Enhances recovery after surgery

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Early removal of catheter. • Early oral ... A multidisciplinary workgroup was ... on both ERAS workgroups, the Department of Anesthesia is slow to change the.

Enhanced Recovery After Surgery (ERAS): Quality Improvement in Patient Care using Evidence-Based Practices Lisa Parks, MS, RN, CNP and Sarah Kincaid, MSN, RN, CNP, CNL The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center—Columbus, Ohio

Background Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative care pathway designed to achieve early recovery for patients who are undergoing oncologic surgical procedures. ERAS pathways encompass the interval prior to surgery to the day of discharge. In order to improve patient care, advanced practice nurses used evidence-based practice to develop a multidisciplinary pilot protocol for Whipple patients.

ERAS

Preoperative • Preadmission counseling • Fluid and carbohydrate loading • No prolonged fasting • No/selective bowel prep • Antibiotic prophylaxis • Thromboprophylaxis • No premedication

Innovation

Sample ERAS Process

Nutrition

Activity

Postoperative

Intraoperative • Short-acting anesthetic agents • Mid-thoracic epidural No drains • Avoidance of salt and water overload • Maintenance of normothermia (body warmer/warm intravenous fluids)

Day of Surgery

• • • • • • • • •

Mid-thoracic epidural No NG tube Prevention of PONV Avoidance of salt & water overload Early removal of catheter Early oral nutrition Non-opioid oral analgesia/NSAIDs Early Mobilization Stimulation of gut motility

Medication

Treatments

Purpose The goal of the project was to develop a standardized plan of care enabling all disciplines caring for the patient to be consistent and evidence-based thereby improving quality and reducing morbidity. A multidisciplinary workgroup was developed with the purpose of developing a pilot program.

Interventions • Current literature was systematically reviewed with key words: ERAS; fast track; early mobility; early feeding. • Clinical pathways and process maps were designed using evidence-based practice and standards of care.

• Standardized order sets were developed and individuals were identified as monitors to assess patient outcomes and collect data to revise and improve patient care and clinical pathways. • Standardized patient and family education was developed using various disciplines with significant input from bedside staff nurses

Post-Op Day 1

Post-Op Day 2 (Home)

After Discharge

Ice chips/Clear liquids

Liquids or simple solids

Advance diet as tolerated

Diet as directed

Walk with help Sit in chair every 2 hours Use incentive spirometer every hour while awake

Walk without help 5 times a day Out of bed for 6 hours Cough and deep breath frequently while awake Use incentive spirometer every hour while awake

Walk without help 5 times a day Out of bed for 6 hours Cough and deep breath frequently while awake Use incentive spirometer every hour while awake

Short, frequent walks

Pain pills

Pain pills as needed

PCA pump, epidural, PCA pump, epidural, or pain pills for pain or pain pills for pain control control Urinary Catheter Chew gum Wound care

Planning for Home Care

Advanced practice nurses are trained to design and implement quality improvement projects while mentoring staff nurses to develop patient and family education. Bedside nurses who participate in protocol development understand the need to implement a new way of educating and caring for a specific patient population

References Brady, K., Keller, D., & Delaney, C. (2015). Successful implementation of enhanced recovery pathway: The nurse’s role. AORN Journal, 102(5) 470-481. Gerritsen, A., Wennink, R., Besselink, M., Santvoort, H., Tseng, D., Steenhagen, E., …Molenaar, I. (2014). Early oral feeding after pancreacodouodenectomy enhances recovery without increasing morbidity. HPB 16, 656-664.

Remove urinary catheter Chew gum Wound care

Chew gum Wound care

Discharge planning

Discharge home Home or skilled when passing gas or nursing facility stool

Wound care

Evaluation This is a pilot project implemented within the past six months. Data is currently being collected on length of stay, patient satisfaction, and associated costs.

Hain, D. & Kear, T. (2015). Using evidence-based practice to mor beyond doing things the waywe have always done them. Nephrology Nursing Journal 42(1) 11-21. Lassen, K., Coolsen, M., Slim, K., Carli, F., Aguilar-Nascimento, J., Schafer, M., …Dejong, D. (2013). Guidleines for perioperative care for pancreaticoduodenectomy: Enhances recovery after surgery (ERAS( society recommendations. World Journal of Surgery, 37, 240-258. Nussbaum, D., Penne, K., Stinnett, S., Speicher, P., Cocieru, A., Blazer, D., …White, R. (2015), A standardized care plan is associated with shortened hospital length of stay in patients undergoing pancreaticoduodenectomy. Journal of Surgical Research, 193, 237-249. Pedziwiatr, M., Kisialeucki, M., Wierdak, M., Stanek, M., Natkaniec, M., Matiok, M., …Budzyriski, A. (2015). Early implementation of enhanced recovery after surgery (ERAS) compliance Improves: A prospective cohort study. International Journal of Surgery Teeuwen, P., Biechrodt, R., Strik, C., Groenewoud, J., Brinkert, W., Laarhoven, C., …Bremers, A. (2010). Enhanced recover after surgery (ERAS) versus conventional postoperative care in colorectal surgery. Journal of Gastrointestinal Surgery, 14 88-95 Wallstrom, A. & Frisman, G. (2013). Facilitating earlyrecovery of bowel motility after colorectal surgery: A systematic review. Journal of Clinical Nursing 23, 24-44

Discussion This project has allowed the Quality Committee in the Department of Surgery to look at other patient populations where care is currently not evidence based. Members from the pilot Whipple ERAS project are acting as mentors for the colorectal patient population ERAS workgroup. Despite having Anesthesia present on both ERAS workgroups, the Department of Anesthesia is slow to change the NPO after midnight policy, so as not to cancel cases.

Preoperative

• • • • • • •

Patient education Preadmission counseling Discharge planning Fluid balance Carbohydrate loading Antibiotic prophylaxis Thromboprophylaxis

Intraoperative

• Minimally invasive surgical techniques as appropriate • Multimodal analgesia/anesthesia • Goal-directed fluid therapy • Maintenance of normothermia • Limited use of intraabdominal drains

Postoperative

• • • •

Early mobilization Breathing exercises Avoidance of NG tubes Early removal of drains, lines, catheters • Early oral intake, chewing gum • Opioid-sparing analgesia • Peripheral opioid antagonist

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