Enhanced Recovery After Surgery - Advocate Health Care · Enhanced Recovery After Surgery Thomas...

Enhanced Recovery After SurgeryThomas Aloia, MD, FACS and Vijaya Gottumukkala, MB, BS, MD (Anes), FRCA

The University of Texas MD Anderson Cancer Center

March 7 – 8, 2017

Welcome

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– CODE EXPIRES IN 30 DAYS

– BEING LOGGED ON OR IN ATTENDANCE DOES NOT TRACK CME

• Non-physicians– Certificate of attendance will be sent after March 8th

Contact Carol Rizzie with questions carol.rizzie@advocatehealth.com

Disclosures

• Thomas Aloia, Faculty – Nothing to disclose

• Charles Derus, Planner / Faculty – Nothing to disclose

• Vijaya Gottumukkala, Faculty – Pacira: Consultant

• Carol Rizzie, Planner – Nothing to disclose

• Michelle Ruther, Planner – Nothing to disclose

Vijaya Gottumukkala M.B;B.S, M.D (Anes), F.R.C.A

ProfessorDeputy Chairman & Clinical Director

Director, Cancer Anesthesia Fellowship ProgramDepartment of Anesthesiology & Perioperative Medicine

The University of Texas MD Anderson Cancer CenterHouston, Texas- U.S.A

Enhanced Surgical Recovery Program

• PACIRA

• MEDTRONIC INC.

online-metrics.com

Objectives:

FUNCTIONAL AND DISABILITY FREE SURVIVAL

RISING HEALTH CARE COSTS IN THE US

2015: $ 9,990.00 PP; 17.8% GDP

JAMA 2012; 307:1513-1516

Value Proposition in Health Care

Safe Surgery AndAnesthetic Care

ACUTE SURGICAL CARE IN THE USA

https://www.hcup-us.ahrq.gov/reports/statbriefs/sb186-Operating-Room-Procedures-United-States-2012.pdf.

Transforming health care delivery in the US

What do Consumers Want from Surgical Care?

Bending the cost curveImproving surgical outcomes

Traditional Care Models are not conducive for delivery of value based

surgical care and helping bend the cost curve

Transforming Perioperative Care of the surgical patient

TRANSFORMING PERIOPERATIVE CAREBuilding Blocks - MDACC ESRP

Patient Factors: Disease burden, Medical Optimization, functional status

Surgeon factors: Approach, surgical skill, extent of resectionIm

Deliver High Value Care

• Not a technique• Philosophy of care• Perioperative continuum• Multidisciplinary• Minimize symptom burden and complications• Enhance Functional Recovery• Effective care transitions• Reduce/minimize readmissions• Track outcomes and HRQoL measures• Improve population health• Reduce cost of care delivery

MINIMIZING VARIATION IN PROCESSES OF CARE DELIVERY

Setting up an Enhanced Recovery Program

Fearon KCH, et al. Clinical Nutrition 2005; 24: 466-477

Setting up an Enhanced Recovery Program

• Choose Wisely Campaign

• Optimize patients condition

• Patient and care-giver education and engagement

• MINIMIZE SURGICAL STRESS (MIS)

• Procedure specific opioid sparing analgesia strategies

• Minimize oxygen debt (fluids therapy-hemodynamic optimization-blood management)

• Optimal Anesthetic Care

• Pathway based postoperative care

• Early DRinking Eating AMbulating

• Early diagnosis and rapid response to manage postop complications

• Post discharge care (transitions)

MDACC Enhanced Recovery Pathway

PATIENT EDUCATION, ENGAGEMENT AND EMPOWERMENT

MDACC Enhanced Recovery Pathway Preoperative Maneuvers

• Clear liquids up to 2 hours prior to reporting for surgery

• Preventive analgesia

Celecoxib

XPregabalin/Gabapentin

Oral Acetaminophen

Image modified from aafp.org

Tramadol ER

Enhanced Recovery PathwayIntraoperative Opioid Sparing Strategies

x IV Acetaminophen

Ketamine Or N2O

Dexmedetomidine

Lidocaine infusion

Epidural

XTAP Block

Wound Infiltration

PIC Block

Immediate Postoperative care: PACU and POD 0 Rapid Emergence from Anesthesia

Dynamic Pain Control

Opioid Sparing Strategies

• Choose Wisely Campaign

• Optimize patients condition

• Patient and care-giver education and engagement

• MINIMIZE SURGICAL STRESS (MIS)

• Procedure specific opioid sparing analgesia strategies

• Minimize oxygen debt (fluids therapy-hemodynamic optimization-blood management)

• Optimal Anesthetic Care

• Pathway based postoperative care

• Early DRinking Eating AMbulating

• Early diagnosis and rapid response to manage postop complications

GDT vs. Conventional

A= PNEUMONIA; B= RENAL COMPLICATIONS

MORTALITY

Anesth Analg 2012;114:640–51

Variability in practice and factors predictive of total crystalloidadministration during abdominal surgery: retrospective

two-centre analysis

BJA 114 (5): 767–76 (2015)

Monitoring Needs and Goal-directed Fluid Therapy Within an Enhanced Recovery Program Anesthesiology Clin 33 (2015) 35–49

ANESTHESIOLOGY 2015; 123:307-19

MAINTAINING TISSUE PERFUSIONAVOIDING OXYGEN DEBT

AVOIDING DEEP ANESTHESIA

PERIOPERATIVE ANESTHETIC STRATEGIES AT MDACC

Meta-analysis of RCT assessing use of intraoperative BIS and risk for POD

Avidan MS. IARS 2013 REVIEW COURSE LECTURES

Atelectasis and perioperative pulmonary complications in high-risk patients

Curr Opin Anesthesiol 2012, 25:1-10

Atelectasis and perioperative pulmonarycomplications in high-risk patients

Curr Opin Anesthesiol 2012, 25:1-10

Neuromuscular Reversal and Monitoring

Anesthesiology 2017; 126 (1): 1-4

Postoperative Care In The Hospital“ Get Back on Track “

Ambulation Pulmonary Rehab Balanced Enteral Diet

Opioids: Good, Bad and The Ugly Optimal Fluid TherapyDynamic Pain Control

Improving Postoperative Care

Need Rapid Diagnosis, Response And Rescue

Burden of Postoperative Complications After Major Surgery

Am J Med Qual. 2012; 27:383-390

Effect of Postoperative Complications

Discharge Planning and Post discharge Care

Improving Postoperative Care

Preoperative: Preventive Analgesia (Oral Pregabalin, Celecoxib, Tramadol ER) and PONV prophylaxis

Intraoperative: Regional Block: PVB/Epidural/TAP Block/Wound infiltration, Opioid sparing strategiesSteroids, IV Tylenol,Dexmedetomidine, IV Lidocaine and Ketamine infusionsTIVA Propofol

Optimal anesthetic plan: Normothermia, Euglycemia, Goal directed Fluid therapy, Hemodynamic optimization, Permissive hypercapnia, LPV strategies, Blood management protocol, Avoid deep anesthesiaComplete rversal of NMB

ostoperative: Opioid sparing strategies

Early DRinking Eating AMbulatingEarly diagnosis and rapid responseTransition of care planningTracking measures and outcomes (RIOT)

PERIOPERATIVE CARE OF THE CANCER PATIENTIMPROVING ONCOLOGICAL OUTCOMES-OUR VISION AT MDACC

MDACC ENHANCED SURGICAL RECOVERY PROGRAM

MDASI Life Interference Scores

*Aloia/Gottumukkala, JACS, 2015

MDACC Liver SurgeryTraditional vs. ERLS

Early paincontrol

Complications Mortality LOS

Traditional Recovery-43 Enhanced Recovery-75

Enhanced Recovery In Liver Surgery

Factors for Recovery

Factor No RTB Int RTB Int Uni p-value

Multi p-value OR (95% CI)

Age >=65 22 (32) 17 (35) 0.749

Male 35 (51) 30 (61) 0.259

Preop Chemotherapy 51 (74) 39 (80) 0.475

Minimally Invasive 14 (20) 17 (34) 0.080 0.530

Major Hepatectomy 26 (38) 11 (22) 0.079 0.069

Operation Time >= 300 m 30 (45) 16 (33) 0.235

Epidural 35 (51) 28 (57) 0.491

ERLS 38 (55) 37 (76) 0.023 0.021 2.62 (1.15 – 5.94)

LOS > 5 Days 34 (49) 19 (39) 0.259

Any Complication 35 (51) 19 (39) 0.199

Major Complication 9 (13) 7 (14) 0.846

Variable Pre-ERP Post-ERP p-value

Length of Stay 4 days (2-27) 3 days (1-11) 0.001

Readmissions 11.7% 12% 1.00

GI complications 24% 15% 0.26

Complications

6% 13% 0.22

Neurologic

Complications

0.01% 0.02% 1.00

Hematologic

Complications

6% 14% 0.13

RIOT* 30 (15-52) 22 (20-41) 0.08

ESRP- GYN

Preliminary Impact on LOS/Complications and RIOT

Enhanced Recovery In Liver SurgeryApproach Over Incision

Open MIS

p<0.01

ERILS Readmissions

% High Risk Patients Readmitted

Time to Return to Intended

Oncologic Therapy

0 10 20 30 40

Baseline

Postop Days

Next Step:Can Surgical

Recovery Impact Cancer-

Specific Survivals?

Enhance

RecoveryRIOT

Decrease

Recurrence

Improve Survivals

*Aloia/Gottumukkala, JSO, 2014

OSJ Prevents “Poor Recovery”

• Primary outcome: “Poor Recovery”

– Composite endpoint (LOS > 7 or readmission w/in 30 days)

• Predictors of poor recovery

– Every 1 complication increases risk of poor recovery 2.4-fold

– Use of the OSJ decreases risk of poor recovery 8-fold

Odds Ratio 95% CI P-value

Diversion type 2.28 0.45 – 11.70 0.32

Operation length 1.00 0.997 – 1.011 0.27

Opioid use 1.01 0.991 – 1.025 0.37

# Complications 2.43 1.645 – 3.596 < 0.001

OSJ (yes vs. no) 0.12 0.031 – 0.459 0.002

Shah & Cata et al- Unpublished data

Impact on PRO’s, Opioid Consumption,

PACU pain scores

• MDASI-OC: Significant decrease in severity of nausea,

sleep disturbance, constipation, urinary urgency and

difficulty with memory during the hospitalization period

• 70% reduction in intra-operative morphine equivalents

(P<0.001)

– Pre-ERP median 151 mg (25-263)

– Post-ERP median 45 mg (5-137.5)

• 34% reduction in PACU pain scores (p=0.01)

– Pre-ERP mean 6.04

– Post-ERP mean 3.98

Enhanced Recovery After Thoracic

Surgery

Ann Thorac Surg 2015;99:1953–60

MDACC ERP Teams – 2012 to 2017

Anesthesiology

Surgery

Nursing

Pharmacy

Nutrition

Surgery

Colorectal

Surgery

Bladder

Surgery

Breast

Surgery

Thoracic

Surgery

Understanding Process- Measuring Outcomes

planzsolutions.com

• What elements should be

routine care ?

• What are core elements of

• How do we define core elements ?

• How do we track compliance ?

• What outcomes do we measure ?

• What tools do we use to measure outcomes ?

• How do we normalize elements of care ?

Patient Reported Outcomes Frequency/Definition

Procedure specific perioperative symptom

burden

MDASI Symptom Severity

(validated 13 core items, plus procedure specific module

items) Pre-op; Daily until discharge; Weekly for up to 3

months postop

Postoperative morbidity (symptom burden and

functional interference)

Postop days 1,3,5,7 and at discharge and first

postoperative follow-up

Return to baseline functional status Days from surgery to return to baseline functional

status

Clinical Outcomes Frequency/Definition

Post operative complications Count, frequency, grade

Medical readiness for discharge (MRD) and

Return to Intended oncological therapy (RIOT)

Days from surgery to MRD and RIOT

All Readmissions 30, 60 and 90 Day

Business Outcomes Frequency/Definition

Length of hospital stay Days from surgery to discharge

Episode or total TDABC cost for patient Total true MDACC costs / total patient costs

Modified from John Calhoun- ICCI, MDACC

CHANGE ISHARD AT THE BEGINNING

MESSY IN THE MIDDLE

GORGEOUS AT THE ENDMarlosneoldeous.com

PERIOPERATIVE CARE OF THE CANCER PATIENTIMPROVING ONCOLOGICAL OUTCOMES-OUR VISION AT MDACC

Thank you for your attention

vgottumukkala@mdanderson.org

How to Build the ERAS Team

Thomas A. Aloia, MDAssociate Professor of Surgical Oncology

Division Director of Quality and Outcomes

Deputy Department Chair for Education

Associate Head, Institute for Cancer Care Innovation

Advocate MDs 02.2017

Disclosures

• Financial: None

• Personal: Recovering Transplant Surgeon

Agenda/Challenges

• Why do you want to do ER?

• Issues

– Trainee

– Patient

– Anesthesia/Surgery

– Nursing

– Hospital Administration

• Teamwork

I can’t tell you how to

build an ER program

unless you tell me why

you want to do ER

Why Do You Want to Do ER?

What Is Your Vision/Goal??

Elements

Anesthesia-Surgery-Nursing

What is the Goal?

More Than LOS?

0 50 100

Physical Performance Tests

Patient Satisfaction

Immunologic Factors

Pain Med Usage

Quality of Life

Bowel Function

Readmission

Mortality

Morbidity

% of Papers

MD Centric

Patient Centric

*Day & Aloia, BJS, 2015

What Is Your ER Goal?

A. Reduce complications– Enhanced Safety Program

B. Save the hospital money– Enhanced Finance Program

C. Lower length of stay– Enhanced Discharge Program

D. Make them to poop faster (see answer C.)– Enhanced BM Program

E. Help patients recover faster– Enhanced Recovery Program

Agenda/Challenges

• Issues

– Trainee

– Patient

– Nursing

• Teamwork

Surgeon/Trainee Issues

• Single largest impediment to LOS reduction is unwillingness to advance diet– Eliminate from ordersets and vocabulary

• Sips of Clears

• ADAT

• Full Liquid Diet

– POD0-1 Clears ad lib

– POD2 Regular or ADA Diet

• Second largest impediment to LOS is excessive fluid administration post op– SL at 600 mL PO intake

– UO 50cc/2 hrs acceptable

Mayo Clinic Colectomy LOS

Intervention #4:

No fluid bolus

without attending

approval

Agenda/Challenges

• Issues

– Trainee

– Patient

– Nursing

Patient Recovery is the GoalCrossing the Quality Chasm

Health Care Goals

• Aim 1: Safe

• Aim 2: Effective

• Aim 3: Patient-Centered

• Aim 4: Timely

• Aim 5: Efficient

• Aim 6: Equitable

Patient Goals

• Don’t Hurt me

• Cure me

• Recover me

• See me quickly

• Avoid unnecessary tests

• Don’t Bankrupt me

The Institute of Medicine. Crossing the Quality Chasm:

A New Health System for the 21st Century, 2001

Agenda/Challenges

• Issues

– Trainee

– Patient

– Nursing

People don't resist change. They resist

being changed

-Peter Senge

Setting up an Enhanced Recovery ProgramElements, Buy-in, Hurdles, and Conflict Resolution

Lesson 1:It’s Not Personal,

So Don’t Make It Personal

Non-Narcotic AnalgesiaControl: Surgeon Surg/Anesth Anesthesia

• Preop

– (Limited bowel prep)

• Intraop

– Antiemetics

– Small Incisions

– Local Analgesia

• Postop

– Minimized Tubes and Drains

– Early Feeding

– Early Mobilization

MIS + ER

• Preop– Education

– Prehabilitation

– Premedication

– Diet

• Intraop– Steroids

– PROMPT Anesthesia

– Regional Blocks

– Fluid Limitation

• Postop– Non-Narcotic Analgesia

– Immediate Feeding

– SL IVF

-Many more elements

-Much more

collaboration

Communication Keys• Long before the case

– Premeds

– Regional blocks

– Fluids

– Narcotics

• Night before case– Next day’s plan

• After the case– Share successes

• If the metric of success is patient recovery and surgeons never show anesthesiology providers an early recovered patient they should not expect buy-in

The Best Part of ERAS

Implementation

• Bringing Together Surgery and Anesthesia

Agenda/Challenges

• Issues

– Trainee

– Patient

– Nursing

• Teamwork

Nursing Concerns

• Patients are moving too fast– Diet intolerance

– Foley removal failures

– Discharge planning

• Concern for inadequate pain control– Stairstep prn regimen

• Mild pain (1-4)=Tylenol

• Moderate pain (5-7)=Tramadol

• Severe pain (8-10) (low dose dilaudid and call)

– Very low dose Dilaudid PCARemember the Goal:

Patient Experience

NOT Patient Torture in

A Quest to Reduce LOS

Epidurals and Foleys

• Women

– foley out when independent to the bathroom

• Men

– <30 no help

– 30-50 ambulate to bathroom=foley removal

– >50 premed with Flomax and removeAutomatic foley

removal orders

are associated

with a 17%

replacement rate

“Anyone who

advocates for Foley

removal on a set

day or time has not

had one replaced

while awake” ~TAA

Agenda/Challenges

• Issues

– Trainee

– Patient

– Nursing

• Teamwork

To the C-Suite:

1. Join the Team

2. Resource the Team

3. Let doctors be doctors and

nurses be nurses

4. The ROI will come

LOS reduction is

the residue of a

high-quality ERP

ESRP Annual $ Impact

4.7 dTHE FORMULA

(Total OR/1000) X days reduced LOS

=$millions to margin per yr

(13,000 inpt operations/1000 x 2.5 days LOS)

13 x 2.5=$32.5 million per year

Agenda/Challenges

• Issues

– Trainee

– Patient

– Nursing

• Teamwork

ER Team Set-up Plan

1. Determine the Why

2. Form the Team– Punch tickets

– Meet weekly

3. Revise/Develop ordersets and pathways

4. Develop compliance metrics– Measure and Report

5. Develop outcome metrics (PRO)– Measure and Report

ER Team Set-up Plan

– Meet weekly

Simon Sinek: Start with Why

“People do not buy WHAT you do,

they buy WHY you do it.”

Team members don’t buy-in to the

product or change they are working

on, they buy-in to why the team is

making the product or change.

There are only two ways to

influence human behavior:

you can manipulate it or

you can inspire it.

Patient-centered care is

inspirational.

Catherinescareercorner.com

ER Team Set-up Plan

– Meet weekly

Early vs. Late Adopters

The Team

• Anesthesia/Surgery

• Nursing

– Clinic

– Periop

– Inpatient

The (Super) Team

• Anesthesia/Surgery

• Nursing

– Clinic

– Periop

– Inpatient

• Pharmacy

• Nutrition

• Patient Education

• PMNR

• Coordinator

• IT

ER Team Set-up Plan

– Meet weekly

Brent James

“It’s more important that you do it the

same way than what you think is the

right way.”

Brent James

“It’s more important that you

[organization] do it the same way

than what you [individual] think is the

right way.”

Think globally (patient-centric),

then act locally

Ordersets and Pathways

www.sages.org/smart-enhanced-

recovery-program

ER Team Set-up Plan

– Meet weekly

iet…

Colorectal ERAS Studies Elements Reporting

Named Element Explained Element Compliance Reported

*Day, Gottumukkala & Aloia, BJS, 2015

ER Team Set-up Plan

– Meet weekly

windsonline.com

ERAS Plan

PROs: Symptom Interference

ElementsReduce Anxiety,

Narcotics, and

Fluids

Return to Normal

Function ASAP

Anesthesia-Surgery-Nursing

If your focus is

the patient’s

recovery

experience, your

program will be

successful.

VM-Many Thanks

Thomas A. Aloia, M.D., F.A.C.S.MD Anderson Cancer Center

@mdahpbaloiataaloia@mdanderson.org

Thank You!ER @ MDACC

Steven Swisher/Thomas Feeley

Vijay Gottumukkala/Thomas Rahlfs/Carin Hagberg

John Calhoun

Clinical TeamsHPB Anesthesia/CRNAs

Surgical Oncology and HPB Surgery Fellows

Sharon Fielder/Whitney Dewhurst/Leigh Samp

Research TeamsCharles Cleeland/Shelley Wang

Ryan Day, MD, Bradford Kim, MD, MPH, Catherine Hambleton, MD

Pharmacy/Nutrition Support

Patient Education and Engagement

Early F

Goal D

irecte

Enhanced Recovery

What Areas

Need Most

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