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1 Does Enhanced Recovery Improve Outcomes? Click to edit Master subtitle style Kaare Weber, MD Director of Surgery Associate Medical Director, Surgery A MEMBER OF THE MONTEFIORE HEALTH SYSTEM

2 mes? Click to edit Master subtitle style Kaare Weber, MD No Director Disclosures of Surgery Associate Medical Director, Surgery A MEMBER OF THE MONTEFIORE HEALTH SYSTEM

3 Enhanced Recovery After Surgery (ERAS) ERAS multimodal approach to perioperative care designed to reduce surgical stress, organ dysfunction, and postoperative complications ERAS focuses on standardization of preoperative, intraoperative and postoperative care pathways to include all team members including the patient Europe created the International ERAS Society 2010 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) endorses ERAS programs In 2017, Improving Surgical Care and Recovery (ISCR) program created by ACS and Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality and funded by the Agency for Healthcare Research and Quality (AHRQ) o Goal aid hospitals across the country to adopt ERAS pathways 3

4 4 ERAS Studies: Europe

5 5 ERAS Studies: US Experience

6 6 ERAS Studies: Community & Lay Press

7 Benefits of Enhanced Recovery Program Improved Patient Satisfaction Improved Pain Management Reduced LOS Reduced Hospital Acquired Pneumonia Reduced Surgical Site Infections Improved Patient Outcomes Reduced Readmission Rates Reduced VTE Reduced UTI Reduced Blood Transfusions 7

8 Multidisciplinary Team House Staff Care Management Nutrition Pharmacy Respiratory Wound Care Surgeon Patient Nurse Anesthesia Physician Assistant Office Staff Physical Therapy Informatics Team Infection Control Medical Subspecialties 8

9 Standardized Programs for Each Phase of Care Patient Multimodal EducationPain Limit fasting Neurontin PO x1 Carb Beverage dose Incentive Spirometer Standardized Bowel Prep Nasal Swab Oral Care CHG Bath x3 Glucose Control Multimodal Pain Plan Pre-op Intra-op Clear Multimodal Liquids POD Pain #0 Hep-lock IV Ofirmev after x24 PO Multimodal Pain tolerated Chloraprep Skin Prep hours then PO IV Ofirmev Foley Removal Appropriate Antibiotics Tylenol IV Toradol if not Early aggressive Normothermia ambulation Toradol if not VTE contraindicated Prophylaxis Fluid Optimization Antiemetic contraindicated Exparel Field Block Prophylaxis Antiemetic Infiltration Prophylaxis Glucose Neurontin Control Glucose Control Multimodal Narcotics Pain for Plan IV Ketamine Multimodal Pain Plan breakthrough Wound Limit protector narcotics Bowel IV Lidocaine Isolation Tech. (soon) Post-op 9

10 ERAS WPH Outcomes First 12 months Intestinal Surgery Indicator Pre-ERAS Post-ERAS Source Pain Management 45%ile 99%ile HCAHPS Length of Stay Meditech Surgical Site Infections 1.30 SIR 0.78 SIR NHSN VTE Events 26% 23% Midas Pneumonia 6.29 (8) 4.07 (4) NSQIP Renal Failure 2.06 (5) 1.3 (0) NSQIP Urinary Tract Infection 2.05 (4) 1.73 (0) NSQIP Morbidity (19) (11) NSQIP Mortality 3.33 (4) 2.83 (2) NSQIP Return to OR 4.9 (5) 5.23 (6) NSQIP Readmissions 9.96 (7) (7) NSQIP HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems NHSN National Healthcare Safety Network NSQIP National Surgical Quality Improvement Program (Smoothed Rate) 2015 vs YTD Sept 10

11 Colorectal Patient Satisfaction Scores - Pain 100 Pain Satisfaction Scores Pre & Post ERAS MPP Implementation ERAS Implemented November 2015 Percentile Ranking (May YTD) Pain Management Overall Pain Well Controlled Staff do Everything to Help with Pain Linear (Pain Management Overall) 11

12 Elective Colorectal Surgery Average Length of Stay ERAS Implemented November Count of UnitNumber Average of LengthOfStay 12

13 Colorectal SSI White Plains Hospital Colorectal Standardized Infection Ratio (SIR) ERAS Implemented November (Sept YTD) 13

14 Colorectal VTE 30% 25% 6/23 White Plains Hospital % Colorectal VTE from all Periop VTEs ERAS Implemented November /13 20% 2/11 15% 10% 5% 0% (Nov YTD) 14

15 NSQIP Colorectal Pneumonia ERAS Implemented November

16 NSQIP Colorectal UTI ERAS Implemented November

17 NSQIP Colorectal Morbidity ERAS Implemented November

18 NSQIP Colorectal Mortality ERAS Implemented November

19 NSQIP Colorectal Return to OR ERAS Implemented November

20 NSQIP Colorectal Readmissions ERAS Implemented November

21 ERAS Summary ERAS is becoming a standard protocol for surgery patients Evidence demonstrates improved outcomes without ability to pinpoint most important components Many believe multimodal pain plan is key to the success of an ERAS protocol Requires cultural change, persistence and patience 21

22 Thank you! A MEMBER OF THE MONTEFIORE HEALTH SYSTEM 22 22