Creating an Early Recovery Order Set for Colorectal Surgery-It s the Journey as well as the Destination

Transcription

1 Creating an Early Recovery Order Set for Colorectal Surgery-It s the Journey as well as the Destination Jason D. Sciarretta, MD, FACS Grand Strand Medical Center, Myrtle Beach, SC University of South Carolina

2 Disclosures I have no financial disclosures The ACS-NSQIP and the hospitals participating in the ACS-NSQIP are the source of the data used herein: they have not verified and are not responsible for the statistical validity of the data analysis of the conclusions derived by the authors

3 Background ASCRS/SAGES committee: define current best-quality care ERP: Enhanced Recovery Protocol ERAS: enhanced recovery after surgery elective surgery. set of standardized perioperative procedures & practices Not intended for emergency surgery Goal: improve patient outcomes Bardram L, et al. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Lancet. 1995;345:

4 Background Contemporary colorectal surgery: open operations Longer length of stay: ~ 8 days vs 2-5 days laparoscopic 2 Higher cost 2 Higher rates of SSI: 20% 3 Perioperative nausea vomiting >80% 4 Readmission rates >35% Delay bowel function 1 1. Kang CY, Chaudhry OO, Halabi WJ, et al. Outcomes of laparoscopic colorectal surgery: data from the Nationwide Inpatient Sample Am J Surg. 2012;204: Thiele RH, Rea KM, Turrentine FE, et al. Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. J Am Coll Surg. 2015;220: Eberhart LH, Mauch M, Morin AM, Wulf H, Geldner G. Impact of a multimodal anti-emetic prophylaxis on patient satisfaction in high-risk patients for postoperative nausea and vomiting. Anaesthesia. 2002;57: Nagle D, Pare T, Keenan E, Marcet K, Tizio S, Poylin V. Ileostomy pathway virtually eliminates readmissions for dehydration in new ostomates. Dis Colon Rectum. 2012;55:

5 Quality Metrics: 15 variables reviewed COLORECTAL Model Dates of Surgery 1/1/ /31/2016 Total Cases Observed Observed Events Rate Predicted Observed Rate Expected Rate Odds Ratio CI Lower CI Upper Outlier Decile Comment Needs Improveme nt Needs Improveme nt Needs Improveme nt Needs Improveme nt Needs Improveme nt Mortality Morbidity HIGH 10 Ventilator > 48 hrs HIGH 10 SSI HIGH 10 Readmission

6 Surgeons & surgical residents Anesthesiologist GME QI Coordinator Administration support Office Staff & Manager Surgical Services Educator SICU/SSU Educator Dietician Director Infection Prevention Marketing/Public Relations 5

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8 ERAS elements Preadmission nutrition: clear liquids <2 hrs before GA, CHO loading SSI: care bundle chlorhexidine shower, operative measures, prophy abx Bowel prep + oral antibiotics: decrease SSI, C. Diff infection Multimodal opioid-sparing pain management Goal directed fluid therapy Multimodal antiemetic prophylaxis Ngt and foley removal Earl Mobilization, PO intake, shame feeding

9 Enhanced Surgical Recovery Timetable Project Components Aug Oct 2016 Nov 2016 Jul 2017 Sep Dec 2017 Jan May 2018 Planning CPOE Order Set Build Project Kick Off MEC Approval Equipment Training Monitor Success Metrics Project Close : Ongoing Monitoring & Improvement 8

10 November - March 2017 Group A = 42 Background OOB at least by POD 0 or 1 Group B = 20 Not OOB by POD 1 Mobilization at least once POD Mobilization BID POD Intraoperative antiemetic 32 6 Intraoperative IV fluids cc cc Foley out POD Tolerating clears POD IV discontinued POD Multimodal Pain Management 29 3 Unplanned readmission 0 0 Disposition Home = 41 Skilled care not home = 1 Home = 19 Skilled care not home = 1 Average LOS One outlier 23 days Geometric LOS

11 2017 Elective Colon without ERAS ERAS (1-3 elements) No ABX with bowel prep ERAS (4 or more elements - early mobility, limited narcotics, multimodal pain management,antiemetic prophylaxis) No ABX with bowel prep ERAS >4 elements MBP with ABX # Cases LOS SSI 23.07% 4.76% 12% 0% Superficial 11.54% 0 % 4% 0% Deep 7.69% 0 % 4% 0% Organ Space 3.85% 4.76% 4% 2% Bowel function return 6 days (1 pt) 4.05 days 3.88 days 1.83 days Readmission rate 15.39% 0% 8% 0%

12 ERAS elements In Summary: Where are we today??? 56 patients later: partial or complete ERAS orders -LOS = 1.4 day reduction in LOS -$141,000 cost savings -Infection rate 20% > 10% -Return of bowel function: 6 >1.8 days -No readmissions

13 Enhanced Surgical Recovery Carmichael JC et al. Clinical Practice Guidelines for Enhanced Recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and Society of American GI and Endoscopic Surgeons. Dis Colon Rectum Aug;60(8): Thank you Questions???