uab care eras gyn onc...nelson g, et al. enhanced recovery pathways in gynecologic oncology. gynecol...

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?



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?



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?



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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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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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

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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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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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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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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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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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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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Co

mp

licati

on

s

Volume Load

OPTIMAL

EdemaOrgan dysfunctionAdverse outcome

HypoperfusionOrgan dysfunctionAdverse outcome

OverloadedHypovolemic

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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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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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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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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



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



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



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




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




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 Outcomes

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UAB Outcomes

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UAB Outcomes

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UAB Outcomes

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UAB Outcomes

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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.

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