enhanced recovery after surgery: acceleration of positive...

Enhanced Recovery After Surgery: Acceleration of Positive Outcomes

10/7/2017

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Standardization of surgical care the Vanderbilt Experience

Tim Geiger, MD, MMHC

Associate Professor of Surgery

Executive Medical Director, Surgery Patient Care Center

Chief, Division of General Surgery

Director, Colon and Rectal Surgery Program

Operations management

Ford.comVanderbilt.edu

Vs.

Assembly line serviceIndividualized care

My experience with standardization vs. individualization of care

• Individual approach to after surgery care• It was really hard to remember who liked what

• I got yelled at a lot• I did not like that

• Then “Fast Track” protocols became the “in” thing• Dozens of publications over 20+ years• Multiple surgical fields• Multiple components

Pinterest.com


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2010 “Fast track” pathway• Laparoscopic techniques when possible

• Decreased IV fluids Intra-Op

• Normothermia

• Epidural catheters

• Minimize opioids

• Mu opioid antagonists

• Early feeding

• Early ambulation

Driver for change• Followed most of the “Fast Track guidelines”

• NSQIP reported- top 20% of participating hospitals in Length of Stay

• Early 2012- national reporting of infection rate was being implemented• Infection rate after colon surgery

higher at VUMC than expected

Start Easy

• Increase communication in a small scale– Colorectal surgery service only- largest volume of cases

• Decrease variability in the process– Two fold intent-

• Decrease in variability should increase quality/outcomes

• Easier reporting/investigation of data for retrospective review


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Moving forward• First task-

Made a formal “bowel isolation” technique standard colorectal practice

• Second task-Standardization of pre-op orders:

Use of standard oral prepUse of standard IV antibiotics Use of standard oral antibiotics

Colon and Rectum Surgery Bundle• Rolled out across the adult enterprise

Hospital wide colon and rectal infections


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Lessons learned

• Use of a best practice model to provide care reduced complications• Best practice does not mean perfect data/100% agreement

• Administration must “buy in”

• Started with a small group of stakeholders

• Clinicians always want to do better- however change is hard

ERAS Protocol 2014

• Matt McEvoy and I began to look at all of our processes for bowel surgery

2 plans of action-• Reduce LOS by decreasing variability through the peri-operative

process• Reduce cost

• Improve satisfaction

• Creation of the perioperative surgical home• Create a group of clinicians dedicated to seamless care/better coordinated care

• Monthly meetings to discuss pathway and outcomes

Main Components of ERAS Pathway

Preoperative Intraoperative Postoperative

Patient Counseling Standard PONV prophylaxis Scheduled NSAIDs, APAP, gabapentin

Regional/neuraxial block

placement

Opiate avoiding/ sparing anesthetic Lidocaine infusion postoperatively

Scheduled oral multimodal

analgesia

No gastric tube PCA use not standard; oral opioids PRN for

breakthrough pain*

“NO BUGS” Protocol Early oral intake

Goal-directed fluid therapy Early ambulation

Avoidance of or early removal of urinary

catheter and drains

if patients were taking opioids prior to admission for chronic pain condition, these were continued through the perioperative period;


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Pre-op identification• VPEC evaluation

• Day prior to surgery- email schedule with identified ERAS cases are sent to anesthesia providers

• Email refers back to pathway

protocols

• TAP/TEC- protocols for

who/what

• Plenty of time to communicate

Gabapentin: 900mg PO; 600mg PO if > 65 yo; 300 mg PO if >75 yoTylenol: 1000mg PO if > 70 kg; 650mg PO if <70 kg; omit if history of liver disease

Scopolamine patch: Use if >2 risk factors; Avoid >65y or concern for over-sedationPre

-Op

1-2

hr

pre

op

Induction (preference for propofol as hypnotic)Ketamine: 0.25-0.5mg/kg IV bolus if <65 yo; 0.25mg/kg IV bolus if >65 yo+

Lidocaine: 1.5 mg/kg IV bolus Methadone: 10-20mg IV if chronic opioid user

No narcotics, use esmolol/metoprolol for HR/BP control

Maintenance (Volatile or Propofol TIVA)Use of SV for GDFT protocol with FloTrac or NexFin

Ketamine: 5 mcg/kg/min infusion after induction until fascial closureLidocaine: 2 mg/kg/hr decreased to PACU dose by weight

Ketorolac: 30mg IV at fascial closure; omit if h/o renal dysfunction or GI bleedNo narcotics - if pt tachypneic, consider methadone 5mg IV q 10min prior to emergence

esmolol/metoprolol for HR/BP controlPONV prophylaxis - ondansetron 4mg IV plus dexamethasone 8-10 mg (unless given in TAP

blocks)

Intr

aop

erat

ive

In a

dd

itio

n t

o ‘

NO

BU

GS’

Pro

toco

l

Laparoscopic/Hand Port Assisted CasesBilateral TAP block with 25cc 0.25% bupiv and

4mg dexamethasone per side*

Laparotomy CasesThor epip to be used during case with bupiv

0.1% with hydromorphone 10mcg/ml

+use bolus syringe from pharmacy *done in Holding; add rectus sheath blocks if incision above T9


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ERAS Protocol 2014• Perioperative Consult Service (PCS)

• Anesthesiologist, Senior Resident, 2 Interns• Perform VPEC Oversight and ERAS for CRS Oversight, including

postoperative rounding/communication with CRS Team from PACU to discharge with 2-week post-discharge pain/PONV plan

• Based on “best practice model” and incorporated our “NO BUGS” pathway

All CasesGabapentin: 400mg-600mg PO tid until d/c,

then 300mg PO tid x7 days, then 100mg PO tid x 7 days; reduce if elderly/ sedatedTylenol: 1000mg PO q6h, then 500mg-1000mg PO q6h x 3 days,

then prn; decrease to 650mg per dose if < 70kg Ketorolac: 30mg IV q6h x 3 days; reduce to 15mg IV q6h >65 yo or Cr>1.5 or <50 kg

Ibuprofen or Diclofenac: PRN x 7 days after d/cOpioids: oxycodone 5mg PO PRN and then advance to others if needed.

Post

-Op

erat

ive

Laparoscopic/Hand Port Assisted CasesLidocaine: 1mg/min if < 70 kg, 1.5mg/min if 70-100 kg, 2 mg/min if > 100 kg for 24 hours

postoperatively; avoid if on other antiarrhythmic

LaparotomyThoracic epidural: bupivacaine 0.1% with

hydromorphone 10mcg/mlOnce epidural discontinued on POD1-3,

Lidocaine: 1mg/min if < 70 kg, 1.5mg/min if 70-100 kg, 2 mg/min if > 100 kg for 24 hours after epidural discontinued; avoid if on other

antiarrhythmic

Early results

• Decrease length of stay (LOS)• Phase 1 by 22%, Phase 2 by 24% vs.

baseline

• No change in readmission rates

• Decreased narcotic usage

• Decreased hospital costs-• Could care for 4 patients in the new system

for the cost of 3 in the old system• Net margin increase of 67% per case


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Early Results

Length of Stay:

• Phase 0- 4.45 days (N=179)

• Phase 1- 3.32 (N=124)

• Phase 2- 3.31 (N=140)

Time to First Oral Intake and Gastrointestinal Output*

Phase 0(N=179)

Phase 1 (N=124)

Phase 2(N=241)

P

0 v. 1 1 v. 2 0 v. 2

Hours to first PO intake (liquid) 9±6 8±5 8±6 <0.01 0.69 <0.01

Hours to first meal 44±38 44±32 35±25 0.93 <0.01 <0.01

Hours to first stool output** 30±25 24±16 22±18 0.03 0.33 <0.001

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Use of Preoperative ERAS Bundle Components for Multimodal Analgesia Before and After Implementation of the ERAS Pathway for Colorectal

Patients

Perc

enta

ge (%

) o

f Pa

tien

ts R

ecei

vin

g C

om

po

nen

t

*

** *

*

Pre-Intervention (N=179) Post-Intervention (N=124) Data as % of group receiving bundle component

*P<0.0001

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ketorolac APAP Gabapentin PCA

Use of Postoperative ERAS Bundle Components for Multimodal Analgesia Before and After Implementation of the ERAS Pathway for Colorectal

Patients

Perc

enta

ge (%

) o

f Pa

tien

ts R

ecei

vin

g C

om

po

nen

t

Pre-Intervention (N=179) Post-Intervention (N=124) Data as % of group receiving bundle component

*P<0.001

*

* *

*


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Early Results

• Opioid administration:

• Costs:

AN ENHANCED RECOVERY PROGRAM IN COLORECTAL SURGERY HAS THE POWER TO DECREASE A BROAD RANGE OF COMPLICATIONS

• NSQIP data on all elective colorectal procedures from 1/2011 through 10/2016

Current results

18 month washout period 1182 patients in total

632 pre-ERAS550 post-ERAS

Presented at the American Society for Enhanced recovery, publication pending

Results

• Statistically significant reduction in:• SSI

• Respiratory

• Transfusion

• UTI

• Sepsis

• Cardiac

• Readmission rates

• LOS

• Only exceptions- AKI, Heme, ED visits


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Results• We maintained a decreased LOS

• We maintained decreased cost per patient to provide care

• We showed that in over 600 patients we improved nearly every part of their measurable outcome

• We created and sustained a significant change in patient care

Decrease the opportunity to do something Different than best practice

By choosing the best model of how a patient should progress through the system

• Care was consistent

• Very little staff/nursing confusion

• Residents knew what to do

• Patients whom were not “on pathway” were identified faster

• By decreasing the points of variability, there was more time to handle all of the other parts of “individualized care” (big 5)

• Combination was more efficient- you have more time to spend on co-morbid conditions, discharge planning, medications, etc.

Standardization of Surgical Care

• Improved outcomes

• Decreased costs

• Decreased length of stay

• Collaboration across medical specialties is a must

• Builds a consistent model for training the next generation

• Leaves less room for error and more time for patient care


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Conclusion

• It is not standardization Vs. individualized care

• It is standardization AND individualized care

X

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