Enhanced Recovery: Train-the-Trainer

Feb 2015

Garth Vatkin, RN, MHA – ERAS Collaborative Nursing Co-Chair

Nancy Garrett-Petts, RN – Clinical Nurse Educator, Royal Inland Hospital

ERAS Collaborative

Enhanced Recovery of the

Colorectal Surgery Patient!

Now lets talk…

What is it?

Enhanced Recovery after Colorectal Surgery is…

- Evidence based- Patient centered- Outcome directed- Teamwork and multidisciplinary driven

…pathway to decrease complications and speed up recovery

WHY COLORECTAL???

1. Established program

2. Bang for our $$$

3. What the data shows

Who is Involved?

Pre-Operative Phase

Surgeon Office & GI LabSurgeon considerations: Start patient/family teaching• Discuss ERAS - Provide Patient and Family Information booklet• Reinforce patient participation & expected length of stay Indicate to booking office that patient will follow ERAS pathway• ERAS protocol (i.e. note on booking form, use a pre-op PPO)• Order bowel prep (surgeon preference)• Order prophylactic antibiotic (surgeon preference)• Order VTE prophylaxis

Booking OfficeIndicate ERAS on slate

Schedule patients for the morning (when possible)

Pre-Surgical Screening (PSS) / Pre-Admission Clinic (PAC)

Nurse considerations: Reinforce education to patient and family:• Patient and Family Information • Pre-Operative Instructions • Patient Log (if used)• Discharge Booklet

Anaesthesiologist considerations (where applicable): Discuss anaesthetic options with patients

Carbohydrate Loading Beverage

What is it?• Complex carbohydrate supplement

Rationale• Patient can undergo surgery in a metabolically

fed state

When & How • 12 hours and 1-3 hours (org. specific) prior to

surgery time• Self administered prior to surgery time

Day Care Surgery

Nurse considerations:

• Confirm carbohydrate beverage taken • Flag patients record as ERAS • Attach chewing gum to chart• Start IV and put on an infusion pump • Administer prophylactic antibiotic • Pre-warm & maintain normothermia• Administer VTE prophylaxis

Intraoperative Phase

Operating Room

Anaesthesia responsibilities:

• Intraoperative fluid management

• Narcotic sparing analgesia

• Prophylactic antibiotic• Double check if it has been administered• Re-dose as required

• Prophylactic anti-emetic

• Maintain normothermia

• VTE Prophylaxis (site specific)

Post-Operative Phase

Recovery Room

Nurse considerations:

• Minimize narcotic use while optimizing patient comfort through multi-modal orders

• Encourage sugar free chewing gum

• Encourage deep breathing, ankle exercises

• Continue prophylactic anti-emetic

• Maintain normothermia

• VTE prophylaxis (mechanical)

• Full Fluids

• IV fluids provided on infusion pump

Surgical Ward

Nurse considerations:

• Review and follow Pre-Printed Orders

• Early return to diet – Enterstomal Therapy & Dietician support

• Encourage chewing gum

• Support early ambulation = Group effort (physio & nursing)

• Monitor urinary output, apply protocol

• Remove urinary catheter as soon as possible

• Early discontinuation of IV fluids

• Use narcotic sparing analgesia

Continued…

Surgical Ward Continued…

Patient and Family Teaching:

• Reinforce the elements of the patient pathway

• Review and encourage use of patient log book (if applicable)

• Identify and address barriers for discharge

• Reinforce discharge instructions and provide the Discharge Booklet

Outcomes – Quantitative & Qualitative

Sustainability

Take Away Points

*No one falls off the pathway*- Complications are avoidable

- Improved ‘processes of care’ = improved results

- Change is possible and sustainable

- We are all accountable for our patients outcomes

- Patients are willing partners in their recovery

Last Point…..MAKE IT FUN