ClicktoeditMastersubtitlestyleDoes Enhanced Recovery Improve Outcomes?Kaare Weber, MD

Director of SurgeryAssociate Medical Director, Surgery

A M E M B E R O F T H E M O N T E F I O R E H E A L T H S Y S T E M

ClicktoeditMastersubtitlestylemes?

Kaare Weber, MDDirector of Surgery

Associate Medical Director, Surgery

A M E M B E R O F T H E M O N T E F I O R E H E A L T H S Y S T E M

NoDisclosures

3

EnhancedRecoveryAfterSurgery(ERAS)

• ERASmultimodalapproachtoperioperativecaredesignedtoreducesurgicalstress,organdysfunction,andpostoperativecomplications

• ERASfocusesonstandardizationofpreoperative,intraoperativeandpostoperativecarepathwaystoincludeallteammembers– includingthepatient

• EuropecreatedtheInternationalERASSociety2010• AmericanCollegeofSurgeonsNationalSurgicalQualityImprovementProgram

(ACSNSQIP)endorsesERASprograms• In2017,ImprovingSurgicalCareandRecovery(ISCR)programcreatedbyACS

andJohnsHopkinsMedicineArmstrongInstituteforPatientSafetyandQualityandfundedbytheAgencyforHealthcareResearchandQuality(AHRQ)o GoalaidhospitalsacrossthecountrytoadoptERASpathways

4

ERASStudies:Europe

5

ERASStudies:USExperience

6

ERASStudies:Community&LayPress

7

BenefitsofEnhancedRecoveryProgram

ImprovedPatient

Outcomes

ImprovedPain

ManagementReducedLOS

ReducedReadmission

Rates

ReducedVTE

ReducedBlood

TransfusionsReducedUTI

ReducedSurgicalSiteInfections

ReducedHospitalAcquiredPneumonia

ImprovedPatient

Satisfaction

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MultidisciplinaryTeam

PatientNurse

PhysicalTherapyPhysician Assistant

Pharmacy

SurgeonNutritionCareManagement Respiratory

Anesthesia

Wound Care

Office Staff InformaticsTeamMedical SubspecialtiesInfectionControl

House Staff

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StandardizedProgramsforEachPhaseofCare

••PatientEducation••Limitfasting••CarbBeverage••IncentiveSpirometer••StandardizedBowelPrep••NasalSwab••OralCare••CHGBathx3••GlucoseControl••MultimodalPainPlan

Pre-op

••Chloraprep SkinPrep••AppropriateAntibiotics••Normothermia••VTEProphylaxis••FluidOptimization••AntiemeticProphylaxis••GlucoseControl••MultimodalPainPlan••Woundprotector••BowelIsolationTech.

Intra-op••ClearLiquidsPOD#0••Hep-lockafterPOtolerated

••FoleyRemoval••Earlyaggressiveambulation

••AntiemeticProphylaxis••GlucoseControl••MultimodalPainPlan

Post-op

MultimodalPain• NeurontinPOx1

dose MultimodalPain• IVOfirmev• IVToradolifnot

contraindicated• ExparelFieldBlock

Infiltration• IVKetamine• Limitnarcotics• IVLidocaine(soon)

MultimodalPain• IVOfirmevx24

hoursthenPOTylenol

• Toradol ifnotcontraindicated

• Neurontin• Narcoticsfor

breakthrough

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ERASWPHOutcomesFirst12months– IntestinalSurgery

Indicator Pre-ERAS Post-ERAS Source

PainManagement 45%ile 99%ile HCAHPS

LengthofStay 7.61 5.78 Meditech

SurgicalSiteInfections 1.30SIR 0.78SIR NHSN

VTEEvents 26% 23% Midas

Pneumonia 6.29 (8) 4.07(4) NSQIP

RenalFailure 2.06 (5) 1.3 (0) NSQIP

UrinaryTractInfection 2.05 (4) 1.73 (0) NSQIP

Morbidity 17.68 (19) 14.43 (11) NSQIP

Mortality 3.33(4) 2.83(2) NSQIP

ReturntoOR 4.9 (5) 5.23 (6) NSQIP

Readmissions 9.96 (7) 10.13 (7) NSQIPHCAHPS– HospitalConsumerAssessmentofHealthcareProvidersandSystemsNHSN– NationalHealthcareSafetyNetworkNSQIP– NationalSurgicalQualityImprovementProgram(SmoothedRate)2015vs.2016YTDSept

11

ColorectalPatientSatisfactionScores- Pain

53

99 99

27

99 99

60

99 99

0

10

20

30

40

50

60

70

80

90

100

2015 2016 2017(MayYTD)

Percen

tileRa

nking

PainSatisfactionScoresPre&PostERASMPPImplementation

PainManagementOverall PainWellControlled StaffdoEverythingtoHelpwithPain Linear(PainManagementOverall)

ERASImplementedNovember2015

12

ElectiveColorectalSurgery– AverageLengthofStay

0

20

40

60

80

100

120

140

160

180

0

2

4

6

8

10

12

2014 2015 2016 2017

CountofUnitNumber AverageofLengthOfStay

ERASImplementedNovember2015

13

ColorectalSSI

ERASImplementedNovember2015

1.3

0.73

1.41

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

2015 2016 2017(SeptYTD)

WhitePlainsHospitalColorectalStandardizedInfectionRatio(SIR)

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ColorectalVTE

ERASImplementedNovember2015

0%

5%

10%

15%

20%

25%

30%

2015 2016 2017(NovYTD)

WhitePlainsHospital%ColorectalVTEfromallPeriopVTEs

2/11

6/23

3/13

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NSQIPColorectalPneumonia

ERASImplementedNovember2015

16

NSQIPColorectalUTI

ERASImplementedNovember2015

17

NSQIPColorectalMorbidity

ERASImplementedNovember2015

18

NSQIPColorectalMortality

ERASImplementedNovember2015

19

NSQIPColorectalReturntoOR

ERASImplementedNovember2015

20

NSQIPColorectalReadmissions

ERASImplementedNovember2015

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ERASSummary

• ERASisbecomingastandardprotocolforsurgerypatients• Evidencedemonstratesimprovedoutcomeswithoutabilitytopinpointmostimportant

components• ManybelievemultimodalpainplaniskeytothesuccessofanERASprotocol• Requiresculturalchange,persistenceandpatience

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A M E M B E R O F T H E M O N T E F I O R E H E A L T H S Y S T E M

Thankyou!