the pathways to improve patient care enhanced recovery after surgery (eras) presented by deborah...

The pathways to improve patient care

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Enhanced Recovery After Surgery (ERAS)

Presented by Deborah Bachand Manger of Surgical Service Project & Implementation for VIHA

“Would you tell me, please, which way I ought to go from here?”

“That depends a good deal on where you want to get to,” said the Cat.

“I don’t much care where–” said Alice.

“Then it doesn’t matter which way you go,” said the Cat.



ERAS programs follow well trodden paths…Evidence based, internationally proven to improve outcomes and patient satisfaction…



Medication

Cognition Pain

Mobility

Bowel/bladder

Nutrition/hydration

48/6

Elderly-friendly/ patient-centered care

Collaborative inter-professional team Care-related communication

CDMR

• Promoting self management and care through education and prehabilitation

• Optimizing preoperative nutrition• Normalizing GI/GU function• Minimizing pain • Early feeding postoperatively – as soon as appropriate• Optimizing early ambulation• Discontinuing attached lines, drains, tubes as soon as appropriate• Optimizing respiratory function



Pathway Principles

The Travel Guide



Surgery is a Journey

Think of

ENHANCED SURGICAL PATHWAYS

as the GPS to help our patients navigate the system…

Your name: _____________________

Before, During and After

Colon (Bowel) Resection Surgery A guide for adults having a colon (bowel) resection at Victoria General or Royal Jubilee Hospitals. Please:

Read this booklet the day you get it.

Keep it beside your phone to write down any further instructions.

Bring it to all your appointments before and after your surgery and to the hospital the day of your surgery.

Changing traditional practice can be a tall order…Most of us are firmly rooted in our practice norms…



Operating Room

Before Now Inconsistent

practice

Consistent Practice Anesthesia Protocol Developed.

Key points: Consider Spinal for all minimally invasive

surgery Consider Epidural for all open cases unless

contraindicated All patients to receive antiemetics Perioperative heparin to be administered to all

patients Lactated Ringers is solution of choice, and

restrict maintenance fluid to 15ml/kg/hr Active warming of the patient Use of Fi02 of 0.8 Timely antibiotic administration

Care Post Operatively

Before Now

Diet◦ Slow progression of ice chips to

fluids Activity

◦ Slow to mobilize Investigations

◦ Different depending on surgeon Foley

◦ Stayed in until epidural removed

Pain Control◦ variable

Diet◦ Full Fluids POD 0, Light diet by

POD 1 Activity

◦ Dangle POD 0 5hours or more of activity by POD 4

Investigations◦ Standardized bw on POD 1 & 3

Foley◦ Removed on POD 2

Pain Control◦ Goal: 3 or less on pain scale◦ Around the clock tylenol

Care Post Operatively

Before Now

Wound Care◦ At the discretion of nurses

DVT prophylaxis◦ Varied by surgeon

Epidural◦ Removed approx day 4 or 5

IV ◦ inconsistent

Discharge ◦ Varied by surgeon

Wound Care◦ No change

DVT prophylasis◦ Standardized (SC Heparin)

Epidural◦ Stopped Day 2, removed day 3

IVo SL when intake is 1200 cc/day or

until no longer needed Discharge

◦ Standing criteria◦ Target: Discharge on POD 4

There will be obstacles…



And some pitfalls…



Mean LOS for Colorectal Surgery

Some patients will ‘fall off the pathway’

The challenge for the care team is to reassess the needs for each individual and optimize the recovery within the changed care journey.



• Patient satisfaction increases with improved outcomes.• Complications and risk of infections are decreased• Hospital length of stay is shortened• Access is improved for all surgical patients.



The Outcome…Everyone’s a Winner!

Thank you

the pathways to improve patient care enhanced recovery after surgery (eras) presented by deborah...

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