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 postdischarges 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
• Identify ERAS
patients
• Bowel prep and
CHG
washclothes
administered
• Targeted preoperative
multimodal
(electronic, in
person and
paper) education
to set
expectations and
engage patient in
their care
Preoperative
Clinic
Anesthesia
clinic
appointment
• Introduce epidural
anesthesia option
• Instruction about
day of surgery
• Carbohydrate drink 2
hrs before surgery
• Celebrex, neurontin,
tylenol, scopolamine
patch pre-op
• Standard SSI and DVT
prevention
• Epidural placed by
APS
• Heplock placed
• Standard Intra-op TIVA
by dedicated team of
anesthesia providers
• Goal directed IV
hydration to minimize
fluid overload
• Early mobilization in
recovery room
Prep Area
Operating Room
Recovery Room
Postoperative
• Standard postoperative ordersets
• All patients (with and
without epidurals)
followed by APS with
standard practice
and maximal nonnarcotic pain
regimen
• Coordinated DC
planning by case
manager
• PAL line f/u calls
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
Into Practice
(TRiP)
1.
Summarize the evidence
in a checklist
Reducing Surgical Site
Infections
Comprehensive Unit
based Safety Program
(CUSP)
•
Emerging Evidence
1.
Identify local barriers to
implementation
Educate staff on
science of safety
•
Local Opportunities to
Improve
2.
Identify defects
3.
Measure performance
•
Collaborative learning
3.
4.
Ensure all patients get
the evidence
• Engage
• Educate
• Execute
• Evaluate
Assign executive to
adopt unit
4.
Learn from one
defect per quarter
5.
Implement
teamwork tools
2.
Technical Work
Adaptive Work
DRAFT – final pending AHRQ approval
Discussion
DRAFT – final pending AHRQ approval