Enhanced Recovery After Surgery (ERAS) for Elective Colon Resection Surgery at

Vancouver General Hospital

Quality Forum 2014

Disclosure Statement

We do not have any affiliation (financial or otherwise) with a commercial organization that may have a direct or indirect connection to this initiative or the content of this presentation.

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Background

• The risk-adjusted reports from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) demonstrate that patients at Vancouver General Hospital undergoing colorectal surgery have a high odds ratio of postoperative morbidity (1.50-1.54).

o Odds ratio >1.0 indicates hospital is performing worse than expected

• Morbidity impacts patients safety and experience,

increases length of stay and health care costs.

True North Goals

Enhanced Recovery After Surgery

Pre-operative Intra-operative Post-operative

•Pre-admission education •Active warming •Early oral nutrition

•Early discharge planning •Opioid-sparing technique •Early ambulation

•Reduced fasting duration •Surgical techniques •Early catheter removal

•Carbohydrate loading •Avoidance of prophylactic NG tubes & drains

•Use of chewing gum

•No/selective bowel prep •Defined discharge criteria

•Venous thromboembolism prophylaxis •Goal directed peri-operative fluid management

•Antibiotic prophylaxis •Pain & nausea management

•Pre-warming

Audit of compliance & outcomes

Active Patient Involvement

Whole Team Involvement

Methods • A multidisciplinary team (anesthesiologists, surgeons, frontline staff,

organizational leaders and quality improvement staff) was formed in February 2013.

Goal: • To decrease the morbidity rate for general surgery patients

undergoing elective colorectal surgery at Vancouver General Hospital by 50 % by June 2014.

Implementation: • The ERAS protocol was implemented in two phases.

Implementation

Phase 1

February-October 2013 June 2013-Ongoing

Provided ongoing education for surgical staff on the ERAS protocol Developed ERAS documents:

o Standardized order sets o Clinical pathway & kardex o Patient teaching booklet o Poster highlighting changes in practice

Implemented intra-operative components by a core group of anesthesiologists Audited compliance with intra-operative components Measured patient outcomes in post- anesthesia care unit (PACU)

Phase 2

November 2013-Ongoing

Implemented pre-operative and post-operative components Audited compliance with all ERAS components Measured patient outcomes within 30 days after surgery

Progress so far…..

• June-December 2013 Audited103 cases for intra-operative components

• Compliance 80-100%: Normothermia Prophylaxis antibiotics within 60min of skin cut Appropriate prophylaxis anti-emetics

• Areas of opportunity: Goal directed fluid management Antibiotics re-dosing

Progress so far….. • November-December 2013

Audited 31 cases for all components • Compliance 80-100%: Pre-admission education Use of chewing gum

• Areas of opportunity: Use of ERAS order set Early mobilization Appropriate use of anti-emetics Appropriate removal of urinary catheter

Mean Length of Stay* in Post Anesthesia Care Unit (PACU)

*Times patient enters PACU to times when PACU discharge criteria is met

Complications in Post Anesthesia Care Unit

Mean Hospital Length of Stay (days)

7.3 7.2

4.8

October November December

Lessons Learned

• Process mapping • Team building • Communication • Culture of quality and patient safety

Sustainment Plan • Continue ongoing education of staff • Continue to engage patients and family • Continue to audit 100% of ERAS patients • Disseminate audit results to Steering Committee

and stakeholders monthly • Celebrate the team’s accomplishments

Acknowledgments

• VGH Perioperative Teams • VCH NSQIP Team • ERAS Steering Committee • Numerous Patients and Families • Stephen Parker: Clinical Nurse Specialist, PHC • Deborah Bachand: Projects Manager, Surgical Services, VIHA

Contact Information

Andrea Bisaillon, RN BscN Operations Director - Surgical Services andrea.bisaillon@vch.ca Tracey Hong, RN BscN Quality and Patient Safety Coordinator tracey.hong@vch.ca