The pathways to improve patient care

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Enhanced Recovery After Surgery (ERAS)
The pathways to improve patient care
Presented by Deborah Bachand Manger of Surgical
Service Project Implementation for VIHA
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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 dont much care where said Alice.Then it
doesnt matter which way you go, said the Cat.
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ERAS programs follow well trodden paths

• Evidence based, internationally proven to improve
  outcomes and patient satisfaction

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48/6

• Medication
• Cognition
• Pain
• Mobility
• Bowel/bladder
• Nutrition/hydration

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CDMR

• Elderly-friendly/ patient-centered care
• Collaborative inter-professional team
• Care-related communication

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Pathway Principles The Travel Guide

• 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

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Surgery is a Journey
Think of ENHANCED SURGICAL PATHWAYS as the GPS
to help our patients navigate the system
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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.
Your name _____________________
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Changing traditional practice can be a tall order

• Most of us are firmly rooted in our practice
  norms

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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

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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

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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
• IV
• SL when intake is 1200 cc/day or until no longer
  needed
• Discharge
• Standing criteria
• Target Discharge on POD 4

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There will be obstacles
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And some pitfalls
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Mean LOS for Colorectal Surgery
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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.

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The OutcomeEveryones a Winner!

• 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.

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Thank you