Download - The pathways to improve patient care
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.
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ERAS programs follow well trodden paths…Evidence based, internationally proven to improve outcomes and patient satisfaction…
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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
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Pathway Principles
The Travel Guide
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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…
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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
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…
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And some pitfalls…
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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.
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• 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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The Outcome…Everyone’s a Winner!
Thank you