Enhanced Recovery After Surgery Getting it Right

Transcription

1 Enhanced Recovery After Surgery Getting it Right Aalok Agarwala, M.D., M.B.A. Division Chief, General Surgery Anesthesia Associate Director, Quality and Safety, MGH DACCPM Assistant Professor, Harvard Medical School

2 Disclosures I have no relevant financial relationships or interests to disclose. Hasbro, Inc.

3 Outline Background What is ERAS? The Evidence for ERAS - Why bother? Implementation Making it Happen

4 Objectives To describe the evidence for the effectiveness of Enhanced Recovery After Surgery To discuss the essential elements required to successfully introduce and implement an Enhanced Recovery Program at your institution

5 What is Enhanced Recovery? Enhanced Recovery After Surgery (aka ERAS or Enhanced Recovery) is a patient-centered, evidence-based approach to care designed for planned surgery. Enhanced Recovery Pathways (ERPs) contain a bundle of elements that, implemented, collectively can: Empower patients to be partners in their own care Reduce complications and improve outcomes Decrease length of hospital stay and reduce costs

6 Common Elements of ERPs American Society for Enhanced Recovery, 2016

7 Elements of ERPs Months to Weeks Pre-op Shared decision making Preop health optimization (smoking cessation, anemia, prehabilitation ) Immediately Pre-op Fluid optimization, limit fasting Carbohydrate loading Multi-modal analgesia Intra-op Minimally invasive surgery Fluid optimization Multi-modal analgesia with minimal narcotic PONV prophylaxis Limit Lines/Tubes/Drains Immediately Post-op Regional Anesthesia for post-op pain when applicable Limit narcotics, oral analgesics PONV prophylaxis and tx Fluid optimization Early mobilization Early oral intake Discontinue NGT, Foley, Drains ASAP Later Post-op Support normal oral intake Look for complications early (e.g., AKI) Encourage mobility Discharge as soon as criteria met Recovery Early and frequent contact for reassessment and reassurance

8 Months to Weeks Pre-op Element Shared decision making Patient and family engagement through education Cessation of Smoking and excessive alcohol intake Nutritional screening, assessment, and nutritional support as needed Medical optimization of chronic disease Treatment of anemia Prehabilitation Intended Goal Ensure patient and family fully understand risks, benefits, and alternatives to surgery Reduce anxiety, set realistic expectations, improve protocol adherence Reduce complications Reduce complications, reduce time to functional recovery Reduce complications Reduce need for transfusion Improve functional status and reduce time to functional recovery

9 Immediately Pre-op Element Limit fasting per guidelines Preoperative carbohydrate drink Preoperative DVT prophylaxis Multimodal analgesia, including acetaminophen, NSAIDs, and/or gabapentinoids Intended Goal Reduce preoperative dehydration, reduce need for IV fluid Reduce insulin resistance, improve patient satisfaction,?faster recovery Reduce complications Reduce need for opioids, reduce postoperative ileus Epidural analgesia for open cases (when appropriate) Reduce need for opioids, reduce postoperative ileus

10 Intraoperatively Element Use minimally invasive surgery when possible Appropriate antibiotic prophylaxis Multimodal analgesia, avoid/minimize long-acting opioids Fluid optimization to reduce under- or overhydration PONV prophylaxis Avoid/limit use of NG tubes Avoid/limit use of surgical drains Maintain normothermia Intended Goal Reduce complications, less pain, faster recovery, Reduce infection Reduce need for opioids, reduce postoperative ileus Reduce complications, reduce postoperative ileus Reduce time to oral intake, improve patient satisfaction Reduce risk of PNA, encourage oral intake Reduce pain, improve patient mobilization Reduce complications

11 Immediately Post-op Element Multimodal analgesia, limit opioids PONV prophylaxis and treatment Fluid optimization Intended Goal Reduce ileus, pain control reduces insulin resistance, supports mobility Support early oral intake, support energy intake Reduce complications, reduce postoperative ileus Discontinue NGT, Foley, drains ASAP Early mobilization Early oral intake Reduce complications, encourage oral intake, support early mobilization Earlier return to normal function, reduce postoperative ileus Support energy and early return to normal gut function

12 Later Post-op Element Support oral intake, consider use of protein and energy-rich supplements Intended Goal Support energy and protein supply, reduce starvation-induced insulin resistance Encourage mobility Multimodal analgesia, limit opioids Earlier return to normal function Reduce ileus, pain control reduces insulin resistance, supports mobility Look for complications early (e.g., AKI) Discharge as soon as criteria met Early and frequent contact post-discharge Minimize readmissions Reduce LOS, get patients home faster Address patient concerns early, prevent complications and readmissions

13 Why Bother? Dozens of studies demonstrating improvement in process and outcome measures after implementation of ERPs Colorectal Surgery Gynecology Hysterectomy Orthopedics TKR/THR, Spine Hepatobiliary Whipple, Hepatectomy Urology Cystectomy and Nephrectomy Observed Outcome Benefits Decreased Morbidity Ileus SSI CAUTI Improved Operational and Financial Performance Reduced Length of Stay (almost always) Reduced Readmissions (occasionally) Decreased Overall Hospital Cost (frequently)

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15 Colorectal Surgery 2014 Meta-analysis: 2376 colorectal surgery pts from 16 RCTs comparing ERP vs. Conventional post-op care ERP associated with: Decreased overall morbidity (RR = 0.60, 95% CI ) Decreased medical complications (RR = % CI ) Decreased length of hospital stay of 2.28 days (95% CI days) No differences in readmissions Greco M, et al. World J Surg Jun; 38(6): Another 2014 systematic review and meta-analysis: Patients from RCTs in all surgical disciplines, including colorectal, orthopedics, urology and upper gastrointestinal tract surgery 38 RCTs with 5,099 patients. ERP associated with: Decreased risk of all 30-day complications (RR = 0.71, 95% CI ) Decreased length of stay of an average of 1.14 days No change in readmission rates No reduction in mortality Nicholson A, et al. Br J Surg Feb; 101(3):

16 Gynecologic Oncology Study Patient population Methodology Results for the intervention cohorts Marx et al, 2006 Cytoreductive surgery for ovarian cancer Prospective cohort study of n=72 before a multimodal rehabilitation protocol and n=69 after implementation LOS decreased from 7.3 days to 5.4 days, p<0.05 Reduced severe medical complications from 14% to 2%, p<0.01 Reduced readmissions 10% to 3%, p<0.05 Gerardi et al, 2008 Cytoreductive surgery with rectosigmoid colectomy for ovarian cancer Prospective cohort study of n=45 before a clinical pathway and n=19 after implementation LOS decreased from 10 days to 7 days, p=0.014 No difference in time to flatus No difference in readmission Cost savings of $5,410 per patient, p=0.028 Kalogera et al, 2013 Complex cytoreductive Prospective cohort study of LOS decreased from 10.7 days to 6.5 days, p<0.001 surgery for ovarian n=78 before a enhanced Time to flatus decreased from 4 days to 3 days, cancer recovery pathway and n=81 p<0.001 after implementation No difference in postoperative complications, readmissions or mortality Cost savings of $7,600 per patient, p=0.006 De Groot et al, 2014 Abdominal surgery for gynecologic malignancies Cohort study of n=38 before a enhanced recovery after surgery protocol and n=77 after implementation LOS decreased from 7 days to 5 days, p<0.001 Time to functional recovery decreased from 6 days to 3 days, p<0.001

17 Benign Gynecology Study Patient population Methodology Results for the intervention cohorts Dickson et al, 2012 Abdominal hysterectomy for benign conditions Retrospective cohort study of n=176 before a rapid recovery protocol and n=190 after implementation LOS decreased from 3 days to 1 day, p< No difference in postoperative complications Miller et al, 2011 Yoong et al, 2014 Kalogera et al, 2013 Abdominal hysterectomy for benign conditions Vaginal hysterectomy for benign conditions Pelvic organ prolapse surgery Retrospective cohort study of n=100 before a hysterectomy enhanced recovery pathway and n=123 after implementation Cohort study of n=50 before a enhanced recovery after surgery program and n=50 after implementation Prospective cohort study of n=77 before a enhanced recovery pathway and n=76 after implementation LOS decreased from 3 days to 2 days, p< POD1 discharges increased from 7% to 34%, p< No difference in readmissions LOS decreased from 45.5 to 22.0 hours, p<0.01 No difference in readmissions or ER visits Gross cost savings of 9.25% per patient ($ per patient, no significance testing performed) LOS decreased by 46.1% POD1 discharges to 6.5% p<0.001 No difference in postoperative complications, readmissions or mortality No difference in cost

18 Liver Surgery 2017 Meta-analysis of 7 RCTs 996 patients for open or lap liver resection ERP associated with: Fewer complications (OR 0.52, 95% CI: , P <.0001, I = 0%). Decreased LOS by 3.17 days (95% CI: to -2.35, P <.00001, I = 89%) Time to first flatus decreased by 0.9 days (95% CI: to -0.45, P =.0001, I = 98%) Zhao Y. et al. Medicine Aug;96(31):e Meta-analysis of 8 studies, 580 patients analyzed: 292 cases in ERAS group and 288 cases in traditional care ERAS associated with: Decreased postop complication rate (OR = 0.34, 95%CI: , P = 0.008) Significantly decreased LOS (MD = -3.31, 95%CI: , P < ) Decreased cost of hospitalization (MD = -1.0, 95%CI: , P < ) Accelerated time to diet (SMD = -1.79, 95%CI: , P = 0.01) Decreased time to first flatus (MD = -0.51, 95%CI: , P = 0.01) No significant difference in intraoperative blood loss, blood transfusion, or operative time Yang R, et al. Int J Surg Dec;36(Pt A):

19 Liver Surgery 2017 Meta-analysis: 19 studies with 2575 patients (4 RCTs, 15 nrcts of ERAS in open and lap liver resection) ERAS associated with: Lower overall morbidity rate (OR = 0.65, 95% CI= , P=0.001) Time to bowel function recovery improved in ERAS group Intraop blood loss minimally decreased in ERAS group ERAS: LOS 2.07 days shorter (95% CI = 2.76 to 1.38, P< ) Hospital Costs decreased by ~20-30% in ERAS group No difference in mortality, readmission rates, transfusion rates Wang C, et al. J Gastroint Surg. 2017:21(3)

20 Pancreatic Surgery 2016 Systematic Meta-Analysis - 14 nonrandomized comparative studies with 1409 ERAS cases and 1310 controls ERAS associated with Overall morbidity decreased in ERAS group (OR: 0.63; 95%CI: , P< ) Postoperative LOS decreased by 4.17 days (95%CI: 5.72 to 2.61, P< ) No difference in postoperative pancreatic fistula (POPF) Delayed gastric emptying (DGE) lower in ERAS group (OR: 0.56; 95% CI: , P<0.0001) No difference in readmission rates, reoperation, or mortality In-hospital costs (reported by 4 studies) decreased by ~20% to 48%

21 Urologic Surgery Cystectomy 3 rd most commonly implemented pathway. Several heterogeneous studies, with results ranging from no benefit to decreased LOS of 4 days and reductions in complications of 30-50% Nephrectomy Very limited outcome data at this point, but given the nature of surgery, the length of stay, and complications, it is likely that these patient will benefit

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23 Implementation Step 1: A Champion Step 2: Build the Case Step 3: Assemble the team Step 4: Create your pathway Step 5: Get buy-in Step 6: Refine the Pathway Step 7: Run a pilot Step 8: Expand Step 9: Sustain Step 10: Do it again!

24 1. Finding the Champion If not you, then who? Traits of an effective leader Someone who can organize Someone who will facilitate Someone who can negotiate Someone who can teach Someone who can persuade Someone who has the trust of others, and can effectively communicate the case for change

25 2. Building the Case Building the case for why Enhanced Recovery is needed is critical How the patient and family experience will improve How clinical outcomes will change Why this is beneficial for the hospital Building the case for change enables you to: Find executive sponsorship Argue for administrative support Gain project management support Start building engagement from other clinicians and leaders across the hospital

26 2. Building the Case Know your audience If speaking to clinicians, bring the evidence If speaking to the C-suite, bring the numbers Know how to use patient stories to change hearts, as well as minds Gather baseline data for your institution Find your own complication rates and length of stay Model the improvement and potential impact for your institution

27 3. Assemble the Team Identify Key Stakeholders Surgery, Anesthesia, PACU, Preop, Clinic Nursing Share the vision A patient-centered approach for common purpose Build buy-in Listen to concerns, identify potential barriers

28 Who should be on the team? Surgery Surgeons Residents APRNs Office Staff Anesthesia Anesthesiologist CRNAs Pain Specialists Pre-anesthesia testing Administrative ERAS Coordinator Admin Support IT/Data specialist Nursing Clinic RN Preop RN OR RN PACU RN Floor/Unit RN Allied Services Nutrition Pharmacy PT/OT Social Work

29 4. Create your pathway Start with current process Identify what works well and what doesn t Use available resources Protocols and pathways already exist, don t reinvent the wheel! Modify protocols for your institution Resources and local practices differ significantly Local modification improves implementation success Start with ONE service line

30 5. Get Buy-in Share the Vision, share the evidence Use your team Surgeon should lead for surgeons, Nurse should lead for nursing staff Share the protocol, get feedback When necessary, find acceptable compromise (but not where there is strong evidence) Don t wait for everyone to get on board before you start you will find resistance Explain benefits, use evidence, be sympathetic to concerns, find ways to make adoption easier

31 6. Refine your pathway With your team, consider each step of the protocol What changes are necessary from current practice? What resources are necessary? Who will be responsible for each step? How long will it take to change practice? How difficult will it be? What will we measure? How will we document and get the data?

32 7. Run a pilot Choose a single surgeon, or a single population Run the pathway Identify areas of challenge Collect data Iterate as needed (PDSA) Collect data deming.org

33 8. Expand Share results of the pilot Share successes Communicate with executive sponsors Request additional resources Get the laggards on board

34 9. Sustain After the initial push for implementation, attention can shift and success can lag Continued leadership is important Communication is key Education and Training must be institutionalized Continued data collection, analysis, and reporting

35 10. Do it Again! Once you ve completed one service line find another to start working on Use what you learned to smooth the next implementation Don t forget about previous implementations

36 Implementation Success Success requires collaboration you CANNOT do it alone! Local adaptation Strong leadership Sustained commitment Continuous learning Hospital support Measurement and Data

37 Key Points Enhanced Recovery has shown benefits in reducing complications and hospital LOS across multiple surgical procedures Patients and hospitals stand to benefit significantly with successful implementation, especially in the face of capacity constraints and decreasing reimbursement Implementation takes a team with strong leadership and commitment Data will help you be successful

38 Questions and Discussion