Beverly Morningstar MD, FRCP(C) Elaine Avila RN, BScN

Transcription

1 Beverly Morningstar MD, FRCP(C) Elaine Avila RN, BScN

2 Outline The University of Toronto ERAS guideline introduction to ERAS how we created the guideline specific elements of guideline with evidence Implementation of guideline at Sunnybrook ieras study Success to date

3 What is ERAS? Have you heard of ERAS? Do you already have an enhanced recovery program in your hospital?

4 What is ERAS? Multimodal program developed to decrease postoperative complications speed recovery promote early discharge Accomplish by adopting best practices to prepare patients preoperatively decrease perioperative stress, postop pain, GI dysfunction, infection promote early mobilization

5 Where it all began

6 What keeps patients in hospital after surgery? Key factors: parenteral analgesia (PAIN, VOMITING) IV fluids (GI dysfunction: ILEUS, NAUSEA/VOMITING) weakness (LACK OF MOBILITY, PAIN)

7 Basic ERAS principles Optimize health (anemia, smoking) Patient education, discharge planning Preop: carbohydrate loading and hydration Intraop: MIS, fluid optimization, TEA Postop: avoidance of opioids and N/V, early mobilization and feeding Discharge: when goals are met

8 How did we get here? 1.Establish baseline practice of ERAS components in Toronto 2.Identify essential components 3.Identify barriers to implementation 4.Develop a guideline based on best evidence and consensus

9 1. Baseline practice at 7 U of T hospitals patients having elective colorectal procedures colon (71.4%) rectal (28.6%) laparoscopic 46.3%, open 43.6%, converted 10.2% mean hospital stay: 8 days; median hospital stay 6 days

10 1. Baseline practice at 7 U of T hospitals 2009

11 Why didn t we follow best evidence? Unaware of guidelines/literature Evidence not convincing Not culturally appropriate Too expensive Lack of buy-in from multidisciplinary team

12

13 2. Essential components: Evidence from the literature

14 Evidence for ERAS programs Meta-analysis of 6 RCTs evaluating colorectal ERAS programs (n 452): decreased LOS by 2.5 days 50% decrease in 30 day morbidity for every 4.5 patients in the ERAS groups, 1 complication was avoided no increase in readmission rate Eskicioglu 2010, Adamina 2011

15 3. Understanding barriers and enablers Interviewed surgeons, anesthesiologists, RNs Main themes: 1. interprofessional collaboration, communication, change in culture 2. evidence-based recommendations, protocols, standardized orders 3. patient and family involvement along the whole hospital experience

16 4. Guideline based on best evidence and consensus 2010: individual interventions reviewed by multidisciplinary working group from 7 hospitals surgery, anesthesia, nursing (floor, APS, etc.), nutrition, physiotherapy : guideline developed, distributed to stakeholders for review Feb 2012: guideline finalized at workshop anesthesia, surgery and nursing from McGill hospital champions, local meetings

17 Guideline Recommendations Preoperative Intervention Patient education Reduced fasting duration Intraoperative Interventions Avoidance of drains and nasogastric tubes Perioperative Fluid Management Intraoperative Postoperative Perioperative Pain Management Thoracic epidural analgesia IV lidocaine acetaminophen, gabapentin Postoperative Interventions Early mobilization Early enteral feeding Chewing gum Early removal (and avoidance) of urinary catheters

18 Who s eligible for ERAS? Abdominal perineal resection Low anterior resection Subtotal colectomy Pelvic pouch Ileocolic resection Sigmoid resection Reversal of Hartmann Right hemicolectomy Left hemicolectomy Any segmental resection of the colon Closure of ileostomy Exception: Multivisceral resection

19 Preoperative counselling: Surgeon s office standard colorectal educational booklet given at time of consent Bring to PAC and hospital admission surgeon should discuss expected length of stay (3 d colon, 4 d rectal) smoking cessation oral iron

20 Preoperative counselling: Preassessment Clinic Fasting guidelines and carbohydrate loading pain management options by anesthesiologist/nurse in PAC Expectations re: Early ambulation Postop diet Gum chewing Removal of urinary catheter

21 Preoperative fasting: Recommendations solid foods until midnight clear liquids 2 hours preop encouraged to drink apple juice or other carbohydrateenriched drink night before surgery and again 2 hours preop

22 Safety of shortened fast regurgitation and aspiration requires gastric volume of >200 ml gastric volume 1-2 hr after clear fluids: ml Ljungqvist O et al. Br J Surg 2003;90:400

23 Preoperative fasting: Rationale Recommended fast for solids: 6-8 hr Actual fast: hr Prolonged fast triggers gluconeogenesis, insulin resistance; dehydration Correlation between postop insulin resistance and length of hospital stay Patients should come to surgery in a metabolically fed state (not starving, ketotic) Nascimento J et al. World J Gastrointest Surg 2010;2:57-60

24 Preoperative carbohydrate loading Drinking preop carbohydrates may lead to reduced insulin resistance and stress response to surgery improved patient comfort decreased thirst, hunger, anxiety decreased postop nausea and vomiting, earlier return of bowel function shortened length of stay Nascimento J et al. World J Gastrointest Surg 2010;2:57-60

25 Safety of carbohydrate drink 2 hr preop

26 Intraop interventions: Avoiding NG tubes 37 RCTs (5711 pts) comparing NG tube vs. no NG tube/early removal showed earlier time to flatus (p< ) fewer pulmonary complications significantly shortened len length of stay Nelson NR et al. Cochrane Database Syst Rev 2010;3:CD004929

27 Intraop interventions: Avoiding drains Prophylactic abdominal drains should be avoided May be used following APR (based on consensus only) Evidence: 2 meta-analyses of 6 RCTs (1140 pts) comparing drains to no drains found no difference in mortality or anastomotic leak rate

28 Intraoperative Fluid Management: Recommendations low volume maintenance crystalloid using a balanced salt solution (Ringer s Lactate or Plasmalyte ) at 1-2 ml/kg/hr goal-directed fluid replacement using noninvasive cardiac output monitoring devices

29 Evidence for fluid minimization Brandstrup B et al. Annals of Surgery 2003;238:641-8

30 Crystalloid minimization Discuss during surgical briefing Accept a low urine output both intraop and postop ( permissive oliguria ) 1/3 ml/kg/hr averaged over 8 hr Education: anesthesiologists, surgeons, PACU and ward nurses, residents and students

31 Too little, too much, or just right?

32 Evidence for goal directed fluid management GDT T

33 Evidence for goal directed fluid management

34 Technology for goal directed fluid management Low risk patients: Masimo PVI (Pleth Variability Index) uses finger probe High risk patients: FloTrac requires art line

35 Postoperative fluid management: Recommendations get rid of IV ASAP (saline lock in PACU) if IV fluid necessary, not more than 75 ml/hr of 2/3-1/3 with meq potassium/day, or balanced salt solution the use of saline is to be discouraged volume status should be assessed before fluid boluses are given. Do not give boluses based on low urine output or low blood pressure alone

36 Pain management guidelines preoperative acetaminophen 1 gm and gabapentin 300 mg po thoracic epidural analgesia (TEA) for all open colorectal surgery pts for hr postop Consider TEA for laparoscopic cases in special cases (high risk of pulmonary complications, opioid tolerance) IV PCA/oral sustained-release opioids plus multimodal analgesia post laparoscopic sx

37 Early mobilization: Recommendations

38 Early mobilization: Recommendations patients should be dangled for 15 min POD#0 at 2200 hr all meals sitting in a chair ambulation q 4-6 hrs during the day goal: >400 m POD#1, >600 m POD#2 no IV, O 2 NP, TV in room!

39 Early feeding: Recommendations clear fluids 2 hours postop if awake, alert and capable of swallowing, Ensure Plus in evening full diet beginning POD 1 13 RCTs (1173 pts): early diet vs. NPO until flatus Decreased wound infection (RR=0.77), deep space infection (RR=0.87), anastomotic dehiscence (RR=0.69), pneumonia (RR=0.76) mortality (RR=0.41) risk of vomiting slightly increased (RR=1.27) Anderson HK, Cochrane Database Syst Rev 2006: CD004080

40 Early feeding: Implementation strategies colorectal diet fluids, comfort food, puddings patient controlled diet encourage patients, families to bring food from home

41 Gum chewing: Recommendations chew one stick of gum 5 min at least tid starting on POD#1 bring 2 packages of gum to hospital meta-analysis demonstrates: reduction of ½ day to first flatus reduction of 1 day to first BM trend to reduced length of stay Fitzgerald JE et al World J Surg 2009;33:

42 Early removal of urinary catheters: Recommendations Remove catheter within 24 hours of surgery (am POD#1) Exception: low colorectal or coloanal anastomosis, remove within 72 hrs with or without an epidural catheter The above recommendations do not apply if a catheter is needed for monitoring purposes

43 Early removal of urinary catheters: Evidence Colorectal pelvic surgery: no difference in urinary retention POD 1 vs. 5 Rectal resections: d urinary retention POD 1 vs. 5 (31% vs. 10%) BUT d UTI rates POD 1 vs. POD 5 (20% vs. 42%) Zmora Dis Colon Rectum 2010; Benoist, Surgery 1999; Zaouter, Reg Anesth Pain Med 2009

44 What about urinary catheters with epidurals? In patients with epidural in situ: comparison of catheter in for duration of epidural 3-5 days vs. < 24 hours higher incidence of UTI (p=0.0004) prolonged hospital stay early removal not associated with significantly higher rates of recatheterization (about 10%) Zmora Dis Colon Rectum 2010; Benoist, Surgery 1999; Zaouter, Reg Anesth Pain Med 2009

45 Protocol compliance and length of stay J Maessen et al. Br J Surg 2007;94:

46 Adherence to pathway and outcomes 20 elements in pathway 2 most significant factors in improved outcome: carbohydrate drink preop decreased risk of delayed discharge by 44% perioperative fluid management each additional 1L IV fluid increased risk of complications by 32% Gustafsson UO et al. Arch Surg 2011;146:

47 Adherence to pathway and outcomes Gustafsson UO et al. Arch Surg 2011;146:

48 Don t be discouraged! Introduction of fast track program vs traditional care n=107 Poor compliance in fast track group: average of 7.4 of 13 FT modalities per patient achieved Decreased LOS 2.5 days Polle SW et al. Dig Surg 2007;24:

49 Further reading Clinical Nutrition 2012;31:

50 Further resources

51 Sunnybrook Health Sciences Centre: ERAS Implementation Strategy

52 Sunnybrook Health Sciences Centre Odette Cancer Centre Sunnybrook Health Sciences Centre (Main Building)

53 Patient journey Odette Odette Odette PAC (GI Nurse) (Surgeon) (Admin) (Anesthesiologist) Same Day Surgery (Anesthesiologist) Same Day Surgery (RN) PAC (Admin) PAC (RN/Pharm) Same Day Surgery (Admin) OR PACU D4ICU & C6

54 Leadership support BPIGS Network CEO and President VP, Chief Nursing Executive Quality and Patient Safety Operations Director Chief, Odette Cancer Centre & Regional Vice President, Cancer Care Ontario Departmental Heads & Chiefs

55 Stakeholders engagement Team Engagement (pizza lunches) GI clinic Pre Assessment Clinic Same Day Surgery PACU C6 Unit D4ICU Residents Surgeons Anesthesiologist Administrative assistants Patient Care Managers Inter-professional team members Diversity & Inclusion

56 Stakeholders engagement General Surgery QI Committee Review, monitor, evaluate and make recommendations to improve outcomes in general surgery Best practices: normothermia, pre-warming, surgical site infection

57 Working groups Pre-op Pre-op process Patient education Patient identification process Pre-op preprinted orders Post-op Post-op process Post-op pre-printed orders Discharge

58 Education

59 Education

60 Tools & Enablers #1 Admin. Assistant s Office: The Pre-op Package ERAS Education guideline for nurses ERAS sticker / patient identifier ERAS letter ieras study consent Pre-op and Post-op orders ERAS booklet

61 Tools & Enablers

62

63 ERAS (Enhanced Recovery After Surgery for Colorectal patients) Education Guide For Nurses OCC GI Clinic Visit Pre-Admission Clinic Same Day Surgery C6 Unit Bring the booklet Bring gum Mobility: Patient to dangle on the side of bed day/night of surgery Complete activity log Bring the booklet Bring gum Mobility: Patient to dangle on the side of the bed day/night of surgery Complete activity log before discharge home NPO/High carbohydrate drinks Bowel prep review Completes pre-op checklist Confirms NPO status, bowel prep completed ERAS Booklet and patients belongings with family member Confirms gum has been purchased and brought to hospital Bring the booklet Bring gum & chew gum Mobility: Patient to dangle on the side of the bed day/night of surgery Complete activity log &questionnaire before d/c home

64 Tools & Enablers (cont.)

65 Tools & Enablers (cont.) Colorectal Diet Combination of fluid and comfort items like juice soup, hot entrees and pudding (vs. sandwiches) New Perianesthesia Pathway Orientation Leadership Accountability / Reporting Data Senior Friendly Strategy

66 As a team, we help patients prepare for and recover from surgery the ERAS way!

67 Awareness campaign Surgical Grand Rounds Sep. 21, 2012 Implementing Enhanced Recovery After Surgery: 17 hospitals, 3000 staff, reduced complications - priceless! :, Avery B. Nathens MD

68 Generate wins (Sep-Dec) Total # ERAS Patients 42 Total # ERAS patients who received ERAS booklet Total # of ERAS patients who completed the questionnaire Total # of ERAS patients bed spaced in another unit Utilization of preprinted orders (Nov-Dec) = 100% Patient are getting the booklet Dangling patients POD0 Patients are bringing / chewing their gum Patients are getting clear fluids POD0 Patients are ambulating POD1 Foley discontinued POD1 (for colon)

69 Site visits Health Sciences North (Sudbury) May 2013 The Ottawa Hospital June 2013 London Health Sciences Centre August 2013

70 Site visits

71 Length of stay ERAS Implementation: Median LOS 10 9 No. of Patient Days Previous LOS Median LOS 0 Sep Oct Nov Dec Jan Feb Mar Sep 2012-Mar 2013

72 Evaluation: ieras Study Adopting Research to Improve Care (ARTIC) Program Successful adoption of innovation into the practice Build partnership and share best practices to improve care and drive quality improvement ERAS received CAHO Funding October 2012 awarded 1.5 million dollars to implement ERAS at 15 hospitals across the province Hiring of ERAS Site Coordinator

73 Evaluation: ieras Study ieras study: (1) level of compliance with each individual intervention or recommendation (2) complication rate (3) length of stay (4) readmission rate Data reporting - Quarterly Implement changes in response to audit results in real time, and share best practices.

74 Data collection (1) Enhanced Recovery After Surgery Data Form Pre-op information Pre-op questionnaire Intra-op: Operative Information Intra-op: Medication Information Intra-op: Anesthesia information POD 0 POD 1-14 (2) 30-Day Follow-up Total# Patients consented: 50

75 Sunnybrook celebrates 1 year of ERAS!!! GI clinic nurses Pre Assessment Clinic nurses Same Day Surgery nurses PACU nurses C6 Unit nurses Residents Surgeons Anesthesiologists Administrative assistants Patient Care Managers Inter-professional team members Surgeon-in-Chief Operations Director

76 ERAS: Through the eyes of a patient Thank you to all the SHSC professionals that were involved in my diagnosis surgery and postoperative care. I appreciate all your kind and caring efforts on my behalf. You were awesome and I appreciate it! This guide help me so much for my fast recovery. The detailed information about the program is very easy to follow and easy to understand. With the help of Dr. Ross and his staff and the nursing team I would like to extend my sincerest thanks for the excellent care provided to me.

77 ERAS: Through the eyes of nurses Patients understand what to do. They are reading it. There s heightened awareness and education knowing that it s part of their recovery. It s empowering because they re part of their care. Patients seem to like it, they know what to expect. It s helpful to family members it allows them to be involved in the care, to support and reinforce the expectations.

78 ERAS for colorectal patients 15 hospitals 3000 staff engaged 2100 patients per year 4200 patient days saved Reduced morbidity Priceless!

79 Leadership support Keys to successful ERAS implementation Dynamic and enthusiastic working team Share common goal Education & training Regular communication and engagement Patience & persistence Audit Building a Community of Practice Transforming care Building Partnerships

80 ERAS IQ Test The goal of the ERAS Program is: a. Decrease postoperative complications, postoperative pain, and gut dysfunction b. Discharge patients as soon as possible c. Improve patient preoperative and postoperative experience Decrease post-operative complications, postoperative pain, and gut dysfunction

81 ERAS IQ Test Patients should do this at the side of their bed for minutes starting the day of surgery. a. Dangle b. Move c. Stand Dangle

82 ERAS IQ Test Patients should be encouraged to start this on post-op Day 1, for 5-10 minutes at least 3 times a day. a. Deep breathing and coughing b. Chewing gum c. Ambulate Chew one stick of gum

83 Thank You!