SUSP Surgeon call February 26, 2014

1. Enhanced Recovery (ERAS) SUSP Surgeon call February 26, 2014

2. What is ERAS? • First proposed by Dr. Henrik Kehlet, British Anesthesiologist • Multimodal approach to control postoperative pathophysiology and rehabilitation. Br. J. Anaesth. 1997;78:606-617. • “The hypothesis that a combination of unimodal evidence based care interventions to enhance recovery will subsequently decrease need for hospitalization, convalescence and morbidity.” Kehlet H. LangenbecksArchSurg (2011) 396:585–559 • Supportedby large bodyofevidence in virtuallyeveryfieldfromvasculartobariatricsto Whipple tocolorectal

3. Supporting DATA • Dis Colon Rectum 2013 – Meta-analysis of 13 studies demonstrating significantly decreased LOS, complication rate, similar readmit and mortality • Typically all studies demonstrate a 50 – 60% reduction in LOS • Duke experience (abstract ASA 2011) • Before/after design demonstrated significant reduction in LOS, surgical site infection, urinary tract infection, hypotension requiring treatment • Mayo experience (Lovely J, et al. Br J Surg. 2011;99:120-126.) • Before/after design demonstrated 44% of patients discharged on POD 2, opiod requirements less without increased pain scores, complication rate similar, hospital costs were reduced by an average of $1,039/pt

4. Goal of ERAS Implement a standardized, patient centered protocol Integrate the pre-operative, intra-operative, post-operative and post-discharges phases of care to reduce LOS Improve patient experience and satisfaction and decrease variability

5. Basic Principles of ERAS • Enhanced Recovery is a multidisciplinary and collaborative approach focusing on: -Patient education and participation -Optimization of perioperative nutrition -Standardization of perioperative anesthetic plan to minimize narcotics, intravenous fluids and post operative nausea and vomiting -Stress relief -Early mobilization and oral intake

6. Main shifts in mentality • Pain management • Goal is to diminish narcotic intake • Fluid management • Goal is to avoid volume overload – bowel edema • Activity • Goal is to induce early mobility and get the bowels moving!

7. Develop Clinical Specifics and Standardization of care Clinic Prep Inpatient and ICU unit PACU (pain control and mobilization) Post-op pain control plan

9. Financial Analysis

10. Example of ERAS Pathway at Johns Hopkins Hospital

12. ERAS Evaluation • Audit of processes (pain regimen, fluid in OR and post-op, education, mobility, diet etc.) • Length of Stay • Pain scores post-operative • HCAPS • 30 day Morbidity • Readmission • Monthly reports and feedback to optimize implementation

13. Our Model Reducing Surgical Site Infections Translating Evidence Into Practice (TRiP) Comprehensive Unit based Safety Program (CUSP) • Emerging Evidence • Local Opportunities to Improve • Collaborative learning • Summarize the evidence in a checklist • Identify local barriers to implementation • Measure performance • Ensure all patients get the evidence • Engage • Educate • Execute • Evaluate Educate staff on science of safety Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools Technical Work Adaptive Work

14. Discussion