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Enhanced Recovery After Surgery (ERAS) for Elective Colorectal Surgery at Vancouver General Hospital Quality Forum 2015.

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Presentation on theme: "Enhanced Recovery After Surgery (ERAS) for Elective Colorectal Surgery at Vancouver General Hospital Quality Forum 2015."— Presentation transcript:

1 Enhanced Recovery After Surgery (ERAS) for Elective Colorectal Surgery at Vancouver General Hospital Quality Forum 2015

2 Disclosure Statement We do not have any affiliation (financial or otherwise) with a commercial organization that may have a direct or indirect connection to this initiative or the content of this presentation.

3 Our Site

4 Background The risk-adjusted reports from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) demonstrated that patients at Vancouver General Hospital undergoing colorectal surgery had a high odds ratio of postoperative morbidity (1.49). o Odds ratio >1.0 indicates hospital is performing worse than expected Morbidity impacts patients safety and experience, increases length of stay and health care costs.

5 True North Goals

6 Enhanced Recovery After Surgery Key Components Pre-operativeIntra-operativePost-operative Pre-admission counsellingActive warmingEarly oral nutrition Early discharge planning Use of multi-modal pain management Early ambulation Reduced fasting durationSurgical techniques Early catheter removal Carbohydrate loading Avoidance of prophylactic NG tubes & drains Use of chewing gum No/selective bowel prep Defined discharge criteria Venous thromboembolism prophylaxis Use of multi-modal anti-emetic prophylaxis Antibiotic prophylaxis Use of goal directed peri-operative fluid therapy Pre-warming Audit of compliance & outcomes Active Patient Involvement Whole Team Involvement

7 Methods A multidisciplinary team (anesthesiologists, surgeons, frontline staff, organizational leaders and quality improvement staff) was formed in February 2013. Goal: To decrease the morbidity rate for general surgery patients undergoing elective colorectal surgery at Vancouver General Hospital by 50 % by November 2014. Implementation: The ERAS protocol was implemented in two phases.

8 Implementation Phase 1 February-October 2013June 2013-Ongoing  Provided ongoing education for surgical staff on the ERAS protocol.  Developed ERAS documents: o Standardized order sets. o Clinical pathway & kardex. o Patient teaching booklet. o Poster highlighting changes in practice. o Automation of ERAS on OR Slate.  Implemented intra-operative components by a core group of anesthesiologists.  Audited compliance with intra-operative components.  Measured patient outcomes in post- anesthesia care unit (PACU). Phase 2 November 2013-Ongoing  Implemented pre-operative and post-operative components.  Audited compliance with all ERAS components.  Measured patient outcomes within 30 days after surgery on 100% of ERAS cases.

9 ERAS Audit Summary for November 2014 (n=18) 80% Pre-operative Intra-operative Post-operative

10 Components sustained >80% compliance Pre-operative components: Pre-admission counselling Use of Chlorhexidine wipes Antibiotic prophylaxis within 60 minutes of skin cut Intra-operative components: Normothermia (36-38ºC) Use of multi-modal anti-emetic prophylaxis Post-operative components: Gum chewing Tolerated high protein drink (Boost)

11 Areas of Opportunity Use of goal directed fluid therapy Early mobilization Appropriate use of anti-emetics post-operatively Appropriate removal of urinary catheter Advancement of the patient diet

12 % of Components with Compliance > 80% (n=21) 80 %

13 Aggregation of Marginal Gains to Provide Large Benefi t From “The Slight Edge” by Jeff Olsen

14 Aggregation of Marginal Gains to Provide Large Benefit From “The Slight Edge” by Jeff Olsen Preoperative counselling Preoperative preparation Admission Intraoperative Management Recovery Room Post-operative Management Discharge SUCCESS FAILURE

15 Pre ERAS Implementation Post ERAS Implementation July 2011-June 2013 n=101 Nov 2013-Aug 2014 n=174 % Change Overall Morbidity37.6%21%  44.1% Median Length of Stay (day) 75  28.6% General Surgery Elective Colorectal Surgery NSQIP Non Risk Adjusted Data

16 Lessons Learned The Power of Real Time Auditing It Takes Time to Change Culture Communication is Vital Value of Patient Partnerships

17 Sustainment Plan Transition of auditing back to unit champions Revise documents (PPO, Pathway, etc.) Full implementation of the Patient Checklist Continue ongoing education of staff Continue to engage patients and family Continue to audit 100% of ERAS patients Disseminate audit results to Steering Committee and stakeholders monthly Celebrate the team’s accomplishments

18 Acknowledgments VGH Perioperative Teams VCH NSQIP Team ERAS Patients and Families ERAS Steering Committee

19 Contact Information Andrea Bisaillon, RN BscN Operations Director - Surgical Services Tracey Hong, RN BscN Quality and Patient Safety Coordinator

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