ERAS Jonathan Hughes, MD, FASA

ERAS Goals

• To reduce complication rates and length of stay

using evidence based medicine

ERAS • ‘Enhanced Recovery After Surgery’

• 1997: Henrik Kehlet

• Preemptive analgesia

• “Why is the patient in the hospital today?”

• 2001: Ken Fearon and Olle Lungqvist start a collaborative group on perioperative

care

• 2001-2005: ERAS study group composed of leading European Surgical groups met

regularly

• Great discrepancy between practices

• Sought to examine the process of change from tradition to best practice

• 2005-Published first set of guidelines

Discharge/LOS

• Krell RW, Girotti ME, Dimick JB. Extended length of stay after surgery:

complications, inefficient practice, or sick patients? JAMA surgery.

2014;149(8):815-820. doi:10.1001/jamasurg.2014.629.

• Examined LOS relative to complications

• 22,644 patients undergoing colorectal surgery

• 42.8% of patients with extended LOS (>9 days) did not have a documented

complication

• Conclusion:

• “These results suggest that much of the variation in resource use

surrounding surgical episodes may be caused by practice style differences

rather than differences in technical quality or patient illness.”

“Determinants of Survival after Major

Surgery and the Adverse Effect of

Postoperative Complications”

• Annals of Surgery-2005

• NSQIP data merged with BIRLS (VA database)

• over 100,00 patients who underwent 8 types of

operations over 9 years - avg follow-up of 8

years

• A 30 day postoperative complication of any type

reduced median long-term survival by 69%

Dimick, J.B., et al. “Who pays for Poor Surgical Quality?

Building a Business Case for Quality Improvement.”Journal

of the American College of Surgeons.202(6): 933-7; June

2006.

ERAS is a Perioperative

Protocol • Pre-op

• Intra-op

• Post-op

• Not a “Buffet”

• Proportion of patients with postoperative morbidity

is significantly reduced with higher levels of ERAS

compliance.

ERAS at Bristol • Approached Dr. Scharfstein in July 2016

• First Meeting 9/21/16

• Anesthesia

• Surgery

• Pharmacy

• Nutrition

• Nursing

• Quality

• EPIC

• and many more

ERAS at Bristol

• Pre-op

• Identify Patients

• Educate at PAT

• Thoracic epidural

• smoking cessation

• Exercise regimen

• Preoperative Hydration

• Accurate patient weight

ERAS at Bristol • Intra-op/DOS

• Avoid dehydration and starvation

• Clears up until 2 hours prior to induction

• Clearfast

• Multimodal analgesia

• Thoracic Epidural

• NSAID’s

• Tylenol

• Neurontin

• Ketamine Infusion

• Goal Directed Fluid Therapy

• Weight based - Cheaper than non-invasive/invasive methods, equally effective

• Correct fluid, in the correct amount, at the correct time

ERAS patient at BRMC

• PAT: 89 kg

• DOS: 88.0 kg

• POD 0: 88.4 kg

• POD 1: 88.8 kg

• POD 2: 88.0 kg

ERAS at BRMC

• Post-op

• Early feeding - POD 0

• Early mobilization - POD 0

• Optimal analgesia

• Early removal of foley/NG tubes

• Aggressive PONV prophylaxis/rescue

• Chewing gum

ERAS at BRMC

• Discharge

• Goal Directed, not Time-Directed

• Goals

• Ambulating/Able to complete ADL’s

• Pain Controlled with PO meds

• Return of Bowel Function

• Tolerating Diet

ERAS at BRMC • Began 4/1/17

• Only took 6 months

• Going Forward

• Data Collection

• Further standardization

• Further expansion/compliance

• Physicians

• Nursing

• Patients

• Continued modification if evidence so dictates

Results

• United States

• 23,098 pts from 2006/2007

• Mean LOS 9.5 days

• England

• 1998-2010 - 240,873 pts

• Median LOS - 10 days

• Italy

• 2005-2014 - 353,941 pts

• Median LOS 13 days

Results

Outcomes ERAS

(Apr-Sep 2017)

Colorectal

(2016)

National Avg

(2006-2007)

Case Count 33 154 23,098

Return of

Bowel Function 1.24 - -

Median LOS 3 6 9.5

30 day

readmission 9% (3 pts) 7.10% -

30 day

occurence 18.18% 27.90% -

NSQIP ERAS Variables

Results

%Compliance Avg. LOS

69.23 9.4

80.77 6

82.05 4

83.08 3.6

83.33 3.6

86.54 3.2

Savings • Average cost per inpatient day (TN, non-profit)

• $1,880

• Days reduced compared to control: 99

• Total savings: ~$186,000

• Average cost for post-op event:

• $22,000

• Reduction of total post-op events: 4

• ~$88,000

• Total estimated savings for 6 months:

• ~$274,000

NSQIP ISAR (April 2016 - March 2017)

-William G. Pollard

“Learning and innovation go hand in hand.

The arrogance of success is to think that what

you did yesterday will be sufficient for

tomorrow.”

-Jonathan Hughes, MD

“Never let science and logic win out over fear

and superstition”

Staff Education

• ERAS Computer Based Learning modules(CBL)

created by education-Mandatory

• Lidocaine

• Epidural

• Weekly Tip Sheets from Quality Department

• ICOUGH CBL

• Staff meeting

Why chewing gum for ERAS?

• Chewing gum can stimulate bowel movement following

abdominal surgery.

• The act of chewing sends signals to the bowel.

• It also increases the production of gastric juice and

other digestive juices without the bowel having to digest

any food.

• Patients can experience flatus and bowel movements

up to a day sooner than patients who do not chew gum.

Encourage your ERAS patients to chew gum 4x

daily for at least 10 minutes at a time!

NSQIP Tip of the Week

Communication Barrier

• Who are our ERAS patients?

• Dome lights

• ERAS Banner

• on bed board identifies ERAS patient

Dome light/Bed board

ERAS Banner in EMR

Easy reminder to staff that the patient is an ERAS patient.

Helping Staff Work Simpler

• Job Breakdown

• Simplified the step-by-step work flow (handout)

• Charting

• ERAS flowsheet

• ERAS packet collection

• Designated location

ERAS Flowsheet

Barriers

• Staff buy-in

• Flavor of the month?

• Compliance with charting

• New employees

• Packet and EMR

The Pot of Gold

• Shift in Culture

• Ambulation

Questions?

hughesjr@gmail.com

Dorie.wykes@balladhealth.org