Improving Outcomes in

Colorectal Surgery Dr. Tom Wallace

General Surgeon

NSQIP Surgeon Champion

Enhanced Recovery Lead

Royal Inland Hospital

Kamloops BC

Royal Inland Hospital (RIH)

245 Beds Kamloops 100,000 population

100 Elective Colon Resections per year

I already do ‘best

practices’

My patients already have great

outcomes.

Challenges

How do patients do at our

hospital?

35%

17%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Morbidity SSI

9

0

1

2

3

4

5

6

7

8

9

10

Length of Stay

Pre Intervention

April 2011 – May 2013

Can we do better?

Pre Intervention

April 2011 – May 2013

SSI Bundle

May 2013 – May 2014

Pre-Op

Patient received pre op scrub

Optimal Hair Removal (Clippers or None)

Appropriate antibiotic Timing (0-60 min pre cut

time)

Appropriate antibiotic given

Pre Op BGM Value

Pre op Bowel Prep & Oral Antibiotic

Intra- Op

Appropriate Isolation technique

Wound barrier used

Antimicrobial sutures used

Antibiotic re-dosing for surgeries > 4 hrs

Normothermia

Intra Op fluid volume

Intra Op BGM Value

Post - Op

Normothermia

Total Fluid volume in PAR

High O2 for 1 hr in PAR

BGM in PAR

Standardized wound care orders given

(Remove POD 2)

Patient Education Post Op

The Team

Department of Anesthesia

Pre Surgical Screening

NSQIP

Operating Room

Wound/Ostomy Nurses

Daycare Surgery

PAR

Physio

Surgical Ward

Division of General Surgeons

SSI Bundle

Pre Op Intra Op

Post Op

SSI Bundle Compliance June 17, 2013 – October 31, 2015

0% 20% 40% 60% 80% 100%

Dressing removed POD 2

Standardized Wound Care orders

BGM in PAR Taken

High 02 for 1 hr

Normothermia in PAR

Intra Op BGM Taken

Intra Op Warming

Intra Op temp taken

Abx re-dosing > 4 hrs

Antimicrobial Sutures

Wound Barrier

Isolation Technique

Pre op bowel prep

Pre BGM Taken

Appropriate Abx

Appropriate Abx Timing

Appropriate Hair Removal

Pre Op Scrub

Intra Op

Pre Op

Post Op

35%

17%

27%

10%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Morbidity SSI

Pre Intervention (n=94) SSI Bundle (n=95)

Length of Stay

9

7

0

1

2

3

4

5

6

7

8

9

10

Pre Intervention (n=94) SSI Bundle (n=95)

Pre Intervention

April 2011 – May 2013

SSI Bundle

May 2013 – May 2014

ERAS

May 2014 – October 2015

Can we do better?

ERAS Pre-Operative Elements

ERAS Intra-Operative Elements

ERAS Post-Operative Elements

ERACS Compliance November 2015 – October 2015

0% 20% 40% 60% 80% 100%

Foley out by POD 2 (October)

Foley out within 48 hrs

Solids by POD 2

Mobilized BID POD 2

Mobilized POD 0 or 1

Prophylactic antiemtic x 24 hrs

IV discontinued POD 0 or 1

Clear Fluids started POD 0 or 1

Chewed gum POD 0 or 1

No abdominal/pelvic drains

Multimodal antiemetic

Normal temp on arrival in PAR

Multimodal pain management

Goal Directed Fluid Therapy

Oral Abx

Prophylactic abx 0-60 min of cut time

Pre op VTE Prophylaxis

Both doses of Carbohydrate Drink

Pre-admission Councelling

Intra Op

Pre Op

Post Op

35%

17%

27%

10%

20%

4%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Morbidity SSI

Pre Intervention (n=94) Post SSI Bundle (n=95) Post ERACS (n=165)

Morbidity and SSI

9

7

5

0

1

2

3

4

5

6

7

8

9

10

Pre Intervention (n=94) Post SSI Bundle (n=95) Post ERACS (n=165)

Pre Intervention (n=94) Post SSI Bundle (n=95) Post ERACS (n=165)

Length of Stay

Conclusions

Successful Implementation of an SSI Bundle and

ERAS has led to:

• Length of Stay

• Adverse Events

• Patient Satisfaction

• Culture / Teamwork

• Sustained Improvements