Objectives Principles of ERAS multiple small interventions effect - - PowerPoint PPT Presentation

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Enhanced recovery in gynecologic surgery improving post-operative care

2017 UCSF Obstetrics and Gynecology Update: What Does the Evidence Tell Us?

Jocelyn S. Chapman, MD Assistant Professor Department of Obstetrics, Gynecology & Reproductive Sciences Division of Gynecologic Oncology University of California San Francisco

Traditional care on POD#1 ERAS care on POD#1

Enhanced recovery after surgery (ERAS)

Objectives

• What is the rationale for the ERAS pathway?
• What are the key elements of an ERAS pathway?
• What patients are likely to benefit from an ERAS

pathway?

Principles of ERAS – multiple small interventions effect big changes.

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Principles of ERAS – an ounce of prevention…

Prevention Cure

One way to reduce length of stay…

Standing on the shoulders of giants – ERAS improves post-op outcomes

Outcomes Marx et al. (2006) Chase et al. (2008) Gerardi et al. (2008) Carter et al. (2012) Kalogera et

• al. (2013)

Wijk et al. (2014)

Type of surgery

Cytoreductive surgery Abdominal or vaginal hysterectomy;

• pen staging

Cytoreductive surgery Cytoreductive surgery & open staging Cytoreductive surgery, open staging & pelvic

• rgan prolapse

Abdominal hysterectomy

Length of stay difference

• 1 day

NS

• 3 days

NS

• 3 days
• 0.5 days

Postoperative complications

NS NS NS NS NS NS

Mortality

NS NS NS NS NS NS

Readmissions

NS NS NS NS NS NS

Reoperations

NS

• NS

NS

• NS

Total hospital cost difference

• 6293
• 6634
• Table adapted from Nelson, Kalogara & Dowdy in Enhanced recovery pathways in gynecologic oncology. Gynecol Oncol. 2014 Dec;135(3):586-94.

ERAS pathways for gynecologic surgery: who and how?

Pitter MC, Simmonds C, Seshadri-Kreaden U, Hubert HB. The Impact of Different Surgical Modalities for Hysterectomy on Satisfaction and Patient Reported Outcomes. Interact J Med Res 2014;3(3):e11.

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Our motivation: discharge by noon ERAS implementation: like herding cats

At least I’m not responsible for implementing ERAS…

Why would trainees undertake such a task?

Residents & Fellows

Surgeons, Anesthesia Faculty, OR Staff & Nursing personnel ERAS

Patient education

PREPARING FOR ENHANCED RECOVERY

Expecta ons for prior to surgery

• On the day before surgery you may eat what you like.
• A er midnight on the day of surgery, you may con nue to drink water,

Boost Breeze (available for free on the 3rd floor of Mt. Zion), Gatorade,

• r filtered, clear apple juice.
• You must stop drinking 2 hours prior to surgery. If you con nue to

drink or drink fluids other than those listed above, then the anesthesia doctors will cancel your surgery for safety reasons.

Expecta ons for the evening of surgery

• Your nurse will be helping you get out of bed 6 hours a er surgery.
• Your bladder catheter will be removed 6 hours a er surgery, and you will

be able to urinate on your own.

• It is our top priority that you are as comfortable as possible, and you will

have access to as many oral pain medica ons as needed to control your discomfort.

Expecta ons for the morning a er surgery

• You will be able to eat a regular diet on the day following your surgery.
• You will be able to return home the day following your surgery.
• You will be asked to fill out a pa ent sa sfac on survey prior to

discharge from the hospital.

Expecta ons for home

• You will be sore a er surgery and may need to take pain medica ons.
• You should consider having a family member or friend assist you at home

as you recover.

• You will be able to reach your doctors by phone if you have concerns

during recovery.

Chapman JS, Roddy E, Ueda S, Brooks R, Chen LL, Chen LM. Enhanced Recovery Pathways for Improving Outcomes After Minimally Invasive Gynecologic Oncology Surgery. Obstet Gynecol. 2016 Jul;128(1):138-44. doi: 10.1097/AOG.0000000000001466.

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ERAS protocol for minimally invasive GynOnc surgery

Multi-modal anti-emetics TAP block or IV lidocaine

Intra-op

Minimize fluids Boost Breeze No bowel prep

Pre-op

Gabapentin, APAP, NSAID Walk and foley out within 6 hrs Gabapentin, APAP, NSAID

Post-op

Regular Diet

Chapman JS, Roddy E, Ueda S, Brooks R, Chen LL, Chen LM. Enhanced Recovery Pathways for Improving Outcomes After Minimally Invasive Gynecologic Oncology Surgery. Obstet Gynecol. 2016 Jul;128(1):138-44. doi: 10.1097/AOG.0000000000001466.

Cohort Characteristics

ERAS (n=55) Controls (n=110) P-value

Age, years 59.3 (20.1-83.1) 59.3 (15.4-88.6) 0.989 ASA status 2 (1-4) 2 (1-4) 0.569 Length of Surgery, minutes 214 (16-376) 199 (58-470) 0.802 Estimated Blood Loss (EBL), mL 100 (10-1000) 150 (5-3000) 0.800 Robotic cases 26 (47) 55 (50) 0.741 Post-operative Diagnosis 0.280

Uterine cancer

32 (58) 68 (53)

Ovarian Cancer

10 (18) 19 (44)

Cervical cancer / dysplasia

7 (13) 20 (3)

Other cancer

1 (2) 1

Benign

5 (9) 2

Data are n (%), mean±standard deviation, or median (interquartile range).

Chapman JS, Roddy E, Ueda S, Brooks R, Chen LL, Chen LM. Enhanced Recovery Pathways for Improving Outcomes After Minimally Invasive Gynecologic Oncology Surgery. Obstet Gynecol. 2016 Jul;128(1):138-44. doi: 10.1097/AOG.0000000000001466.

Compliance with ERAS elements

Multi-modal pain interventions pre- & post-operatively

ERAS (n=55) Controls (n=110) P-value TAP block

32 (58)

< 0.0001

Pre-

• perative

Gabapentin

44 (80) 2 (2)

< 0.0001 Tylenol

45 (82) 2 (2)

< 0.0001 NSAIDs

25 (46)

< 0.0001

Post-

• perative

Gabapentin

33 (60) 6 (5)

< 0.0001 Tylenol

51 (93) 88 (80)

0.034 NSAIDs

12 (22) 19 (17)

0.481

Data are n (%), mean±standard deviation, or median (interquartile range).

Chapman JS, Roddy E, Ueda S, Brooks R, Chen LL, Chen LM. Enhanced Recovery Pathways for Improving Outcomes After Minimally Invasive Gynecologic Oncology Surgery. Obstet Gynecol. 2016 Jul;128(1):138-44. doi: 10.1097/AOG.0000000000001466.

Compliance with ERAS elements

Anti-emetics, diet, fluids & urinary catheter

ERAS (n=55) Controls (n=110) P-value

Post-operative nausea & vomiting intra-operative prophylaxis

0.009

Multimodal anti-emetics

43 (78) 59 (53)

Single

11 (20) 48 (44)

None

1 (2) 3 (3)

Regular / Diabetic Diet

51 (93) 69 (62) < 0.0001

Intra-operative fluids, mL

1500 (200-3400) 1400 (200-7200) 0.60

Urinary catheter duration+, hours

11 (2-18) 21 (1-80) < 0.0001

+ patients who underwent radical hysterectomy had urinary catheter management per primary surgeon’s discretion Data are n (%), mean±standard deviation, or median (interquartile range).

Chapman JS, Roddy E, Ueda S, Brooks R, Chen LL, Chen LM. Enhanced Recovery Pathways for Improving Outcomes After Minimally Invasive Gynecologic Oncology Surgery. Obstet Gynecol. 2016 Jul;128(1):138-44. doi: 10.1097/AOG.0000000000001466.

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Patient outcomes

Pain, opiate use & length of stay is reduced for ERAS patients

ERAS (n=55) Controls (n=110) P-value

Fentanyl intra-op (mcg)

224 (50-400) 272 (50-600) 0.004

Morphine Equivalents (mg)

30.7 (5.3-55.7) 44.3 (4.2-161.7) 0.0009

Visual Analogue Scale (VAS) Score Post-op Day 0

2.39 (0-7.3) 2.61 (0-7.1) 0.236

Visual Analogue Scale (VAS) Score Post-op Day 1

2.60 (0-5.7) 3.12 (0-6.7) 0.027

Length of Stay

31.4 (±8) 51.4 (±65) <0.001

Patients discharged on POD #1

51 (93) 66 (60) <0.001

Readmission

3 (5.5) 9 (8.2) 0.525

Data are n (%), mean±standard deviation, or median (interquartile range).

Chapman JS, Roddy E, Ueda S, Brooks R, Chen LL, Chen LM. Enhanced Recovery Pathways for Improving Outcomes After Minimally Invasive Gynecologic Oncology Surgery. Obstet Gynecol. 2016 Jul;128(1):138-44. doi: 10.1097/AOG.0000000000001466.

ERAS - Impact on Length of Stay

93% discharged POD#1 60% discharged POD#1 Traditional care ERAS care

Chapman JS, Roddy E, Ueda S, Brooks R, Chen LL, Chen LM. Enhanced Recovery Pathways for Improving Outcomes After Minimally Invasive Gynecologic Oncology Surgery. Obstet Gynecol. 2016 Jul;128(1):138-44. doi: 10.1097/AOG.0000000000001466.

Patient satisfaction remains high

PRE-ERAS (N=89) POST-ERAS (N=51) P VALUE COMPLETELY SATISFIED 0.85 (76/89) 0.88 (45/51) 0.55 SOMEWHAT SATISFIED 0.12 (11/89) 0.12 (6/51) NOT SATISFIED 0.02 (2/89) 0 (0/51)

Nyakudarika N, Chen LL, Chen LM, Chapman JS. Patient satisfaction after open gynecologic oncology surgery with enhanced recovery pathway. Abstract presented at the Western Association for Gynecologic Oncologists meeting 2017.

POET: Pre-Operative Education Tool

N (%) What information did you find helpful prior to surgery? 10 Important contact information 7 70% Description of laparoscopic procedures 7 70% How to care for yourself at home 7 70% Post-operative medications 5 50% Did you like our approach to pre-operative teaching 10 *Yes 10 100% No 0% Of the information provided to you at your visit with your surgeon, how much do you recall? 10 100% 8 80% 75% 2 20% 50% 0% 25% 0% 0% 0% Was the interval between your pre-operative visit and the surgery too long, too short, or just right? 9 Too long 2 22% Too Short 0% Just Right 7 78% 10 Yes 10 100% No, I felt rushed to leave 0% No, I felt that I was kept too long 0% Did you have time to ask questions and feel prepared at discharge? 10 Yes 10 100% No 0% Did you pick up your medications prior to surgery? If no, did you have difficulty? 10 Yes 10 100% No, had difficulty 0% No, did not have difficulty 0% Did you receive consistent information from us re: surgery, hospital stay, and post-op care? 10 Yes 10 100% No 0% Question Do you feel you were discharged from the hospital in a timely manne? Wang B, Brunger J, Parrot J, Adrian C, Pubolls J, Beggs P, Chen LM, Chapman JS. POET: A Perioperative Education Tool to improve satisfaction amongst patients undergoing gynecologic oncology minimally invasive surgery. Abstract presented at the UCSF Health Improvement Symposium 2017.

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Conclusions

• Enhanced recovery pathways have been shown in a variety of

post-operative settings to provide benefit both to patients & to health care institutions

• ERAS pathways can also decrease LOS in patients undergoing

minimally invasive gynecologic cancer surgery

• Include all stakeholders – patients, providers, nurses & medical

support staff can overcome system challenges to effect change.

• Patient satisfaction remains high and may even improve with

more rigorous pre-operative education.

Question #1

TRUE OR FALSE: I can implement my favorite parts of an ERAS pathway in my practice and expect to see significant changes in length of hospital stay.

• A. True
• B. False

FALSE

Prevention Cure

True False

56% 44%

Question #2

Which of the following is TRUE when implementing an ERAS pathway?

• A. Patient expectations should be addressed

pre-operatively.

• B. Physicians are the only people who need

to change their practices.

• C. Patients are likely to be unhappy with

ERAS protocols. Prevention Cure

P a t i e n t e x p e c t a t i

• n

s s h

• .

. . P h y s i c i a n s a r e t h e

• n

l y . . . P a t i e n t s a r e l i k e l y t

• b

e . . .

97% 3% 0%

Question #3

Considering the evidence, what outcome can you expect from implementing and ERAS pathway in your practice?

• A. Patients will have higher pain scores on the

first post-operative day.

• B. Patient’s surgeries will be less complicated.
• C. Patients will have a decreased hospital length
• f stay.

Prevention Cure

P a t i e n t s w i l l h a v e h i g h e r . . . P a t i e n t ’ s s u r g e r i e s w i l l b e . . . P a t i e n t s w i l l h a v e a d e c r . . .

0% 98% 2%

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“Better is possible. It does not take

• genius. It takes diligence. … And

above all, it takes a willingness to try.”

Atul Gawande, MD Better: A Surgeon’s Notes on Performance