Early Recovery after Surgery (ERAS): Applying Consistently What We ve Known for 20 Years Dr. Kurt Heiss, MD Objectives Laying Foundation: Who, Why Explore Components: What Start a Program: How and When Dealing with Resistance: Teams and Audits Why ERAS? Enhanced Recovery after Surgery 20 yrs old Henrik Kehlet: Why is the patient [still] in the hospital? Bundling Kehlet et al.. Br J Surg. 1999 Feb;86(2):227-30 1
Enhanced Recovery After Surgery (ERAS) 13 Randomized Controlled Trials Hundreds of publications ERAS Society www.erassociety.org ERAS results in: 2-3 day reduction in the length of stay Decreased rate of complications by 20-30% No increase in readmission!!! Reduced LOS Decrease in nonsurgical complications No increase in readmissions 2
Objectives Laying Foundation: Who, Why Explore Components: What http://www.erassociety.org Start a Program: How and When Dealing with Resistance: Teams and Audits The major influence over fluids, nutrition and electrolytes of the ERAS protocol is: ERAS 22 Crit Care Clinics 26 (2010): 527-47 a. Routine full liquid diet on post op day 1 b. Intraoperative use of LR at 10 cc/kg/hr to avoid fluid/salt overload c. Use of NuLytely as a non osmotic bowel prep d. Pre op fluid and carbohydrate loading e. Early removal of the NG tube on POD 2 Enhanced Recovery uses Innovative multi-modal pain control by: Fluid/ electrolytes/ nutritional status a. Routine use of low-dose Dilaudid PCA s b. Narcotic-Sparing pain control using gabapentin, NSAIDs and Tylenol c. Acupuncture for post operative pain control d. Limiting Tylenol to avoid toxicity e. Routine use of lumbar epidurals 3
One component of the ERAS protocol that prevents Healthcare Associated Complications (HAC s) is: Pain control a. 5 day Lovenox use to prevent Venous Thromboembolism b. Early Removal of Foley c. Limiting Antibiotic Treatment to 5 days post op d. Use of prophylactic Bactrim while foley is in e. Post op referral to Physical Therapy Enhanced Healthcare Value is generated by the ERAS protocol by helping patients return to function by: Prevention of complications a. Pre op Counseling with Patient Goals b. Limiting NG use to 2 days c. Long acting pre meds to reduce anxiety d. Early mobilization and feeding e. Early discharge to rehab facilities for PT f. Decreasing narcotics charges by standard epidural use and Discussion Return of function 4
Objectives Laying Foundation: Who, Why Explore Components: What Start a Program: How and When Dealing with Resistance: Teams and Audits CHOA ERAS Early Data Routine audit of component compliance by the ERAS team Teaming with Anesthesia and Nursing 5
Possible Agenda Immature Program Agenda Mature Program 1 Who did we do and How did we do last month? Who is coming up this month? What do we expect? Anything unusual? What needs improvement? show the YouTube videos look over the Patient Goal Sheet Some component of Teaching and Teaming and Celebration YouTube Video. Patient Journey Agenda Mature Program 2 Agenda Mature Program 3 Agenda Mature Program 4 Objectives Laying Foundation: Who, Why Explore Components: What Start a Program: How and When Dealing with Resistance: Teams and Audits 6
How to Start an ERAS Program Identify Team members Go to a SAGES or NSQIP meeting Watch some ERAS YouTube videos Read literature on ERASSociety.org website Give a talk to your division inviting them to join in Find an anesthesia colleague who wants to play Engage one of your Nurse Clinicians Ask the Residents on Gen Surgery Try it with one of your CR patients How to Start an ERAS Program - 2 Involve Quality in your hospital Get them to help measure Write guidelines Use quality tools to solve problems P-D-C-A Spread to other services Bariatrics, HPB, Craniofacial, Ortho. and Discussion Let s do an ERAS-walk for a patient See in Clinic, recommend surgery, teach PNP contacts patient, gives HO, scripts, drinks Pre op Clinic repeats protocol, gets Goal Sheet Oral antibiotics on day b4 surgery Drinks CHO clears, pain med cocktail in pre op Regional anesthetic and GDFT 4 cc/kg/hr No narcotics ERAS-walk 2 Intra op Decadron and Zofran Remove foley and NG Early drinks Scheduled Zofran, tylenol, Tordol and Gaba Early ambulation Avoid fluid boluses Regular diet POD 1 with stimulant Protocol-based discharge 7
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