Enhanced Recovery (ERAS)

SUSP Surgeon call

February 26, 2014

DRAFT – final pending AHRQ approval

What is ERAS?
First proposed by Dr. Henrik Kehlet, British Anesthesiologist
– Multimodal approach to control postoperative pathophysiology
and rehabilitation. Br. J. Anaesth. 1997;78:606-617.
“The hypothesis that a combination of unimodal evidence based
care interventions to enhance recovery will subsequently
decrease need for hospitalization, convalescence and morbidity.”
Kehlet H. Langenbecks Arch Surg (2011) 396:585–559
Supported by large body of evidence in virtually every field from
vascular to bariatrics to Whipple to colorectal

DRAFT – final pending AHRQ approval

Supporting DATA
Dis Colon Rectum 2013 – Meta-analysis of 13 studies
demonstrating significantly decreased LOS, complication rate,
similar readmit and mortality
– Typically all studies demonstrate a 50 – 60% reduction in LOS
Duke experience (abstract ASA 2011)
– Before/after design demonstrated significant reduction in LOS,
surgical site infection, urinary tract infection, hypotension
requiring treatment
Mayo experience (Lovely J, et al. Br J Surg. 2011;99:120-126.)
– Before/after design demonstrated 44% of patients discharged
on POD 2, opiod requirements less without increased pain
scores, complication rate similar, hospital costs were reduced
by an average of $1,039/pt

DRAFT – final pending AHRQ approval

Goal of ERAS
Implement a standardized, patient centered protocol

Integrate the pre-operative, intra-operative, post-operative and post-

discharges phases of care to reduce LOS

Improve patient experience and satisfaction and decrease

variability

DRAFT – final pending AHRQ approval

Basic Principles of ERAS
Enhanced Recovery is a multidisciplinary and collaborative approach
focusing on:

-Patient education and participation

-Optimization of perioperative nutrition

-Standardization of perioperative anesthetic plan to minimize

narcotics, intravenous fluids and post operative nausea and vomiting

-Stress relief

-Early mobilization and oral intake

DRAFT – final pending AHRQ approval

Main shifts in mentality
Pain management

– Goal is to diminish narcotic intake

Fluid management

– Goal is to avoid volume overload – bowel edema

Activity

– Goal is to induce early mobility and get the bowels moving!

DRAFT – final pending AHRQ approval

Develop Clinical Specifics and Standardization of care
Clinic

Prep

Inpatient and ICU unit

PACU (pain control and mobilization)

Post-op pain control plan

DRAFT – final pending AHRQ approval

DRAFT – final pending AHRQ approval
Financial Analysis

DRAFT – final pending AHRQ approval

Example of ERAS Pathway at Johns Hopkins Hospital

• Carbohydrate drink 2
hrs before surgery
• Celebrex, neurontin,
tylenol, scopolamine
• Identify ERAS patch pre-op
patients Anesthesia • Standard SSI and DVT Post-
• Bowel prep and clinic prevention operative
CHG • Epidural placed by
washclothes appointment APS
administered • Standard post-
• Introduce epidural • Heplock placed operative ordersets
• Targeted pre- • Standard Intra-op TIVA
operative
anesthesia option • All patients (with and
• Instruction about by dedicated team of without epidurals)
multimodal anesthesia providers
(electronic, in day of surgery followed by APS with
person and • Goal directed IV standard practice
paper) education hydration to minimize and maximal non-
to set fluid overload narcotic pain
expectations and • Early mobilization in regimen
engage patient in recovery room • Coordinated DC
their care planning by case
Prep Area manager
Preoperative • PAL line f/u calls
Operating Room
Clinic Recovery Room

DRAFT – final pending AHRQ approval

DRAFT – final pending AHRQ approval
ERAS Evaluation
Audit of processes (pain regimen, fluid in OR and post-op,
education, mobility, diet etc.)
Length of Stay
Pain scores post-operative
HCAPS
30 day Morbidity
Readmission

 Monthly reports and feedback to optimize implementation

DRAFT – final pending AHRQ approval

Our Model
Translating Evidence Comprehensive Unit
Reducing Surgical Site
Into Practice based Safety Program
Infections
(TRiP) (CUSP)
1. Summarize the evidence
in a checklist • Emerging Evidence 1. Educate staff on
science of safety
2. Identify local barriers to • Local Opportunities to
implementation Improve 2. Identify defects

3. Measure performance 3. Assign executive to

• Collaborative learning
adopt unit
4. Ensure all patients get
the evidence 4. Learn from one
• Engage
defect per quarter
• Educate
• Execute
• Evaluate 5. Implement
teamwork tools

Technical Work Adaptive Work

DRAFT – final pending AHRQ approval

Discussion

DRAFT – final pending AHRQ approval