Spreading ERAS Beyond

Colorectal SurgeryMaking it Happen

Dr. Tom Wallace MD FRCSC FACS

General Surgeon

Royal Inland Hospital

Kamloops, BC

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What is Enhanced Recovery?

Traditional Care

Enhanced Recovery

What is Enhanced Recovery?Functional Perspective

Function

What is Enhanced Recovery?Patient Perspective

Partner in their care

Condition optimized preoperatively

Best evidence-based care processes

American Society of Enhanced Recovery

What is Enhanced Recovery?System Perspective

Evidence-based perioperative care processes

Multi-modal and multi-professional teamwork

Continuous audit

Enhanced Recovery Society

What is Enhanced Recovery?System Perspective

Royal Inland Hospital254 Acute Care Beds

Kamloops 100,000 population120 Elective Colon Resections per year

ERAS timeline at RIH

2/20/2019 9

September 2013: Start of the RIH ERAS Program

May 21, 2014: First Colorectal ERAS Patient

November 2014: RIH joined BC ERACS Collaborative

April 2017: First Urology ERAS patient

May 2018: First Gyne ERAS patient

October 2018: 442 Colorectal, 12 Urology and 16 Gynecology patients through program

Making it Happen!

1. The Case for Change2. Build the Team3. Communicate the Vision4. Meeting Resistance5. Action Planning6. Measurement7. Celebrate Success8. Sustainability

The Case for Change

The Case for Change

• “Go, Look, See”

• Process, Value Stream Mapping

Systems

Processes

The Case for Change

35%

17%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Morbidity SSI

Colorectal Pre Intervention

April 2011 – May 2013

Outcomes

The Case for Change System

The Case for Change Process

The Case for Change

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)

Outcomes

Making it Happen

1. The Case for Change

2. Build the Team3. Communicate the Vision4. Meeting Resistance5. Action Planning6. Measurement7. Celebrate Success8. Sustainability

Building the Team

Building the Team

Build the Team

Nursing

Surgery

Enterostomal Therapy

Administration

Physiotherapy

Project Manager Patient

Department of Anesthesia

Pre Surgical Screening

NSQIP

Operating Room

Wound/Ostomy Nurses

Daycare Surgery

PARPhysio

Surgical Ward

Surgeons

Patients

Build the Team

Systems Leadership Approach

• Influence and motivate

• Build relationships and networks

• Shared vision

• Work across disciplines

• Lead without direct managerial control of resources

Build the Team

Making it Happen

1. The Case for Change2. Build the Team

3. Communicate the Vision4. Meeting Resistance5. Action Planning6. Measurement7. Celebrate Success8. Sustainability

Communicate the Vision

Communicate the Vision

Values driven strong belief

ERAS is the right thing to do for patients, staff and organization

Communicate the VisionDifferent message for different stakeholders

Making it Happen

1. The Case for Change2. Build the Team3. Communicate the Vision

4. Meeting Resistance5. Action Planning6. Measurement7. Celebrate Success8. Sustainability

Meeting ResistanceI don’t get it!I don’t like it!I don’t like you!

I already do ‘best

practices’

My patients already have great

outcomes.

I don’t get it!

• Lack of information

• Disagreement with data

• Skeptical of purported benefits

• Lack of engagement

1. Denial: My patients do

well already

2. Anger: #%$&*

3. Bargaining: Ok, let me

look at that data, its clearly

flawed

4. Sadness: Do we really

Suck?

5. Acceptance: What

should we do now?

5 Phases of ‘I don’t get it!’

‘I don’t get it!’Supportive Response

• Make ‘the case for change’

• Patience through the 5 phases

• Benefits for patients, staff, organization

• Lay out the cost of inaction

‘I don’t like it!’

• Emotional, physiological reaction to change

• Perceived threat to job, status, autonomy

• Time – competing priorities

• Traditional ways of working

• Complacency

• Lack of resources / managerial support

• Scope creep

‘I don’t like it!’Supportive Response

• Be sympathetic• Acknowledge Change is

Hard• Ensure support available

to learn new skills, new ways of working

• Address positive aspects of change: ‘What’s in it for me?’ Explain opportunities for staff, patients

Lack of trust or confidence in leadership

‘I don’t like you!’Supportive Response

• Dispel distrust• Take responsibility,

admit when you have been wrong

• Develop relationships

• Listen!• Incorporate ideas

Making it Happen!

1. The Case for Change2. Build the Team3. Communicate the Vision4. Meeting Resistance

5. Action Planning6. Measurement7. Celebrate Success8. Sustainability

Action Planning

Action Planning

Driver Diagrams

PDSA CyclesPriority Matrix

QI Toolbox

828477 Jan 10-17 Adapted with permission of Fraser Health Authority

Enhanced Recovery

After Surgery (ERAS) For

Radical Cystectomy Patients

Patient and Family InformationFor more information on Enhanced Recovery please visit

www.interiorhealth.ca/YourCare/HospitalCare/Surgery/PreparingforSurgery/Pages/ERAS.aspx

PROOF

100% of cystectomy patients on ERAS pathway by May 2018

Increase compliance with

preoperative elements

Driver Diagram

Action Planning

Priority Matrix

Action Planning

Quick Wins

• Big Impact, little effort

Major Project

• Big Impact, complex to implement

Action Planning

Fill Ins

• Little impact, little effort

Hard Slogs

• Are they worth it?

• Crowding out effect

Timeline of Urology ERAS at RIH

December 2015 – March 2016Documentation developed

Staff Education

October 2015Urology baseline data collection April 2016

First Urology ERAS patient

September 2015Initial discussions

November 201812 Urology ERAS

patients

Action Planning

7 months

Making it Happen!

1. The Case for Change2. Build the Team3. Communicate the Vision4. Meeting Resistance5. Action Planning

6. Measurement7. Celebrate Success8. Sustainability

Measurement

Measurement

• What to measure?

• Frequency and duration of data collection?

• How will you collect data

• Reporting and sharing mechanisms for data?

2/20/2019 520% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

No IV/IM Analgesia given after PCA D/C

PCA D/C POD 2

Foley out by POD 2

Solids within 48 hrs

Mobilized BID POD 2

Mobilized POD 0 or 1

Prophylactic given as prescribed (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

Pre Op Analgesia Ordered

Prophylactic abx 0-60 min of cut time

Pre op VTE Prophylaxis

Both doses of Carbohydrate Drink

Pre-admission Councelling

Gyne ERAS Compliance16 patients

Post Op

Pre Op

Intra Op

Results:Gynecology ERAS Outcomes

Pre-ERAS(April 2011 – October 2017)

ERAS (May - October 2018)

# of Elective ERAS Pts 310 16

Morbidity* 10 % 19 %

# of patients with at least 1 complications*

32 3

Average Length of Stay 2.7 days (Median 3) 3 days ( Median 3)

Surgical Site Infection (All Wound) 5.4 % (17) 12.5 % (2)

Urinary Tract Infection 3.8 % (12) 12.5 % (2)

Re-admission 4.1 % (13) 6 % (1)

Return to the OR 2.0 % (6) 0 % (0)

Intra / Post Op Transfusion w/i 72 hrs

of surgery

4.5 % (14) 6 % (1)

Complications / Morbidity includes: Superficial Incisional SSI, Deep Incisional SSI, Organ/Space SSI, Wound Disruption, Pneumonia, Unplanned Intubation, on Ventilator > 48 hours, Progressive Renal Insufficiency, Acute Renal Failure, Urinary Tract Infection, Stroke/Cerebral Vascular Accident, Cardiac Arrest, Myocardial Infarction, Systemic Sepsis (Sepsis or Septic Shock)

Making it Happen!

1. The Case for Change2. Build the Team3. Communicate the Vision4. Meeting Resistance5. Action Planning6. Measurement

7. Celebrate Success8. Sustainability

Celebrate Success

And the Oscar for best ERAS program goes to…

Celebrate SuccessPatients Treated on Pathway

October 2018: 442 Colorectal, 12 Urology and 16 Gynecology patients through program

Celebrate Success

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)

Celebrate SuccessImproved Outcomes

Celebrate SuccessPublications

Pre Surgical ScreeningOperating Room

Daycare Surgery / PARSurgical Ward

The Team

Celebrate SuccessAwards

Making it Happen!

1. The Case for Change2. Build the Team3. Communicate the Vision4. Meeting Resistance5. Action Planning6. Measurement7. Celebrate Success

8. Sustainability

Sustainability

• Regular interdisciplinary meetings

Sustainability

ProcessOutcomesSystem

Share Data

2/20/2019 64

Sustainability

Sustainability

• Seek out training / mentorship from other hospitals

• Look for networking opportunities

• Celebrate successes and milestones

Thank You!

AcknowledgementsDr. Lee Jonat – UrologistDr. Paula Lott - GynecologistDr. James Baughan – General SurgeonDr. Bruce Kilpatrick - AnaesthesiologistJulie Wootton – Quality Improvement ConsultantCheryl Sibbelee – NSQIP SCRKerry Cardwell – NSQIP SCRSue Gardner-Clark– Administration SponsorNancy Garrett-Petts – Educator DCS/PAR