draft – final pending ahrq approval enhanced recovery (eras) susp surgeon call february 26, 2014
Post on 17-Dec-2015
228 Views
Preview:
TRANSCRIPT
DRAFT – final pending AHRQ approval
Enhanced Recovery (ERAS)
SUSP Surgeon call
February 26, 2014
DRAFT – final pending AHRQ approval
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.
Langenbecks Arch Surg (2011) 396:585–559
Supported by large body of evidence in virtually every field from
vascular to bariatrics to Whipple to colorectal
DRAFT – final pending AHRQ approval
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
DRAFT – final pending AHRQ approval
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
DRAFT – final pending AHRQ approval
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
DRAFT – final pending AHRQ approval
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!
DRAFT – final pending AHRQ approval
Develop Clinical Specifics and Standardization of care
Clinic
Prep
Inpatient and ICU unit
PACU (pain control and mobilization)
Post-op pain control plan
DRAFT – final pending AHRQ approval
DRAFT – final pending AHRQ approval
Financial Analysis
DRAFT – final pending AHRQ approval
Example of ERAS Pathway at Johns Hopkins Hospital
• Identify ERAS patients• Bowel prep and CHG washclothes administered• Targeted pre-operative multimodal (electronic, in person and paper) education to set expectations and
engage patient in their care
PreoperativeClinic
DRAFT – final pending AHRQ approval
DRAFT – final pending AHRQ approval
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
DRAFT – final pending AHRQ approval
Our Model
Comprehensive Unit based Safety
Program (CUSP)
1. Educate staff on science of safety
2. Identify defects
3. Assign executive to adopt unit
4. Learn from one defect per quarter
5. Implement teamwork tools
Translating Evidence Into
Practice(TRiP)
1. Summarize the evidence in a checklist
2. Identify local barriers to implementation
3. Measure performance
4. Ensure all patients get the evidence
• Engage• Educate• Execute• Evaluate
Reducing Surgical Site Infections
• Emerging Evidence
• Local Opportunities to Improve
• Collaborative learning
Technical Work Adaptive Work
DRAFT – final pending AHRQ approval
Discussion
top related