Enhanced Recovery After Surgery (ERAS) for Elective Colon Resection Surgery at Vancouver General Hospital. Quality Forum 2014

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1 Enhanced Recovery After Surgery (ERAS) for Elective Colon Resection Surgery at Vancouver General Hospital Quality Forum 2014

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) demonstrate that patients at Vancouver General Hospital undergoing colorectal surgery have a high odds ratio of postoperative morbidity ( ). 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 Active Patient Involvement Pre-operative Intra-operative Post-operative Pre-admission education Active warming Early oral nutrition Early discharge planning Opioid-sparing technique Early ambulation Reduced fasting duration Surgical techniques Early catheter removal Carbohydrate loading No/selective bowel prep Venous thromboembolism prophylaxis Antibiotic prophylaxis Avoidance of prophylactic NG tubes & drains Use of chewing gum Defined discharge criteria Goal directed peri-operative fluid management Pain & nausea management Pre-warming Audit of compliance & outcomes Whole Team Involvement

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

8 Implementation February-October 2013 June 2013-Ongoing Phase 1 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 Implemented intra-operative components by a core group of anesthesiologists Audited compliance with intra-operative components Measured patient outcomes in postanesthesia care unit (PACU) November 2013-Ongoing Phase 2 Implemented pre-operative and post-operative components Audited compliance with all ERAS components Measured patient outcomes within 30 days after surgery

9 Progress so far.. June-December 2013 Audited103 cases for intra-operative components Compliance %: Normothermia Prophylaxis antibiotics within 60min of skin cut Appropriate prophylaxis anti-emetics Areas of opportunity: Goal directed fluid management Antibiotics re-dosing

10 Progress so far.. November-December 2013 Audited 31 cases for all components Compliance %: Pre-admission education Use of chewing gum Areas of opportunity: Use of ERAS order set Early mobilization Appropriate use of anti-emetics Appropriate removal of urinary catheter

11 Mean Length of Stay* in Post Anesthesia Care Unit (PACU) *Times patient enters PACU to times when PACU discharge criteria is met

12 Complications in Post Anesthesia Care Unit

13 Mean Hospital Length of Stay (days) October November December

14 Lessons Learned Process mapping Team building Communication Culture of quality and patient safety

15 Sustainment Plan 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

16 Acknowledgments VGH Perioperative Teams VCH NSQIP Team ERAS Steering Committee Numerous Patients and Families Stephen Parker: Clinical Nurse Specialist, PHC Deborah Bachand: Projects Manager, Surgical Services, VIHA

17 Contact Information Andrea Bisaillon, RN BscN Operations Director - Surgical Services andrea.bisaillon@vch.ca Tracey Hong, RN BscN Quality and Patient Safety Coordinator tracey.hong@vch.ca

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