Enhanced Recovery Processes

Ron Collins, MD FRCP(C)

Medical Director, Surgical ServicesProject Lead, Enhanced RecoveryInterior Health AuthorityStaff Anesthesiologist, KGH

Relative Contributions to Adverse Events and Excess Length of Stay adapted from Fry et al, J Am Coll Surg 2008;207:698-

704

Procedure n % total Adverse event %

Prop. Adv. Events %

Avg. LOS

Prop. All LOS

Colectomy 12,767 9.9 28.9 24.3 9.8 23.5

Sm Bowel resection

3,576 2.8 32.9 7.7 13.9 10.6

Inpt. Chole. 11,718 9.1 7.5 5.7 8.7 4.9

Ventral Hernia

7,477 5.8 10.1 4.9 6.3 3.1

Pancreat. 1,927 1.5 34.9 4.4 6.8 3.0

“Ultimately, improving quality will require efforts that go beyond

outcomes assessment alone. Future work should aim to improve

our current understanding of processes of care associated with

superior surgical outcomes.”

Fry et al., J. Am Coll Surg 2008;207:698-704

Quality Improvement

Efforts to improve quality of care generally depend on assessing three dimensions:

•Structure: the system in which health care is delivered.

•Process: the care received.

•Outcomes: the results of the above (mortality, morbidity including LOS).

• Cohen ME et al, Ann Surg 2009;250:901-907

Variability in LOS After Colorectal Surgery Cohen et al, Ann Surg 2009;250:901-907

NSQIP data from 182 hospitals from Jan/06 to Dec/07: 23,098 patients

eLOS > 75th percentile of distribution, role of complications (19 defined), O/E ratios

No complications: LOS 6.1 days, but eLOS > 8 days

Complications: LOS 16.1 days, but eLOS > 20 days

“…hospitals with lower risk-adjusted morbidity had shorter risk-adjusted LOS.”

“For efficiency measures to be widely accepted in the market, they should be feasible to implement, credible and reliable for patients, and fair and actionable for healthcare providers.”

Enhanced Recovery After Colorectal Surgery

Evidence-Based Surgical Care and the Evolution of Fast-Track Surgery

Kehlet, H. and Wilmore, D.; Ann Surg 2008;248:189-98

Consensus Review of Optimal Peri-operative Care in Colorectal Surgery

ERAS Group; Arch Surg. 2009;144(10):961-969

Implementation of a Fast-track perioperative care Program: what are the difficulties?

Polle, sw et al, Dig surg 2007;24:441-449

ERAS program: 13 elements but only 7.4 implemented per patient

Compliance did not improve with the experience of the team

Attributed to bad collaboration of the three different disciplines in daily practice

No impact on clinical outcomes: LOS, morbidity, patient satisfaction

Implementing new routinesAre we using ”Best practice”?

The German ”Prevalence”Study in ICU

M M Levy, ASPEN 2007

92%

It is not like we think it is….

The German ”Prevalence”Study

M M Levy, ASPEN 2007

92%

4%

Enhanced Recovery After Surgery

“The profession has placed high value on developing the basic science of medicine: it has not emphasized the process by which the science is translated into practice…”

Eddy, DM. N Engl J Med 1982;307:343-7

Adherence to the ERAS protocol and outcomes after colorectal cancer surgery

ERAS group, Arch Surg 2011;146:571-77

27% improvement in adherence (47% to 74%)

27% reduction in any 30 day morbidity

In fact: dose-response curve for adherence:

70% adherence: LOS 7.4 days; OR morbidity: 0.62

80% adherence: LOS 7.0 days; OR morbidity: 0.57

90% adherence: LOS 6.0 days; OR morbidity: 0.33

Elements most predictive of good outcome:

GD fluid management, Pre-operative CHO beverage

Adherence to the ERAS protocol and outcomes after colorectal cancer surgery

ERAS group, Arch Surg 2011;146:571-77

Prospective Cohort Study: 464 controls (2002-04), 489 study (2005-07)

Second cohort higher risk, more difficult surgery

12 ERAS elements, unchanged

Staffing, infrastructure unchanged

Study compared outcomes and adherence for two periods

MLRA examined the importance of each element in the pathway

Interior Health Authority

Our Vision: To set new standards of excellence in the delivery of health services in the Province of British Columbia

IH Overall

Intra-operative Fluid Management

cardio q non cardio q0

500

1000

1500

2000

2500

1140

1962

660

436

colloidcrystalloid

Interior Health Authority

Our Vision: To set new standards of excellence in the delivery of health services in the Province of British Columbia

IH OverallLength Of Stay

Cardio Q Non Cardio Q0

1

2

3

4

5

6

7

8

9

10

6.86

9.41 Series1

17

Length of stay reduced from 12.8 to 4.0 days.RIW reduced from 3.41 to 1.76

Benefit/cost ratio: 2.18ROI: 118%

CIHI estimated cost reduction of 48.4%.

1 5 91

31

72

12

52

93

33

74

14

54

95

35

76

16

56

97

37

78

18

58

99

39

71

01

10

51

09

11

31

17

12

11

25

12

91

33

13

71

41

14

51

49

15

31

57

16

11

65

16

91

73

17

71

81

18

51

89

19

31

97

20

12

05

20

92

13

21

7

0

10

20

30

40

50

60

70

80

UCL

LCL

Kelowna General Hospital Colorectal Patient Length of Stay Starting 3/09/2010

Patient Number

Le

ng

th o

f S

tay

(D

ay

s) UCL:

32.3 UCL: 10.3

Pre-ER-ACS Mean 12.8

ERACS Mean 4.1

ERACS Introduc-tion

CMG: Open Colorectal Resection

Length of Stay R.I.W.

Traditional 11.4 2.5

ERAS 5.1 1.7

CIHI: cost of care reduced by 33%

CMG: Colorectal Resection with Stoma

Length of Stay R.I.W.

Traditional 11.9 3.5

ERAS 6.0 2.1

CIHI: cost of care reduced by 40%

What is the role of GDT?

CardioQN = 23

No CardioQN = 55

CMG 223 4.1 5.8

CMG 227 5.0 7.4

Complications 0 7

AUTONOMYPURPOSE

MASTERY

Enhanced Recovery Society of Canada

• Mission: “To support the development and implementation of processes of care that result in outcome benefits for surgical patients.”

• Sister Society in Canada of ERAS Society• Website: www.enhancedrecovery.ca• Inaugural Chairperson: Prof. F. Carli: MUHC

• Website development courtesy of: Fresenius-

Kabi and Deltex Medical.