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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ERIN, ERAS, and ERP ERIN-Enhanced Recovery in NSQIP ERAS-Enhanced Recovery after Surgery ERP-Enhanced Recovery Program
Enhanced Recovery Multimodal, interdisciplinary Targeted interventions along the continuum of surgical care Decreases surgical stress Improves outcomes Decreases variability of care Decreases costs
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
ERIN Enhanced Recovery in NSQIP collaborative Nationwide, opt in, additional variables Unique collaborative Guided and audited implementation Individual surgeon, site improvement
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
ERIN objective Guided implementation of Enhanced Recovery principles to decrease LOS in colon operations
ERIN outcomes of interest Decrease LOS after colon resection Secondary Pneumonia VTE UTI SSI readmissions
ERIN collaborative creation Solicit sites Define outcome/s of interest Create implementation strategy model Define variables
ERIN collaborative auditing Unique variables Process Outcomes
ERIN Collaborative-details 17 hospitals and health systems 13 process variables 3 specific outcomes variables
Site # beds/hospitals ERIN Collaborative #surgeons Participant #cases/yr Demographics lap reason 1 1150 / 2 4 400 LOS, SSI 2 496 2 150 80% LOS (7.4d) 3 793/1 4 225 Readmissions, (9 th decile) 4 300 /1 1 38 55% LOS (10d) Readmissions 20% 5 414 /1 1.5of 4 82 LOS, (9 th decile) 6 300 / 1 5 120 20% SSI, UTI, Pneumonia, LOS 7 711 2+ 193 43% Ileus, readmissions, LOS (5d) 8 719 2 149 58% SSI, VTE, pneumonia, LOS (7d) 9 1900 2 99 62% LOS (7d) 10 111 5 111 76% Pneumonia, (LOS 3.8) 11 1300 5 800 SSI 12 605 4 138 52% LOS (6-10d) 13 458 5 283 63% System spread, (LOS 4d) 14 250 2 68 35% LOS(7.5d) 15 1100 9 /4 groups 368 48% LOS (6d)
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 24-48 hours postop Foley removed on or before POD 1 IVF discontinued POD 0-1
ERIN Collaborative-outcome variables Return of bowel function, (date) Tolerating diet, (date) Pain managed with PO medication, (date)
ERIN collaborative timeline, expected NSQIP COLON PROCEDURE SPECIFIC DATA COLLECTION October 2014 ERIN VARIABLE COLLECTION AND START-UP January 2015 ERIN COLLABORATIVE STUDY PERIOD
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
ERIN collaborative timeline, expected NSQIP COLON PROCEDURE SPECIFIC DATA COLLECTION October 2014 ERIN VARIABLE COLLECTION AND START-UP January 2015 ERIN COLLABORATIVE STUDY PERIOD
ERIN collaborative timeline, expected NSQIP COLON PROCEDURE SPECIFIC DATA COLLECTION October 2014 ERIN VARIABLE COLLECTION AND START-UP January 2015 ERIN COLLABORATIVE STUDY PERIOD
Completeness ERIN-early review Difficult variables Early data
Data Collection 17 ERIN sites 15 collecting ERIN variables 15 sites accomplishing over 65% complete records 3 consistently incomplete fields
14 ERIN Pilot Hospitals Data Completeness Pre & Intra-operative Elements Number of Hospitals 12 10 8 6 4 2 0-10% complete 11-89% complete 90-100% complete 0 preop counseling allow CLD preop (3h) thor-epidural antiemetic prophy goal directed therapy normothermia PACU multipain management ERIN Variable
12 ERIN Pilot Hospitals Data Completeness Postoperative Elements Number of hospitals 10 8 6 4 2 0-10% complete 11-89% complete 90-100% 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
Not just ERIN sites 239 sites contributing Data Collection June 2014 July 2015 Number of cases entered/site: 1 1523 Mean: 51 / Median 13 (SD 143) 95%: 171, highest values: 1200-1500
All hospitals entering ERIN data: Completeness of entry Preoperative & Intraoperative Elements 250 Number hospitals 200 150 100 50 0-33% complete 34-66% complete 67-100% complete 0 preop counseling allow CLD preop (3h) thor-epidural antiemetic prophy goal directed therapy normothermia PACU multipain management ERIN Variables 74 (31.3%)
Number of Hospitals 200 180 160 140 120 100 80 60 40 20 0 All hospitals entering ERIN data: completeness of entry Postoperative Elements 0-33% complete 34-66% complete 67-100% complete ERIN Variables
ERIN Collaborative, preliminary content 17 ERIN Pilot sites N=1764 cases Baseline data process measure compliance
Pre-Admission ERIN Variable Counseling 1200 1087 (62%) Number of cases 1000 800 600 400 200 0 30 (2%) 647 (37%) Missing No Yes
Allow Clears till 3h Preop 1200 1066 (60%) 1000 800 600 400 200 0 439 (25%) 221 (13%) 38 (2%) Missing No No - high risk patient Yes
Goal-Directed Intraoperative Fluid Therapy 900 800 700 753 (43%) 850 (48%) 600 500 400 300 200 161 (9%) 100 0 Missing No Yes
Mobilization POD 2 1200 1092 (62%) 1000 800 600 400 200 257 (15%) 415 (24%) 0 Missing No Yes
Clear Liquids POD 0 1000 900 935 (53%) 800 700 684 (39%) 600 500 400 300 200 100 0 145 (8%) Missing No Yes
Solids POD 1 1400 1200 1190 (67%) 1000 800 600 400 200 148 (8%) 426 (24%) 0 Missing No Yes
IV Fluids Discontinued POD 1 1600 1400 1480 (84%) 1200 1000 800 600 400 200 138 (8%) 146 (8%) 0 Missing No Yes
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
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 258 7 ERIN 130 4.4 SSI N % Pre ERIN or SSIB 800 /yr 10, 11, 12: 20 Post ERIN 247 6
Enhanced Recovery in NSQIP-Conclusions Collaborative ACTIVE Early successes Pilot of guiding and auditing process change for better outcomes