ERAS - PHILSPEN Main Page

ERAS -‐ Moving Evidence Based Periopera6ve Care to Prac6ce Olle Ljungqvist MD PhD Professor Surgery Örebro University Hospital & Karolinska InsBtutet Sweden PHILSPEN
Manilla, The Phillipines
October 7, 2014
Surgery today •  5% of the populaBon operated in the Western world •  270 million operaBons annually (WHO) •  PerioperaBve care is complex & important •  Best pracBce is not in use •  It takes ≈ 15 years to change pracBce •  ERAS – Enhanced Recovery AWer Surgery aims to help lead the way to use of EBM PerioperaBve OpBmizaBon: Recovery AWer Surgery What are we trying to achieve? Pa6ent back to preopera6ve func6on •  Normal gastrointes6nal func6on –  Normal food intake –  Bowel movement •  Pain control •  Mobility •  No complica6on What is ERAS? • 
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ERAS = Enhanced Recovery AWer Surgery Consensus on perioperaBve care* InternaBonal network – ERAS Society Team work – mulB professional & disciplinary Implementa6on: –  Audit –  Control over care *Fearon et al, Clin Nutr 2005, Lassen et al, Arch Surg, 2009 A Non profit Multi-professional Multi-disciplinary
Medical Society
Founded in 2010
Mission statement: Enhancing Recovery After Surgery
The mission of the Society is to develop perioperative care
and to improve recovery through
•  Research,
•  Education,
•  Audit and
•  Implementation of evidence based practice.
Peri-op fluid
management
Epidural
Anaesthesia
Short acting
anestetics
DVT
prophylaxis
No - premed
Pre-op
councelling
Early
mobilisation
No bowel prep
ERAS CHO - loading/
no fasting
Perioperative
Nutrition
Body heating
devises
Oral analgesics/
NSAID’s
Incisions
No NG tubes
Prevention
of ileus/
prokinetics
Early removal
of catheters/drains
Fearon et al, Clin Nutr 2005 What is in the guidelines? The paBent’s journey Integrated ERAS protocol P
F
R
O
L E
L
POST-‐OP WARD HOME O A
W D CLINIC PRE-‐OP SURGERY / M
U
ANESTHESIA P I
S
3
RECOVERY S
0 I
D O
InteracBve Team audit of outcomes & compliance AY N
Ljungqvist JPEN 2014 The paBent’s journey: in control Integrated ERAS protocol P
F
R
O
L E
L
POST-‐OP WARD HOME O A
W D CLINIC PRE-‐OP SURGERY / M
U
ANESTHESIA P I
S
3
RECOVERY S
0 I
D O
Interac6ve Team audit of outcomes & compliance AY N
Ljungqvist JPEN 2014 Peri-op fluid
management
Epidural
Anaesthesia
DVT
prophylaxis
Remifentanyl
No - premed
Pre-op
councelling
No bowel prep
ERAS Early
mobilisation
Perioperative
Nutrition
CHO - loading/
no fasting
Incisions
Bairhugger
Oral analgesics/
NSAID’s
No NG tubes
Prevention
of ileus/
prokinetics
Early removal
of catheters/drains
Fearon et a al 2005, Lassen et al Arch Surg 2009 ERAS works: Meta analysis 2013 ERAS: shorter length of stay by 2.4 days Zhuang et al et al, Dis Col Rect 2013 ERAS works: Meta analysis 2013 ERAS: Reduce complicaBons by 30% Zhuang et al et al, Dis Col Rect 2013 ERAS obstacle – wish vs. reality Seefeld 2013: ≈ 100 colorectal specialists & SAGES USA 2014 ≈ 250 surgeons
Who is aware of ERAS?
MarBn Hübner 2013 ERAS obstacle – wish vs. reality Seefeld 2013: ≈ 100 colorectal specialists & SAGES USA 2014 ≈ 250 surgeons
Who has an ERAS protocol?
MarBn Hübner 2013 ERAS obstacle – wish vs. reality Seefeld 2013: ≈ 100 colorectal specialists & SAGES USA 2014 ≈ 250 surgeons
Who could provide data on compliance?
MarBn Hübner 2013 And in Sweden •  ”We do ERAS already” •  Length of stay naBonal average –  Colonic resecBons 8 days –  Rectal resecBons 10 days And in Sweden •  ”We do ERAS already” •  Length of stay naBonal average ERAS –  Colonic resecBons 8 days –  Rectal resecBons 10 days 3-‐6 4-‐8 What is the missing link? Team Audit ImplemenBng new rouBnes Are we using ”Best pracBce”? The German ”Prevalence”Study in ICU 100
90
80
70
60
50
40
30
20
10
0
92%
Interview
Use of low tidal volume
M M Levy, ASPEN 2007 It is not like we think it is…. The German ”Prevalence”Study 100
90
80
70
60
50
40
30
20
10
0
92%
Interview
Audit
4%
Use of low tidal volume
M M Levy, ASPEN 2007 The paBent’s journey Integrated ERAS protocol P
R
E
A
D
M
I
S
S
I
O
N
CLINIC PRE-‐OP F
O
L L
POST-‐OP WARD HOME O
W SURGERY / U
ANESTHESIA P 30 D RECOVERY A
Y Interac6ve Team audit of outcomes & compliance Ljungqvist JPEN 2014 ERAS ImplementaBon Program Building Blocks •  World Experts –  Guidelines –  Centers of Excellence (teaching) •  Structured Training –  Breakthrough tailored for ERAS •  Special IT support –  Encare & Partners New guideline 2014: Gastrectomy Colon Pancreas Rectal New guideline 2014: Gastrectomy Colon Pancreas Rectal Do the guidelines work? A test of Compliance ERAS compliance: Length of stay & Readmissions Colorectal cancer
n = 953
p < 0.05
Compliance with ERAS protocol elements
Gustafsson et al, Arch Surg 2011 ERAS compliance: ComplicaBons Per cent patients affected
50"
45"
40"
Colorectal cancer
35"
30"
25"
Complica6ons"
20"
15"
10"
n = 953
5"
p < 0.05
0"
<50%"
>70%"
>80%"
>90%"
Compliance with ERAS protocol elements
Gustafsson et al, Arch Surg, 2011 ERAS compliance: ComplicaBons 13 hospitals 7 countries 50 Per cent patients affected
Colorectal cancer
40 30 Major complica6on Any complica6on 20 10 n = 2352
0 <50% 75-‐90% >90% Compliance with ERAS protocol elements
Multi center study, consecutive patients
Currie et al, Ann Surg, 2014 accepted for publica6on ERAS compliance: 5 year mortality 5 year overall mortality 40% 35% 30% 25% 20% 15% 10% 5% 0% <50% >70% Compliance with ERAS protocol elements
Oppelstrup et al, Swedish Surgical Society August 2014 preliminary data ERAS Society implementaBon •  Center of Excellence
•  Running ERAS, site visits, teachers,
developers
• 
ERAS Implementation Program
• 
Team approach
• 
ERAS Guidelines – best practice
• 
ERAS Interactive Audit System
ERAS ImplementaBon Program Building Blocks •  World Experts –  Guidelines –  Centers of Excellence (teaching) •  Structured Training –  Breakthrough tailored for ERAS •  Special IT support –  Encare & Partners ERAS® Society implementa6on program Philosophy The paBent’s journey Integrated ERAS protocol P
R
E
A
D
M
I
S
S
I
O
N
CLINIC PRE-‐OP F
O
L L
POST-‐OP WARD HOME O
W SURGERY / U
ANESTHESIA P 30 D RECOVERY A
Y Interac6ve Team audit of outcomes & compliance Ljungqvist JPEN 2014 ERAS team approach • 
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Surgeon Anesthes6st HDU specialist Ward nurses Anesthesia nurses Physiotherapist Die66an •  Management Team work: •  Training •  Implemen6ng •  Planning •  Audi6ng •  Upda6ng •  Repor6ng •  Research ERAS team approach • 
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Surgeon Anesthes6st HDU specialist Ward nurses Anesthesia nurses Physiotherapist Die66an Team work: •  Training •  Implemen6ng •  Planning •  Audi6ng •  Upda6ng •  Repor6ng •  Research No esc
ape – all aro
un
•  Management d the t
a
ble Group work shops ERAS Implementa6on plan Prepara6ons S 2 S 1 S 3 28-‐29 nov 2011 S 3 26-‐27 sept 2011 7maj 2012 2 feb 2012 Report of IntroducBon to New situaBon Results (pre ERAS) Video follow-‐up ERAS ReporBng results Dec 2011j-‐
Jan 2012 Goals, measures & ReporBng results Present status Summary of what has Outcomes Half day Start data entry Been learned visit by EIP-‐coach Planning for local Strategies for Planning for ERAS implementaBon
the future implementaBon Develop methods to RouBne use of ERAS Successively start enter data into EIAS for all paBents using ERAS in paBents Work group meeBngs Work group meeBngs, Work group meeBngs for regular interacBve develop a new way of audit audiBng Support by the Coach Support by the Coach Support by the Coach 4 InteracBve work shops over 8 – 10 months 3 acBve working periods at home Ac6ve work periods Follow-‐
up Alumni PaBent informaBon Comprehensive guides and booklets to understand the Enhanced Recovery Programme ERAS® Care plans and pathways References and bibliography The most relevant references for ERAS Nursing Nursing requirements –  Informa6on –  Implementa6on –  Stoma pa6ents ImplementaBon plan – does it work? Results: •  Proof of concept in 5 countries (NL, S, CH, Can, F) •  All show improved outcomes (next slides) •  No dropouts aWer training – all run EIAS •  Major Health providers signing up 10/14/14 44 Length of stay ERAS ImplementaBon NL Gillissen et al, World J Surg 2013 Compliance & total LOS Single center Switzerland 2010 to 2013 Swiss ERAS ImplementaBon Sweden ERAS ImplementaBon Enhanced Recovery Processes of Care Reduce ComplicaBons Kelowna General Hospital Colorectal Patient Length of Stay Starting 3/09/2010
80
UCL: 32.3 60
50
Pre-‐ERACS Mean 12.8 ERACS IntroducBon UCL: 10.3 40
30
UCL
20
10
0
LCL
1
4
7
10
13
16
19
22
25
28
31
34
37
40
43
46
49
52
55
58
61
64
67
70
73
76
79
82
85
88
91
94
97
100
103
106
109
112
115
118
121
124
127
130
133
136
139
142
145
148
151
154
157
160
163
166
169
172
175
178
181
184
187
190
193
196
199
202
205
208
211
214
217
Length of Stay (Days)
70
Patient Number
Length of stay reduced from 12.8 to 4.0 days. RIW reduced from 3.41 to 1.76 CIHI esBmated cost reducBon of 48.4%. Coutersy Dr R Collins, Kelowna, B.C. 49 ERACS Mean ERAS ImplementaBon ERAS Center of Excellence (KOL) ERAS Symposia & other local events ERAS ImplementaBon Program New surgical disciplines; Colorectal, Orhopedics, Gynecology, Urology etc. ERAS®Society 2012 a few ERAS centers, implementaBon just starBng More than one ImplementaBon program ImplementaBon program running/announced ERAS Center in place ERAS center established in 2012 ERAS center discussions 51
ERAS®Society 2014 Growing fast… More than one ImplementaBon program ImplementaBon program running/announced ERAS Center in place ERAS center established in 2014 ERAS center discussions 52
ERAS®Society 2014 …but sBll a lot to do More than one ImplementaBon program ImplementaBon program running/announced ERAS Center in place ERAS center established in 2014 ERAS center discussions 53
ERAS & Cost savings •  New Zealand –  4,000€ / paBent in the ﬁrst 50 paBents. Study visits & full Bme included •  Switzerland –  1,500€ / paBent per ﬁrst 50 paBents. Training & full Bme nurse included •  Canada –  2,200 €/ paBent (esophageal surgery). Roulin et al, BJS 2013, Sammour NZJS 2010, Lee BJS 2013 ERAS ImplementaBon Program Building Blocks •  World Experts –  Guidelines –  Centers of Excellence (teaching) •  Structured Training –  Breakthrough tailored for ERAS •  Special IT support –  Encare & Partners InteracBve Audit System ConBnuous control •  One international database
•  Based on updated Best Practice ERAS Society
developed protocols
•  Internet access, bank security
•  De-identified patient data
•  Data ownership by entering unit
•  National/regional control
ERAS InteracBve Audit System •  Immediate & conBnuous control •  Team approach •  Compare – benchmark •  Check progress over Bme •  Basis for research ERAS Interac6ve Audit System -‐ Easy to use registra6on Context driven helptexts
Symbol explana6on 58 ERAS Interac6ve Audit System -‐ Easy to use registra6on 20-‐2
5 mi
n
utes
/ pa
Bent
Context driven helptexts
Symbol explana6on 59 Interac6ve Team Audit Dashboard Overview diﬀerent parts Surgeries Overview diﬀerent parts Complica6ons Overview diﬀerent parts Length of stay Overview diﬀerent parts Compliance With ERAS Overview diﬀerent parts Filters for detailed analysis ERAS training Analyse the eﬀect of ERAS training Real life example Interview 2010: •  ”Use all elements of ERAS except preop carb” Length of stay esBmated to •  Colonic resecBon: 5-‐7 days •  Rectal resecBon: 7-‐10 days 2010 – Before ERAS 2010 – Before ERAS 2010 – Before ERAS 2010 – Before ERAS 2010 compliance 2011-‐ AWer ERAS training 2011-‐ AWer ERAS training 2011-‐ AWer ERAS training 2011-‐ AWer ERAS training 2011 compliance Understand the outcomes Most common problem: PONV PONV most common Eﬀects of PONV PONV prolongs LOS by 2 days Pats with PONV: Treated How? What did we do? PONV prolongs LOS by 2 days Treatment to paBents with PONV ExplanaBons Preop? Treatment to paBents with PONV ExplanaBons Postop? Ac6ng to control outcomes Before acBons: 26% PONV Most common problem: PONV 26% MulBfactorial problem: Many involved Preop educaBon Preop carbs PONV prohylaxis
Preop sedaBon Controlling ﬂuids
Etc. surgical clinic clinic / anesthesia anesthesia anesthesia anesthesia/PACU/ward Clinic: PaBent educaBon IdenBfy the problem Decide to change Clinic: PaBent educaBon Follow the change over Bme Feed back to personel Clinic: PaBent educaBon Secure quality over Bme ConBnuous feed back Anesthesia / Clinic: Preop carbs Anesthesia: PONV prophylaxis Anesthesia: Avoid Preop sedaBon Anesthesia, PACU & ward: Fluids Result of acBons: PONV reduced PONV reduced from 26% to 14% Summary ü Best pracBce is not in use ü PerioperaBve care is complex and important ü MulB professional & MulB disciplinary apporach necessary ü SystemaBc implementaBon in teams ü InteracBve Audit is a useful tool ü ERAS improves outcomes ü Winners: PaBents, staﬀ, payers 3rd World Congress of ERAS® Society with American Society for Enhanced Recovery Evidence Based PerioperaBve Medicine UK ERAS Society introductory course Henrik Kehlet lecture ERAS Society lecture ERAS Society guidelines ERAS for the surgeon the anesthesiologist the nurse the manager New ﬁndings – abstracts Debates Workshops www.erassociety.org

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