Dr. Kelly Mayson Sandy Pooni Cristina Ferreira Rita Mah Jacqueline Per Mary Cameron-Lane Andrea Bisaillon Tracey Hong Executive Sponsors: Linda Dempster/Patrick O Connor
Methods A multidisciplinary team (anesthesiologists, surgeons, frontline staff, organizational leaders and quality improvement staff) was formed in February 2013. A project charter was drafted Goal: To decrease the morbidity rate for general surgery patients undergoing elective colorectal surgery at Vancouver General Hospital by 50 % by November 2014. Implementation: The ERAS protocol was implemented in two phases.
ERAS Implementation Plan Phase 1 February-October 2013 Provided ongoing education for surgical staff on the ERAS protocol Developed ERAS documents Identification of ERAS cases o Automation June 2013-Ongoing Implemented intra-operative components by a core group of anesthesiologists Audited compliance with intraoperative components Measured patient outcomes in postanesthesia care unit (PACU) November 2013-Ongoing Phase 2 Implemented pre-operative and post-operative components Audited compliance with all ERAS components Measured patient outcomes within 30 days after surgery
Identification of the Cases Identification of VA ORMIS Codes to link the patients on the OR slate and Pre-Admission Clinic appointments Automation of ERAS protocol on OR slate
Anaesthesiologist Engagement Identification of a core group of anaesthesiologist assigned to ERAS patients Education for group as well as the Charge Anaesthesiologist Development of Goal Directed Fluid Management Guideline PDSA, PDSA, PDSA!
Surgeon Engagement Identification of patients for ERAS protocol Development of Pre-Printed Orders Education of MOA Education at Division Meeting and M&M Rounds Education of Residents/Fellows Communicate, Communicate, Communicate!
Pre-Op Team Engagement Identification of unit Champions Education of the ERAS protocol Empower team to remove barriers Provide ongoing feedback regarding process/ outcome measures Modified process based on input from the team Listen, Listen, Listen!
Real Time Audit Conduct chart reviews to collect data to measure: Processes: Auditing compliance with pre-operative, intraoperative and post-operative components Patient outcomes: Milestones Complications in in the Post-Anesthesia Care Unit and 30-day post surgery ACS NSQIP data
ERAS Audit Summary: March-August 2014 (n=100) 80%
Compliance < 80% Compliance with Intra-op ERAS Components & Complications in PACU
Compliance < 80% Compliance with Intra-op ERAS Components & Complications in PACU
Compliance < 80% Compliance with Intra-op ERAS Components & Complications in PACU
Mean Length of Stay in PACU (hh:mm) From times patient enter PACU to times when PACU discharge criteria met
Hospital Length of Stay & Readmission Rate Median LOS (days) Mean LOS (days) Readmission Rate w/in 30 days post-op November 2013 6 7.2 11.8% December 4 4.8 35.7% January 2014 5 8.8 12.0% February 7 7.7 5.3% March 7 10.5 15.8% April 8 7.5 0 May 5.5 11 11.1% June 5 6.3 0 July 5 6 15.8% August 6 6 10.0% September 5 6.4 (1 mortality) 4.5%
VGH Colorectal Surgery Post-op Occurrences NSQIP Risk Adjusted Data Pre ERAS implementation Post ERAS implementation April 2012-March 2013 April 2013-March 2014 % change Overall Morbidity 30.79% 24.98% 18.9% LOS Only includes cases without morbidity events 75% percentile for LOS was 8 days 39.21% 27.31% 30.3% Surgical site infection 17.97% 16.76% 6.7% UTI 4.39% 3.16% 28.0% June 2013: Implementation of ERAS intra-op components Nov 2013: Implementation of ERAS pre-op and post-op components
Lessons Learned Process mapping Team building Communication Culture of quality and patient safety
Sustainment Plan Continue ongoing education of staff Continue to engage patients and family Continue to audit 100% of ERAS patients Disseminate audit results to Steering Committee and stakeholders monthly Celebrate the team s accomplishments
Spread Go Live for Radical Cystectomy October 3, 2014 Active participation with Provincial ERAS Collaborative Active participation with NSQIP ERAS Collaborative
Long Term Impact of Complication Quality and quantity of life fall short for patient who developed any complications within 30 days after OR
Acknowledgments VGH Perioperative Teams VCH NSQIP Team ERAS Steering Committee Numerous Patients and Families Stephen Parker: Clinical Nurse Specialist, PHC Deborah Bachand: Projects Manager, Surgical Services, VIHA
Contact Information Andrea Bisaillon, RN BscN Operations Director - Surgical Services andrea.bisaillon@vch.ca Tracey Hong, RN BscN Quality and Patient Safety Coordinator tracey.hong@vch.ca