1. Enhanced Recovery after Surgery (ERAS): A new era of patient care
Heather Hohenberger, MSN, RN, CIC, CNOR, CPHQ, FAPIC
11/20/2017

2. Conflicts of Interest
The presenter has no conflicts of interest to disclose
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3. Objectives
Upon completion of this session participants will be able to
Share with healthcare teams the preoperative, intraoperative, and postoperative ERAS elements
Verbalize the stakeholders / key roles needed to create a team for ERAS implementation
State patient outcome measures, including the specific hospital reimbursement programs, potentially improved by consistent compliance with the ERAS elements
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4. What is Enhanced Recovery after Surgery (ERAS)?
Evidence based, clinical best practices for surgical patient care acknowledged by multiple healthcare professional organizations & associations packaged as an implementation bundle
Promotion of enhanced recovery protocols driven by
Transition from acute care model of healthcare delivery to population health model
Healthcare reimbursement
Standardization of care
Transition from acute care to population health – shift from clearance to optimization
Healthcare reimbursement – insurers
Standardization of care – evaluating processes
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5. Colorectal Enhanced Recovery
(ERAS Society, 2014)
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6. Enhanced Recovery Phases / Elements
Preoperative
Patient education
Patient optimization
Carb loading & elimination of NPO
Intraoperative
Nausea / vomiting prophylaxis
Opioid sparing, multi modal analgesia
Intentional fluid use
Postoperative
Early food & exercise
Multi modal analgesia
Judicious IV fluid use
Defined discharge criteria
Patient teaching through progress audits
(Marosky Thacker, 2016)
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7. Patient Centered Goals
Elements Principles
Patient education, specialty teaching
Carbohydrate loading & elimination of NPO
Multimodal analgesia
Goal directed IV fluid therapy
Perioperative nausea / vomiting prophylaxis
Patient progress audits
Patient engagement
Euglycemic
Sleeping, comfort, increasing mobility
Euvolemic
Eating / drinking, GI motility
Patient satisfaction
Evaluate your patient! Always wonder: Are the things we do or don’t do for this patient the right thing for this patient at this time?
Consider each point of care from diagnosis to recovery
Implement the evidence for best patient outcomes
(Marosky Thacker, 2016)
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8. Program Planning Steps
Define the population
Identify the existing care processes / surgical care pathways / order sets
Create process maps with the multi-disciplinary team
Current state and future state
Design or update the surgical care pathways / order sets
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9. Define the Population / Create the Team
Anesthesia
Nursing
Pharmacy
Advanced Practice Providers
Quality / Process Improvement
Physical Therapy
Dietitians
Educators
Colorectal Surgery
Head & Neck Surgery
Breast Surgery
Liver Surgery
Gynecologic Surgery
Neuro Surgery
Ortho Surgery
Urology Surgery
Thoracic Surgery
Spine Surgery
(Gottumukkala, 2016)
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10. Workgroups and Structure: Example 1
Enhanced Recovery Steering Team
Preoperative workgroup
Implementing carb loading & elimination of NPO
Patient education
Intraoperative workgroup
Goal Directed Fluid Therapy
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11. Workgroups and Structure: Example 2
Facility leadership
Representatives from the multidisciplinary team
Quality
Statisticians
Advanced Practice Providers
Clinical Informatics
Physical Therapy
Nursing staff
Educators
Dietitians
Education
Order Sets
Implement-ation
Outcomes / Research
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12. Successful Implementation Strategies
The program should be vetted by a key group of influential, culturally skillful early adopters
Identify operational leaders who are passionate and committed
Executive leadership support of the project team & the project plan
Consistent communication of project goals and progress
Regular, open performance feedback of compliance with the program plan
How can you link incentives to participation with the project plan?
Executive leadership support is most crucial in the initiating period.
Performance feedback should be respectfully shared in a predetermined manner. Use crucial conversation skills and keep the team’s eyes on the goal. Rewards and accountability should be given as it is earned.
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13. Evaluating Compliance with the Elements
Evaluate your facility EMR for ability to audit documentation & patient compliance with elements
Explain which elements of patient care (process measures) relate to specific principles of enhanced recovery (outcome measures)
Create a tool for visual data management
Refresh data at routine intervals and share the groups progress
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14. Patient Outcome Measures
Decreasing length of stay
Decreasing readmissions
CMS Medicare Acute Inpatient PPS Readmissions Reduction Program (HRRP)
Decreasing surgical site infections
CMS Medicare Acute Inpatient PPS Hospital-Acquired Condition Reduction Program (HACRP)
CMS Hospital Value-Based Purchasing
Decreasing surgical complications
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15. How Does Enhanced Recovery Impact Population Health?
(WebMD, 2016)
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16. Summary Enhanced recovery is Patient centered Collaborative
Expansive by principles of patient management, rather than element specific
Uniquely implemented for each healthcare system and the population served
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17. Resources for Healthcare Professionals
ERAS® Society
American Society for Enhanced Recovery
Do not search using the phrase ERAS – this stands for Electronic Residency Application System
There are numerous peer reviewed published articles on enhanced recovery.
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18. References
Brady, K.M., & Delaney, C.P. (2015). Successful Implementation of an Enhanced Recovery Pathway: The nurse’s role. AORN Journal, 102(5),
Calhoun, J.D. (2016, April). ERAS Implementation and the Coordinator’s Role. The 2016 Annual Congress of Enhanced Recovery and Perioperative Medicine. Symposium presented at the meeting of American Society for Enhanced Recovery, Washington, D.C.
ERAS Society. (2014). [on-line]. Retrieved from
Gottumukkala, V. (2016, April). Setting up an Enhanced Recovery Program Elements, Buy-in, Hurdles, and Conflict Resolution. The 2016 Annual Congress of Enhanced Recovery and Perioperative Medicine. Symposium presented at the meeting of American Society for Enhanced Recovery, Washington, D.C.
Marosky Thacker, J. (2016, April). Enhanced recovery principles and practice. The 2016 Annual Congress of Enhanced Recovery and Perioperative Medicine. Symposium presented at the meeting of American Society for Enhanced Recovery, Washington, D.C.
WebMD. (2016). Tips to Get Ready for Surgery [on-line]. Retrieved from
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19. Contact Information
Heather Hohenberger, MSN, RN, CIC, CNOR, CPHQ, FAPIC
Quality Improvement Consultant, System Perioperative Services
Indiana University Health
(317) – office
11/20/2017