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Bethany Sarosiek, RN, MSN, MPH, CNLUniversity of Virginia Health SystemCharlottesville, VAErasRN@virginia.edu

Enhanced Recovery After Surgery at the University of Virginia Medical Center

• None

Disclosures

• Provide background and rationale behind implementing an ERAS program

• Describe the key steps for implementation of an interdisciplinary ERAS program

• Identify potential barriers to ERAS program implementation and ways to overcome them

Objectives

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2012 NSQIP data revealed discouraging trends starting in 2008 when outcomes at UVA were better than average:

– Morbidity: 1.35 (from 0.99)– LOS: 0.79 (from 0.99)– UTI: 1.95 (not tracked in 2008)– SSI: 1.37 (from 0.99)

Why ERAS in Colorectal Surgery?

A multimodal approach to perioperative care designed to decrease the time required to recover from surgery

Major components include:• Not starving patients before surgery• Intraoperative “goal-directed therapy” (GDT) – using

advanced hemodynamic monitors to only give IV fluids when they are needed

• Adequate pain control with minimal opioid use• Early ambulation• Patients take ownership of their care

What is ERAS?

• Recognizing the need for improvement, we implemented an Enhanced Recovery After Surgery (ERAS) protocol for all patients undergoing elective colorectal surgery at an academic institution.

• Provide quality care at reduced costs

• Inter-disciplinary effort to standardize care

Our Objective

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• Perioperative teaching• Surgery Handbook• Setting realistic goals and expectations

The Preoperative Phase

• “Goal-directed fluid therapy” (GDT) • Vasopressors for hypotension• Long acting intrathecal opioid • Ketamine and lidocaine infusion• Standardized protocol

The Intraoperative Phase

“Pleth Variability Index” monitors “fluid responsiveness” continuously based on the pulse oximeter waveform

• Clears and OOB in PACU• Elimination of IV opioids from

order set• Lidocaine drip for 48 hours• IVF at 40 cc/hr for 24 hours only• Checklists for nursing staff to

complete WITH patient• Discharge criteria IDENTICAL• Discharge goal POD 3

Ordersets and checklists help to drive care!

The Postoperative Phase

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Inter-disciplinary Partnership

• Core Team• Surgeon• Anesthesia • RN champion

• Partners• Pharmacy/Pain Management • Registered Dieticians• Participating staff from Clinic, Preop, OR, PACU, Postop• Informatics

• Widespread systems changes (EPIC, OR, checklists, pathway)

• Ongoing education prior to implementation

• ERAS implemented August 1, 2013

• All patients undergoing elective abdominal surgery on colorectal service enrolled in protocol regardless of procedure or medical comorbidities

• Compared pre/post data– pre ERAS (08/2012 – 02/2013) – post ERAS (08/2013 – 08/2014)

Colorectal Data Comparison

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LOS relative to Medical Center

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Financial Impact of ERAS

Mean Total Cost Mean Direct Cost

Pre‐ERAS 25,344 20,435

Post‐ERAS 18,777 13,306

$0.00

$5,000.00

$10,000.00

$15,000.00

$20,000.00

$25,000.00

$30,000.00$6,567/pt

$7,129/pt

Financial Impact of ERAS

Pre‐ERAS Post‐ERAS

Expected Direct Costs 13,599 14204

Actual Direct Costs 20435 13306

0

5,000

10,000

15,000

20,000

25,000

+ $6,836/pt

‐$898/pt$746,231 in cost savings

Decision pack in 2014 (>$700,000 investment):

• Clinicians• RN champion to lead effort• 2 LIPs for outpatient and inpatient support• Medical directors - salary support

• Data analyst

• Equipment (OR and post-op monitoring)

The Business Case for Expansion

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Expansion Timeline to Date

GYN ERAS March 2015

Thoracic ERAS March 2016

Whipple ERAS Jan 2017

Colorectal ERAS Aug 2013

• Changing deep-rooted, traditional practices

• Electronic Medical Record Process

• Additional (unforeseen) costs

• Academic medical center w/ rotating staff

• Ongoing iterative process

Barriers

• Comprehensive patient educational materials• Checklists for staff AND patients• EPIC (EMR) support• ERAS indication in ALL phases of care• Frequent compliance audits/data collection• Frequent feedback to providers• Ongoing protocol revisions to ensure application of latest

evidence

From a Systems Perspective:Communication is key!

…Make it as easy as possible to do the right 

thing!

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• Ever-growing interest from add’l surgical services

• Successful implementation of electronic checklist

• ERAS app

• Expanded institutional support

Success Stories

• Multidisciplinary effort

• Buy-in from everyone to standardize care– Will be different at each institution, individual elements not as

important as adhering to 5 main ERAS concepts

• Dedicated surgeon, anesthesiologist, nurse champions

• Strict monitoring of compliance

• Constant feedback and iteration

What does ERAS implementation require?

• Ortho Joint• Spine (Ortho and Neurosurgery)• General Surgery• Thoracic (Esophagectomy)• Hepatic Resection• Breast Surgery• Neurosurgery• Vascular Surgery• Pediatric Surgery• Donor Kidney (Transplant)• Urology

Plans for Expansion

Bottom Line:

• Our GOAL is to expand these principles to every patient undergoing surgery at UVA

• ERAS should be the standard of care - providing quality surgical care at reduced cost with a focus on improving patient outcomes

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Expanded ERAS Program Organizational Chart

Which of the following is not a key concept of an ERAS program:

1. Early ambulation

2. Opioid-sparing multimodal pain management

3. Preoperative fasting

4. Patient education and expectation management

Self Assessment Question 1

Name three key members of a inter-disciplinary ERAS team.

Self Assessment Question 2

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Which of the following could be considered a barrier to ERAS implementation:

1. Remarkable change from traditional practices

2. Cost

3. Continuous change in staff

4. All of the above

Self Assessment Question 3

E R A S =

1) Protocolized care

2) Opioid minimization

3) Focus on mobilization

4) Patient empowerment

5) Reduced healthcare costs

6) More efficient use of scarce resources

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Thank you!

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1. Kehlet, H. Multimodal Approach to Control Postoperative Pathophysiology and Rehabilitation. Br J Anaesth 1997;78:606-617

2. Zhuang, CL et al. Enhanced Recovery After Surgery Programs versus Traditional Care for Colorectal Surgery: A Meta-analysis of Randomized Control Trials. Dis Colon Rectum 2013;56:667-678.

3. Brandstrup, B et al. Effects of Intravenous Fluid Restriction on Postoperative Complications: Comparison of Two Perioperative Fluid Regimens: A Randomized Assessor-Blinded Multicenter Trial. Ann Surg 2003; 238:641-648.

4. Gan, TJ et al. Goal-directed Intraoperative Fluid Administration Reduces Length of Hospital Stay After Major Surgery. Anesthesiology 2002;97:820-826.

5. Barreveld, A et al. Preventive Analgesia by Local Anesthetics: the Reduction of Postoperative Pain by Peripheral Nerve Blocks and Intravenous Drugs. Anesth Analg 2013;116:1141-1161.

6. Thiele, R et al. Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery. J Amer Coll Surg 2015; 220(4):430-443.

7. Modesitt, S et al. Enhanced Recovery Implementation in Major Gynecologic Surgeries: Effect of Care Standardization. Ob & Gyn 2016;128(3):457-466.

8. Roulin, D et al. Cost-effectiveness of the Implementation of an Enhanced Recovery Protocol for Colorectal Surgery. Br J Surg 2013;100:1108-1114.

References