Impact of Adherence Levels

to an ERAS protocol for

Elective Colorectal Surgery E4 session

Disclosure Financial: Speakers Bureau for 3M Canada on the topic of

perioperative normothermia 2015

Faculty of Medicine, Department of Anesthesiology, Pharmacology and Therapeutics, Director of Quality Assurance and Patient Safety VH/UBC Department of Anesthesia and Perioperative Care

ERAS VGH Team: Andrea Bisaillon, Tracey Hong, Medical Students: Yang Huang & Liam Stobart

General Surgeons, Nursing Staff PACU, OR, Ward, PCC , PAC

Enhanced Recovery

“Dose” response relationship

Gustafsson et al. Arch Surg 2011: 146(5) 571-577

N= 953 , * p < 0.05

To ERAS protocol

Why do ERAS at VGH?

Colorectal Procedures -10th decile for NSQIP 30 day morbidity for 27.8% (2011-2013 N= 99)

Mean LOS 10.76 days

SSI 20%

UTI 5%

Method Audited 100% of all cases since implementation in

November 2013-December 2015 . N=369

Have used the BC Collaborative and NSQIP-ERIN data collection tools

Real-time auditing by nursing staff and medical students

Distilled the adherence to 12 components that were considered most important and were documented most consistently

Method: 12 Key Components Pre-operative counseling

Pre-operative anesthesia consult

CHO loading—*am of surgery

Normothermia

Multimodal analgesia

GDFT—use of monitor

Timely antibiotics

Adequate PONV prophylaxis

Fluids Day 0

Solids Day 2

Mobilization POD 0 X 1

Mobilization POD 1 X 2

Method

Compared two cohorts –those with < 75 % adherence and those with > 75% adherence

Patient demographics –ASA status, age, gender

Looked at NSQIP 30 day postoperative morbidity and length of stay

Results: Adherence Rates Pre-operative Counseling 71.9%

Preoperative Anesthesia Consult 94.8%

CHO loading preop 74.1%

Timely antibiotics 85.6%

Normothermia 94.8%

Adequate PONV prophylaxis 86.6%

Goal directed fluid therapy with monitor 54.7%

Multimodal analgesia 74.1%

Fluids on POD 0 61.8%

Mobilization POD 0 40.8%

Mobilization POD 1 X2 71.0%

Solids on POD 1 or 2 33.2%

Results: Patient demographics < 75% adherence (N=211) > 75% adherence (N=158)

Age (mean) 66.61 +/- 14.36 67.61 +/- 12.74

Female/male ratio 44.5/55.5 43/57

ASA 1 4.3% 5.1%

ASA 2 57.8% 60.8%

ASA 3 35.5% 32.3%

ASA 4 2.4% 1.9%

Laparoscopic 63% 82.3%

Open 28.4% 10.1%

MIS converted to open 8.5% 7.6%

RESULTS: NSQIP MORBIDITY and LOS

PRE-ERAS (N=99)

<75% ADHERENCE (N=211)

>75% ADHERENCE (N=158)

P values

All complications

27.8%* 18% 15.2%* P<0.05

Pneumonia 5.1% 5.7% 1.3% P<0.05

Ventilation > 48 hours

5.1% 3.3% 0.6% P=0.08

Reintubation 4.0% 4.7% 0.0% p<0.05

Total Pulm 5.1% 6.3% 1.3% p<0.05

Pulm Emboli 1.0% 0.5% 0.0% P=0.07

LOS (mean) 10.7 8.46 5.81 P<0.05

Univariate Analysis

Did adherence with any of these 12 variable correlate to a decrease risk of a developing “no complications”

Patient pre-education independent predictor of no complications: OR 2.181 CI 1.058-4.496 ( p< .05)

Lessons Learnt Adoption of ERAS pathway has resulted in a significant

decrease in complication and LOS at VH

Increased adherence was associated with an greater reduction in complications, particularly pulmonary complications

We need to do further work to increase adherence to the postoperative variables

Adequate preoperative education is an integral component to the ERAS pathway

Importance of the team approach

Surgical Units

Pre-admission Clinic Pre-operative Care Centre OR

PACU

VCH NSQIP

VGH ERAS Steering Committee

VA Department

of Anesthesia