Enhanced Recovery Processes
Ron Collins, MD FRCP(C)
Medical Director, Surgical ServicesProject Lead, Enhanced RecoveryInterior Health AuthorityStaff Anesthesiologist, KGH
Relative Contributions to Adverse Events and Excess Length of Stay adapted from Fry et al, J Am Coll Surg 2008;207:698-
704
Procedure n % total Adverse event %
Prop. Adv. Events %
Avg. LOS
Prop. All LOS
Colectomy 12,767 9.9 28.9 24.3 9.8 23.5
Sm Bowel resection
3,576 2.8 32.9 7.7 13.9 10.6
Inpt. Chole. 11,718 9.1 7.5 5.7 8.7 4.9
Ventral Hernia
7,477 5.8 10.1 4.9 6.3 3.1
Pancreat. 1,927 1.5 34.9 4.4 6.8 3.0
“Ultimately, improving quality will require efforts that go beyond
outcomes assessment alone. Future work should aim to improve
our current understanding of processes of care associated with
superior surgical outcomes.”
Fry et al., J. Am Coll Surg 2008;207:698-704
Quality Improvement
Efforts to improve quality of care generally depend on assessing three dimensions:
•Structure: the system in which health care is delivered.
•Process: the care received.
•Outcomes: the results of the above (mortality, morbidity including LOS).
• Cohen ME et al, Ann Surg 2009;250:901-907
Variability in LOS After Colorectal Surgery Cohen et al, Ann Surg 2009;250:901-907
NSQIP data from 182 hospitals from Jan/06 to Dec/07: 23,098 patients
eLOS > 75th percentile of distribution, role of complications (19 defined), O/E ratios
No complications: LOS 6.1 days, but eLOS > 8 days
Complications: LOS 16.1 days, but eLOS > 20 days
“…hospitals with lower risk-adjusted morbidity had shorter risk-adjusted LOS.”
“For efficiency measures to be widely accepted in the market, they should be feasible to implement, credible and reliable for patients, and fair and actionable for healthcare providers.”
Enhanced Recovery After Colorectal Surgery
Evidence-Based Surgical Care and the Evolution of Fast-Track Surgery
Kehlet, H. and Wilmore, D.; Ann Surg 2008;248:189-98
Consensus Review of Optimal Peri-operative Care in Colorectal Surgery
ERAS Group; Arch Surg. 2009;144(10):961-969
Implementation of a Fast-track perioperative care Program: what are the difficulties?
Polle, sw et al, Dig surg 2007;24:441-449
ERAS program: 13 elements but only 7.4 implemented per patient
Compliance did not improve with the experience of the team
Attributed to bad collaboration of the three different disciplines in daily practice
No impact on clinical outcomes: LOS, morbidity, patient satisfaction
Implementing new routinesAre we using ”Best practice”?
The German ”Prevalence”Study in ICU
M M Levy, ASPEN 2007
92%
It is not like we think it is….
The German ”Prevalence”Study
M M Levy, ASPEN 2007
92%
4%
Enhanced Recovery After Surgery
“The profession has placed high value on developing the basic science of medicine: it has not emphasized the process by which the science is translated into practice…”
Eddy, DM. N Engl J Med 1982;307:343-7
Adherence to the ERAS protocol and outcomes after colorectal cancer surgery
ERAS group, Arch Surg 2011;146:571-77
27% improvement in adherence (47% to 74%)
27% reduction in any 30 day morbidity
In fact: dose-response curve for adherence:
70% adherence: LOS 7.4 days; OR morbidity: 0.62
80% adherence: LOS 7.0 days; OR morbidity: 0.57
90% adherence: LOS 6.0 days; OR morbidity: 0.33
Elements most predictive of good outcome:
GD fluid management, Pre-operative CHO beverage
Adherence to the ERAS protocol and outcomes after colorectal cancer surgery
ERAS group, Arch Surg 2011;146:571-77
Prospective Cohort Study: 464 controls (2002-04), 489 study (2005-07)
Second cohort higher risk, more difficult surgery
12 ERAS elements, unchanged
Staffing, infrastructure unchanged
Study compared outcomes and adherence for two periods
MLRA examined the importance of each element in the pathway
Interior Health Authority
Our Vision: To set new standards of excellence in the delivery of health services in the Province of British Columbia
IH Overall
Intra-operative Fluid Management
cardio q non cardio q0
500
1000
1500
2000
2500
1140
1962
660
436
colloidcrystalloid
Interior Health Authority
Our Vision: To set new standards of excellence in the delivery of health services in the Province of British Columbia
IH OverallLength Of Stay
Cardio Q Non Cardio Q0
1
2
3
4
5
6
7
8
9
10
6.86
9.41 Series1
17
Length of stay reduced from 12.8 to 4.0 days.RIW reduced from 3.41 to 1.76
Benefit/cost ratio: 2.18ROI: 118%
CIHI estimated cost reduction of 48.4%.
1 5 91
31
72
12
52
93
33
74
14
54
95
35
76
16
56
97
37
78
18
58
99
39
71
01
10
51
09
11
31
17
12
11
25
12
91
33
13
71
41
14
51
49
15
31
57
16
11
65
16
91
73
17
71
81
18
51
89
19
31
97
20
12
05
20
92
13
21
7
0
10
20
30
40
50
60
70
80
UCL
LCL
Kelowna General Hospital Colorectal Patient Length of Stay Starting 3/09/2010
Patient Number
Le
ng
th o
f S
tay
(D
ay
s) UCL:
32.3 UCL: 10.3
Pre-ER-ACS Mean 12.8
ERACS Mean 4.1
ERACS Introduc-tion
CMG: Open Colorectal Resection
Length of Stay R.I.W.
Traditional 11.4 2.5
ERAS 5.1 1.7
CIHI: cost of care reduced by 33%
CMG: Colorectal Resection with Stoma
Length of Stay R.I.W.
Traditional 11.9 3.5
ERAS 6.0 2.1
CIHI: cost of care reduced by 40%
What is the role of GDT?
CardioQN = 23
No CardioQN = 55
CMG 223 4.1 5.8
CMG 227 5.0 7.4
Complications 0 7
AUTONOMYPURPOSE
MASTERY
Enhanced Recovery Society of Canada
• Mission: “To support the development and implementation of processes of care that result in outcome benefits for surgical patients.”
• Sister Society in Canada of ERAS Society• Website: www.enhancedrecovery.ca• Inaugural Chairperson: Prof. F. Carli: MUHC
• Website development courtesy of: Fresenius-
Kabi and Deltex Medical.