Enhanced Recovery After Surgery

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Best Practice in General Surgery. The iERAS Project. Robin S. McLeod. Departments of Surgery and. Health Policy Management and Evaluation. University of ...

Best Practice in General Surgery The iERAS Project

Robin S. McLeod Departments of Surgery and Health Policy Management and Evaluation University of Toronto

Best Practice in General Surgery §  Concept of “Best Practice in General Surgery” introduced at U of T General Surgery retreat in September, 2006 §  Aim: to promote standardized evidence based practices in the Divisions of General Surgery at the adult U of T teaching hospitals §  Rationale §  Improve patient care §  Improve resident education §  Capitalize on expertise within GS §  Be ahead of the potential political agenda §  Unanimous agreement from faculty and residents

Guidelines §   SSI prevention

§  VTE Prevention §  Mechanical Bowel Prep §  Intra-abdominal Infection §  Enhanced Recovery after Surgery §  Post Operative Pain Management §  Diverticulitis §  Pancreatitis §  Bariatric Surgery-VTE prophylaxis §  Indications for Blood Transfusion

Enhanced Recovery After Surgery Programs §  Multimodal programs developed to decrease post operative complications, speed recovery and promote early discharge §  Adopting best practices to prepare patients preoperatively, decrease peri-operative stress, postoperative pain, gut dysfunction, infection, and promote early mobilization

Enhanced Recovery After Surgery Guideline §  Began work in 2009 §  Meta-analysis of 6 RCTS assessing ERAS (Eskicioglu et al) §  50% decrease in 30-day morbidity (RR 0.52, CI, 0.36-0.73) §  Decrease in LOS by 2.5 days (95% CI, 3.92-1.11) §  Audit to assess current status (Aarts et al) §  Retrospective review of 350 patients treated at the 7 U of T adult hospitals

Enhanced Recovery After Uptake Figure 1. Uptake ofof ERASERAS Strategies Surgery: Audit Strategies Pre-op counseling Pre-assessment by Anesthesia Probiotics Given Oral Bowel Prep avoided Carbohydrate Loading Fasting Protocol < = 3 hours Intra-operative fluid restriction** Perioperative hyperoxia O2 > 80% Type of Incision - Transverse No NG Tube Epidural analgesia Standing NSAIDS Clear fluids on day of surgery Ambulation encouraged Early D/C of Foley Catheter*** Regular Domperidone Regular Magnesium Hydroxide Liquid Calorie Supplements 0





Frequency of Use (%)


Enhanced Recovery After Surgery §  Surveyed anaesthetists at each hospital to determine current status re: fluid and pain management §  Assessed perceived barriers and enablers §  Interviews of key stakeholders (Pearsall et al) §  Surveyed general surgery residents (Nadler et al)

What did we learn? §  Lack of communication and collaboration across disciplines §  Skepticism that we could change behavior

Lot of enthusiasm and support Base guidelines on strong evidence Include patients and their families Must be a multidisciplinary approach §  Collaborative, good communication, champions §  Educational interventions §  Institutional buy in §  §  §  § 

Enhanced Recovery After Surgery § Working group developed guideline (surgeons, residents, nurses and anaesthetists) §  Systematic review of all elements in published ERAS protocols §  Met in May 2011 to agree upon interventions included in the “U of T bundle” §  Inclusion of interventions with strong evidence §  Felt to be feasible based on current infrastructure, cost, current culture of practice §  Three subgroups crafted guideline recommendations § Finalized guideline recommendations at a Workshop in February 2012 and also discussed implementation strategies

Guideline Recommendations Preoperative Interventions §  Patient Education-including expectations and LOS §  Reduced Fast and high CHO drinks Intraoperative Interventions §  SSI and VTE prophylaxis §  Avoidance of Prophylactic Abdominal Drains and Nasogastric Tubes Perioperative Fluid Management §  Intra-operative Management §  Post-operative Fluid Management Perioperative Pain Management §  Thoracic Epidural Analgesia §  IV Lidocaine §  NSAIDs, acetaminophen, gabapentim Postoperative Interventions §  Early Mobilization §  Early Enteral Feeding and Chewing Gum §  Early removal (and avoidance) of urinary catheters

Implementation of ERAS Guideline §  Began implementation at the 8 U of T adult hospitals in June 2012 §  Now, 15 academic hospitals involved in the iERAS project which is funded by a CAHO ARTIC grant •  •  •  •  •  •  •  •  •  •  •  •  •  • 

Health Sciences Center North Hamilton Health Sciences Hospital Kingston General Hospital London Health Sciences Center Mount Sinai Hospital North York General Hospital St. Joseph Health Center, Toronto St. Joseph Health Science Center, Hamilton St. Michael’s Hospital Sunnybrook Health Sciences Center The Ottawa Hospital Thunder Bay Regional Hospital Toronto East General Hospital University Health Network (TGH and TWH)

Acknowledgements-BPIGS *Mary-Anne Aarts Fred Brenneman Marcus Burnstein Natalie Coburn *Darlene Fenech Paul Karanicolas Tim Jackson *David Lindsay *Robin McLeod *Avery Nathens *Allan Okrainec *Lorne Rotstein *Peter Stotland Alice Wei

Cagla Eskicioglu Shawn Forbes Jeff Doyle Julie Hallett Grace Ma Melinda Magissano Ashlie Nadler Debbie Li Trevor Wood Ujesh Sheth Amy Glicksman Aman Pooni Claire Harrington Janet Lee Jonathan Hsu Emily Pearsall Marg McKenzie Jhananiee Subendran

Bill Geerts James Teresi Andrew Morris Sandra Nelson Bev Morningstar Stuart McCluskey Frances Chung Naveed Siddiqui Jason Sawyer Laurie Jenkins Maria Monteiro Val Beadle Elaine Avila Joan Parks Shierell Mcghie Leslie Gotlib

Acknowledgements-iERAS Mary-Anne Aarts Rebecca Auer Antonio Ceycedo Margarita Cadeddeu Darlene Fenech Shawn Forbes Anand Govindarajan David Lindsay Hugh MacDonald Gabe Mapeso Catherine O’Brien Allan Okrainec Ori Rotstein Chris Schlacta Peter Stotland

Francis Chung Chris Harle Tony Hicks Darryl Irwin Stuart McCluskey Bev Morningstar Naveed Siddiqui Hanna Tuszynska Linda Onorato Janet Van Vlymen John Agellon Ahmed Hamdy Cyndie Horner Ian Dobson Michael Hiscox Michael Szeto

Donna Harrow Monique Kvaltin Melissa Emslie Debbie Wawryszyn Elaheh Sarvi Michelle Wong Elaine Avila Maureen Savoie Joan Park Mary Dunn Deboura Olson Chris Saby Anna Kacikanis Barbara Blair Carol Lopez

Leslie Gotlib Emily Pearsall Marg McKenzie Jhananiee Subendran

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