uab care eras gyn onc...nelson g, et al. enhanced recovery pathways in gynecologic oncology. gynecol...
TRANSCRIPT
2/13/2018
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Enhanced Recovery after Surgery (ERAS)
in Gynecology
J. Michael Straughn, Jr., MD
Professor, Gynecologic Oncology
University of Alabama at Birmingham
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Outline
What is Enhanced Recovery after Surgery (ERAS)?
Implementing an ERAS program for your patients
Preoperative education
Perioperative management
Postoperative optimization
Outcomes – Others and UAB experience
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What is ERAS?
Enhanced Recovery After Surgery (ERAS)
Collection of best anesthesia and surgical practices bundled into a coordinated care
pathway that benefits the patient and hospital by reducing length of stay,
complications, readmissions, and cost
Pathways have been successful in several surgical specialties
Basse et al, 2000 – 60 patients undergoing colorectal surgery
LOS – 2 days
Benefits are achieved by decreasing stress, maintaining normal
physiologic function, and enhancing early mobilization
Patients benefit from a multi-disciplinary approach to surgical care
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What is ERAS?
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What is ERAS?
The ERAS Society was created in 2001
www.erassociety.org
The mission of the ERAS Society
To develop perioperative care
To improve recovery through research, education, audit and implementation of
evidence-based practice
In 2005, the ERAS Study Group developed and published an evidence-
based consensus protocol for patients undergoing colorectal surgery
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What is ERAS?
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What is ERAS?
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What is ERAS?
Kalogera E, et al. Enhanced recovery in gynecologic surgery.
Obstet Gynecol 2013;122:319-28.
Retrospective cohort study at the Mayo Clinic
Included cytoreductive surgery, staging, and prolapse surgery
Historical control (241) vs. ERAS pathway (235)
Cytoreductive cohort (81 vs. 78 patients)
• Less narcotic use in 48 hrs (80% reduction) with similar pain scores
• More nausea but no increase in ileus
• Decreased LOS (10 vs. 6 days), similar readmission rates (25.9% vs. 17.9%), and similar
complication rates (63% vs. 72%)
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What is ERAS?
Nelson G, et al. Enhanced recovery pathways in gynecologic
oncology. Gynecol Oncol 2014;135:586-94.
Systematic literature search on PubMed
ERAS Society was contacted to identify any unpublished protocols
7 studies that examined the role of ERAS in gynecologic oncology
patients
No randomized control trials
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What is ERAS?
Nelson G, et al. Enhanced recovery pathways in gynecologic
oncology. Gynecol Oncol 2014;135:586-94.
Common interventions included:
Oral intake of fluids up to 2 hours before anesthesia
Solids up to 6 hours before anesthesia
Carbohydrate supplementation
Intra- and postoperative euvolemia
Aggressive nausea/vomiting prophylaxis
Oral nutrition and ambulation the day of surgery
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What is ERAS?
Nelson G, et al. Enhanced recovery pathways in gynecologic
oncology. Gynecol Oncol 2014;135:586-94.
Bowel preparations, NPO after midnight rule, nasogastric tubes, and
intravenous opioids were discontinued
Significant improvements in patient satisfaction, length of stay, and cost
were observed in ERAS cohorts compared to historical controls
Morbidity, mortality, and readmission rates were similar between groups
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What is ERAS?
Nelson G, et al. Enhanced recovery pathways in gynecologic
oncology. Gynecol Oncol 2014;135:586-94.
ERAS is a safe perioperative management strategy for patients
undergoing surgery for gynecologic malignancies
ERAS reduces length of stay and cost, and is considered standard of
care at a growing number of institutions
There is a need for formalized evidence-based guidelines for patients
with gynecologic cancer undergoing surgery
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What is ERAS?
2 part evidence-based guidelines for Gynecologic Oncology
published in 2016
Nelson G, et al. Guidelines for pre- and intra-operative care in
gynecologic oncology surgery: ERAS® Society recommendations –
Part I. Gynecol Oncol 2016;140:313-322.
Nelson G, et al., Guidelines for postoperative care in gynecologic
oncology surgery: ERAS® Society recommendations - Part II.
Gynecol Oncol 2016;140:323-32.
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Implementing an ERAS program for your patients
What is UAB care?
Hospital wide-initiative focused on optimizing care for specific conditions
and ensuring that redefined standards are applied
Goals
Improve quality of care
Reduce variation
Control cost
Initiated ERAS programs for colorectal and urology
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Implementing an ERAS program for your patients
Implementation team and ERAS champion
MDs (surgeons and anesthesia), nursing, administration, informatics
Project goals
Protocol development
Leading Practice Guidelines (LPGs)
Team – STAFF, CLINIC, OR, PACT, PREOP, POSTOP
Audit database to evaluate compliance and outcomes
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Project Goals
The ERAS pathway will address areas where there is
room for improvement such as length of stay, variable
cost per case, readmissions, and infections
Current Performance
(FY 15)
Goal
(FY 17 Q1)
Average O/E LOS Index 1.07 0.95
Readmission % 6.71% 6.0%
% of patients identified as
ERAS0% 90%
SSI % 2.2% 1.0%
Variable cost per case $4,493 $4,200
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Dashboard
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Protocol Development
Work with administrative, physician, and nurse leaders to finalize project charter, develop LPGs, and ensure consensus
Rapid Redesign Session – 7/2016Create Leading Practice Guidelines (LPGs)Develop Key Initiatives (KIs)
Key Initiative (KI) Team MeetingsMeet independently to implement solutions to achieve KI goals
Educate Staff and Stakeholders
Discovery Assessment Process observation, staff interviews, data analysis, stakeholder feedback
First Implementation Meeting – 9/2016Assign key initiative teams
Implementation MeetingsMeet every two weeks to provide KI team updates
Celebration and Project Closure – 11/2016
18
We
eks
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Protocol Development
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Preoperative Education
All patients with a planned laparotomy or hysterectomy are eligible for
ERAS
Transferred patients or those admitted from the ED can be enrolled as inpatients
The surgeon introduces the ERAS concept followed by the clinic nurse
reviewing the education booklet
Teach Back method
Surgery scheduled using the Anesthesia Type
ERAS + General
Intrathecal morphine
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Preoperative Education
Patients are enrolled into Emmi to view educational videos before surgery
Patients with suspected malnutrition are started on Ensure TID until
surgery
The PACT appointment is scheduled at least 7 days prior to surgery
No solid food after midnight
Continue oral hydration with clear liquids up to 2 hours before surgery
(arrival to hospital)
Carbohydrate load with 400 mL Powerade or Gatorade 2 hours before surgery
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Preoperative Education
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Preoperative Education
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Perioperative Management
Patient is identified as ERAS at PACT
Routine patient processing is done
Medication reconciliation, medical interview, labs
Patient education booklet/information is provided
CHG bath instructions
Regular diet until midnight
Clear liquids until 2 hours before surgery
Gatorade/Powerade AM of surgery (carbohydrate loading)
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Perioperative Management
Consent is obtained for intrathecal anesthesia and patient education
questions are answered by a physician
Patient role in recovery is reinforced
Decreased narcotic use
Early feeding
Early ambulation
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Perioperative Management
Multimodal analgesic regimen is given prior to surgery
Tylenol, Celebrex, Gabapentin
Intrathecal injection recommended
TAP (transverse abdominis plane) block
PCA pump if not a candidate for intrathecal
Intraoperative - Lidocaine infusion, Dexamethasone, Propofol
Multimodal postoperative nausea/vomiting prophylaxis
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Perioperative Management
Intraoperative fluids
Goal directed fluid management to maintain cardiac output while avoiding
postoperative volume overload
800 cc/hour
Limit crystalloid – albumin for bolus if MAP < 60 mmHg
Avoidance of normal saline – LR or Plasmalyte
Wound closure trays and change of gloves required
Alexus wound protector for all planned bowel cases
OR debriefing required
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Perioperative Management
Co
mp
licati
on
s
Volume Load
OPTIMAL
EdemaOrgan dysfunctionAdverse outcome
HypoperfusionOrgan dysfunctionAdverse outcome
OverloadedHypovolemic
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Perioperative Management
ERAS Gyn Oncology PowerPlan
Includes PACU and Post-op components
Limited usage of narcotics in PACU
Ice chips in PACU
Initiate LR at 40 cc/hr
If hypotensive, can give 250 cc bolus of LR or 5% albumin
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Postoperative Optimization
Day of Surgery
Clears and advance as tolerated
Out of bed 2 hours
LR at 40 cc/hr
POD 1
Regular diet with Ensure
DC foley and IVFs by 0800
Out of bed 8 hrs – staff to document activity
Hemoglobin in AM with other labs as indicated
Chewing gum recommended
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Postoperative Optimization
Multimodal Pain Control
Acetaminophen
975 mg, Oral, Every 6 hours (scheduled)
Oxycodone regular release (*24 hours after intrathecal)
2.5 mg, Oral, Every 4 hours, PRN Pain, Mild
5 mg, Oral, Every 4 hours, PRN Pain, Moderate
10 mg, Oral, Every 4 hours, PRN Pain, Severe
Hydromorphone
0.4 mg, IV, Every 1 hour, PRN breakthrough pain
Only if pain score >7 more than 1 hour after receiving oxycodone
Notify MD if 2 doses required
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Postoperative Optimization
Based on age and weight of patient
Ketorolac: 15-30 mg, IV, Every 6 hours x 4 doses. Start 12 hours after preoperative
Celebrex dose.
Ibuprofen: 400-800 mg, Oral, Every 6 hours. Start 6 hours after last dose of ketorolac
If GFR <60 or patient unable to take NSAIDs for other reasons
Tramadol: 100 mg, Oral, Every 6 hours. Begin on morning of POD1. For patients <65.
Tramadol: 100 mg, Oral, Every 12 hours. Begin on morning of POD1. For patients >65
or with Cr clearance <30 mL/min
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Postoperative Optimization
Discharge planning starts on POD1
Documentation of daily weights, shower, and ambulation
Discharge when tolerating diet, voiding, and adequate pain control
Assess the need for narcotic prescription
Lovenox for 21 days if cancer diagnosis or high risk
Automated phone call with 72 hours of discharge
Postop visit within 28 days
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Outcomes
Modesitt SS et al. Enhanced Recovery Implementation in Major
Gynecologic Surgeries: Effect of Care Standardization. Obstet
Gynecol 2016;128(3):457-66.
Two ERAS protocols were developed
Full pathway using regional anesthesia for open procedures
Light pathway without regional anesthesia for vaginal and MIS
Usual ERAS pathways
A before-and-after study design compared clinical outcomes, costs, and
patient satisfaction
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Outcomes
Modesitt SS et al. Enhanced Recovery Implementation in Major
Gynecologic Surgeries: Effect of Care Standardization. Obstet
Gynecol 2016;128(3):457-66.
ERAS full protocol → 136 patients compared with 211 historical controls
Median LOS was reduced (2.0 vs. 3.0 days; P=.007)
Reductions were seen in median intraoperative morphine equivalents
(0.3 vs. 12.7 mg; P<.001)
Immediate postoperative pain scores (3.7 vs. 5.0; P<.001)
Total complications (21.3% vs. 40.2%; P=.004)
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Outcomes
Modesitt SS et al. Enhanced Recovery Implementation in Major
Gynecologic Surgeries: Effect of Care Standardization. Obstet
Gynecol 2016;128(3):457-66.
ERAS light protocol → 249 patients compared with 324 historical controls
Decreased intraoperative morphine equivalents (0.0 vs. 13.0 mg; P<.001)
and postoperative (15.0 vs. 23.6 mg; P<.001)
30-day hospital costs were significantly decreased in both ERAS groups
$11,172 vs. $9,899; P<.001
$8,277 vs. $7,606; P<.001
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Outcomes
Modesitt SS et al. Enhanced Recovery Implementation in Major
Gynecologic Surgeries: Effect of Care Standardization. Obstet
Gynecol 2016;128(3):457-66.
Implementation of ERAS protocols in gynecologic surgery was
associated with a substantial decrease in morphine administration,
reduction in length of stay for open procedures, improved patient
satisfaction and decreased hospital costs
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Outcomes
Dickson EL et al. Enhanced Recovery Program and Length of Stay After
Laparotomy on a Gynecologic Oncology Service: A Randomized
Controlled Trial. Obstet Gynecol 2017;129(2):355-62.
Prospective, randomized, controlled trial comparing ERAS protocol with routine
postoperative care among women undergoing laparotomy on the gynecologic oncology
service
A sample size of 50 per group was planned to achieve 80% power to detect a two-day
difference in LOS
103 eligible patients were enrolled between 2013 and 2015
52 in the control group and 51 in the ERAS group
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Outcomes
Dickson EL et al. Enhanced Recovery Program and Length of Stay After
Laparotomy on a Gynecologic Oncology Service: A Randomized
Controlled Trial. Obstet Gynecol 2017;129(2):355-62.
There was no difference in LOS between the two groups
Median 3.0 days in both groups; P=.36
ERAS patients used less narcotics on day 0 (10.0 vs. 5.5 morphine equivalents;
P=.09) and day 2 (10.0 vs 7.5 morphine equivalents; P=.05)
No difference in ambulation, GI issues, complications, or readmissions
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Outcomes
Dickson EL et al. Enhanced Recovery Program and Length of Stay After
Laparotomy on a Gynecologic Oncology Service: A Randomized
Controlled Trial. Obstet Gynecol 2017;129(2):355-62.
When compared with usual care, introducing a formal ERAS protocol did not
significantly reduce LOS
Of note, the historical LOS was 5 days
Issues – Few ERAS elements implemented, compliance not measured, use of ERAS
tenets in the control arm
Was this a poorly developed RCT?
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UAB Outcomes
Audit database to evaluate compliance and outcomes
McKesson and Tableau
Allison Todd, RN
Quarterly ERAS meetings
UAB Gynecologic Oncology Service
Enrollment started November 2016
217 patients enrolled thru December 2017
UAB Gynecology Service
Enrollment started December 2017
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UAB Outcomes
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UAB Study
Retrospective cohort study at UAB
Gynecologic oncology patients undergoing elective laparotomy from
10/2016 – 6/2017
Managed on an ERAS protocol and a control group from the year prior to ERAS
implementation
Patients taking daily opioids prior to surgery were classified as chronic
narcotic users and compared to non-narcotic users
376 patients were identified
197 in the control cohort and 179 in the ERAS cohort
Smith HJ et al. SGO Annual Meeting, March 2018
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UAB Study
Rates of chronic narcotic use were similar between cohorts
20.3% vs. 19.0%; p=0.75
In the ERAS cohort, chronic narcotic users required significantly more
opioids at discharge (1,940 vs. 533 mg OME; p=0.002)
They were also more likely to require additional narcotic prescriptions
within 30 days of discharge
29.4% vs. 7.6%; p<0.001
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UAB Study
LOS and readmission rates were similar in chronic narcotic users versus
non-narcotic users
There was no difference in postoperative pain score in chronic narcotic
users in the ERAS cohort compared to control cohort (2.8 vs. 3.1; p=0.52),
and no reduction in the amount of opioids prescribed at discharge (3,909
vs. 3,276 mg OME; p=0.61)
In non-narcotic users, both postoperative pain scores (1.8 vs. 2.5;
p<0.001) and the amount of opioids prescribed at discharge (1,940 vs.
2,610 mg OME; p<0.001) were significantly reduced with ERAS
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UAB Study
Implementation of ERAS improves pain control and decreases
the amount of opioids prescribed at discharge in narcotic naïve
gynecologic oncology patients.
ERAS does not significantly improve postoperative pain control
or decrease opioid use in chronic narcotic users.
ERAS does decrease LOS.
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Conclusions
Nelson G et al. Enhanced recovery after surgery (ERAS®) in
gynecologic oncology - Practical considerations for program
development. Gynecol Oncol. 2017;147(3):617-20.
Develop a multidisciplinary team and have a champion for the project
Develop your ERAS protocol using the published guidelines
Audit the program using a database to measure compliance and
outcomes
LOS, readmissions, complications
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Acknowledgements
UAB Care
Anisa Xhaja, MHA, MSHQS
Meredith Palmer, MSN, RN, CNL
Jadwiga Wartak, MSHA
Ben Taylor, MD
ERAS Champions
Dan Chu, MD
Jeff Simmons, MD
PACU
Prentiss Lawson, MD
Amanda Chambers, RN
GYN Oncology
Warner Huh, MD
Charles A. Leath, MD
Haller Smith, MD
Danny Mounir, MD
Bethany Fees, CRNP
Clinic
Terrell Halcomb, RN
Carissa Purvis, RN
Jennifer Kelley, RN
OR
Marquilla Brooks, RN
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References
Nelson G et al. Enhanced recovery after surgery (ERAS®) in gynecologic oncology - Practical considerations for program development. Gynecol Oncol. 2017;147(3):617-20.
Nelson G et al. Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations – Part I. Gynecol Oncol.
2016;140(2):313-22.
Nelson G et al. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations - Part II. Gynecol Oncol.
2016;140(2):323-32.
Miralpeix E et al. A call for new standard of care in perioperative gynecologic oncology practice: Impact of enhanced recovery after surgery (ERAS) programs. Gynecol Oncol. 2016;141(2):371-78.
Nelson G et al. Enhanced recovery pathways in gynecologic oncology. Gynecol Oncol.
2014;135(3):586-94.