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Cardiac ERAS

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ERAS - Implementation to Sustainability

Abstract

Background: Knowledge Translation evidence from health care practitioners and administrators implementing Enhanced Recovery After Surgery (ERAS) care has allowed for the spread and scale of the health care innovation. There is a need to identify at a health system level, what it takes from a leadership perspective to move from implementation to sustainability over time. The purpose of this research was to systematically synthesize feedback from health care leaders to inform further spread, scale and sustainability of ERAS care across a health system.

Methods: Alberta Health Services (AHS) is the largest Canadian health system with approximately 280,000 surgeries annually at more than 50 surgical sites. In 2013 to 2014, AHS used a structured approach to successfully implement

ERAS colorectal guidelines at six sites. Between 2016 and 2018, three of the six sites expanded ERAS to other surgical areas (gynecologic oncology, hepatectomy, pancreatectomy/Whipple’s, and cystectomy). This research was designed to explore and learn from the experiences of health care leaders involved in the AHS ERAS implementation expansion (eg. surgical care unit, hospital site or provincial program) and build on the model for knowledge mobilization develop during implementation. Following informed consent, leaders were interviewed using a structured interview guide. Data were recorded, coded and analyzed qualitatively through a combination of theory-driven immersion and crystallization, and template coding using NVivo 12.

Results: Forty-four individuals (13 physician leaders, 19 leading clinicians and hospital administrators, and 11 provincial leaders) were interviewed. Themes were identified related to Supportive Environments including resources, data, leadership; Champion and Nurse coordinator role; and Capacity Building through change management, education, and teams. The perception and role of leaders changed through initiation and implementation, spread, and sustainability. Barriers and enablers were thematically aligned relative to outcome assessment, consistency of implementation, ERAS care compliance, and the implementation of multiple guidelines.

Conclusions: Health care leaders have unique perspectives and approaches to support spread, scale andsustainability of ERAS that are different from site based ERAS teams. These findings inform us what leaders need to do or need to do differently to support implementation and to foster spread, scale and sustainability of ERAS.Gramlich, Leah; Nelson, Gregg; Nelson, Alison; Lagendyk, Laura; Gilmour, Loreen E; Wasylak, Tracy

BMC Health Services Research. 2020 Apr 26;20(1):361; http://hdl.handle.net/1880/111939

Journal Article Downloaded from PRISM: https://prism.ucalgary.ca

Review: The economic benefits of enhanced recovery after surgery programmes

Digestive Medicine Research. All rights reserved. Dig Med Res 2019;2:20 | http://dx.doi.org/10.21037/dmr.2019.08.07

Abstract:

The global economic burden of healthcare is set to continue to grow for the foreseeable future
and methods must be sought to mitigate this burden whilst maintaining the high standard of care we expect to deliver to our patients. There have been numerous studies abundantly demonstrating the benefits of enhanced recovery after surgery (ERAS) programmes and more recently these have included studies lookinginto the economic benefits. It has now been demonstrated that implementation of ERAS  programmes can deliver an overall cost-saving per patient for the institution delivering the surgery itself but also the wider community including primary care providers. Initial implementation is likely to incur an initial cost to the provider, most commonly in the form of employing new, dedicated ERAS personnel or procurement of new medications. Subsequent savings are largely the result of patient’s stay on critical care and within the hospital itself with both likely to be significantly reduced if a patient is enrolled on an ERAS programme. This article explores the literature currently available which has looked into the health economics surrounding ERAS programmes for a number of surgical specialities and from around the world.

Ben Morrison1,2, Leigh Kelliher1,2, Chris Jones1,2

Received: 01 August 2019; Accepted: 27 August 2019; Published: 30 August 2019.
doi: 10.21037/dmr.2019.08.07
View this article at: http://dx.doi.org/10.21037/dmr.2019.08.07

Implementing an Enhanced Recovery After Surgery program for cardiac surgery involves challenges due to the urgency of the procedures as well as the complexity of the perioperative course. In an effort to achieve standard care, reduce the surgical stress response, and improve patient outcomes, ERAS for cardiac surgery is gaining increased attention. However, the need for an organized, methodical implementation process is essential for a successful program.

Enhanced Recovery After Surgery (ERAS) is a bundled approach to perioperative care based upon the philosophy that patients do better when emotional and physiologic stresses are minimized during surgery. The goal of ERAS is to return patients to normal functional status as quickly as possible. Initially designed for patients having colorectal surgery, ERAS programs have now been developed for nearly every surgical subspecialty. Multiple studies examining the effect of ERAS have demonstrated decreased postoperative
complications, length of stay, costs, and increased patient and staff satisfaction. Interest in the application of ERAS to cardiac surgery has grown significantly over the last few years. Several core principles transcend all ERAS cardiac programs. Implementation of cardiac ERAS is more than simply the installation of a protocol. ERAS involves a methodical shift in culture, meeting the challenges of initiating and sustaining meaningful organizational change, and pivoting to a patient-centered system of care to optimize speed and completeness of recovery. Herein we detail the crucial team building, education, planning, and processes needed to develop and sustain a successful ERAS cardiac program.

Semin Thoracic Surg 32:187–196   2020 Elsevier Inc. All rights reserved.Rawn Salenger, MD,* Vicki Morton-Bailey, DNP, AGNP-BC,† Michael Grant, MD, MSE,‡ Alexander Gregory, MD, FRCPC,  Judson B. Williams, MD, MHS,ǁ and Daniel T. Engelman, MD 

Standards for Reporting Implementation Studies

Implementation studies are often poorly reported and indexed, reducing their potential to inform initiatives to improve healthcare services. The Standards for Reporting Implementation Studies (StaRI) initiative aimed to develop guidelines for transparent and accurate reporting of implementation studies. Informed by the findings of a systematic review and a consensus-building e-Delphi exercise, an international working group of implementation science experts discussed and agreed the StaRI Checklist comprising 27 items. It prompts researchers to describe both the implementation strategy (techniques used to promote implementation of an underused evidence-based intervention) and the effectiveness of the intervention that was being implemented. An accompanying Explanation and Elaboration document (published in BMJ Open, doi:10.1136/bmjopen-2016-013318) details each of the items, explains the rationale, and provides examples of good reporting practice. Adoption of StaRI will improve the reporting of implementation studies, potentially facilitating translation of research into practice and improving the health of individuals and populations.

BMJ 2017;356:i6795 doi: 10.1136/bmj.i6795 (Published 6 March 2017)

 

The impact of preoperative carbohydrate loading on patients with type II diabetes in an enhanced recovery after surgery protocol
Abstract

Background: We aimed to determine the effects of preoperative carbohydrate-loading (CHO) as part of an enhanced recovery after surgery (ERAS) pathway on patients with/without type II diabetes (DMII).

Methods: Retrospective review of ERAS patients with CHO, including 80 with DMII, 275 without DMII in addition to 89 patients with DMII from the previous (non-ERAS) year. Outcomes included glucose-levels, insulin requirements, and complications. Logistic regression was used to determine the association of any complication with perioperative glucose control variables.

Results: Among ERAS versus non-ERAS patients with DMII, there were significant differences in median preoperative (142 mg/dL versus 129.5 mg/dL, p = 0.017) and postoperative day-1 glucose levels (152 mg/dL, versus 137.5 mg/dL, p = 0.004). There were no differences in insulin requirements, hypoglycemic episodes, or complications. Complications were not associated with Hgb-A1C%, home DMII-medications, or preoperative glucose measurement on logistic regression.

Conclusions: Patients with DMII tolerated CHO without increasing insulin requirements or substantially affecting glucose levels or complications. Stephanie D Talutis  1 , Su Yeon Lee  2 , Daniel Cheng  3 , Pamela Rosenkranz  4 , Sara M Alexanian  5 , David McAneny  4

cmaj.pngEnhanced recovery after surgery (ERAS) is an evidence-based and multidisciplinary perioperative care pathway and a surgical quality improvement initiative, which has been shown to promote patient mobilization, reduce complication rates after surgery, decrease hospital length of stay and reduce costs, if carefully implemented.

Implementing a New Standard of Surgical Care
Enhanced recovery after surgery (ERAS) is an evidence-based and multidisciplinary perioperative care pathway and a surgical quality improvement initiative, which has been shown to promote patient mobilization, reduce complication rates after surgery, decrease hospital length of stay and reduce costs, if carefully implemented. There is an increasing interest across Canada to implement enhanced recovery after surgery recommendations.1 Several Canadian institutions have succeeded in implementing an official ERAS protocol. However, it can be challenging to start such a program2 because it requires multidisciplinary effort and the buy-in of many stakeholders. Because the ERAS approach has been shown to decrease the stress of surgery3 through its objective to maintain patients’ normal physiology as far as possible, any patient undergoing surgery could benefit from the approach.
Alon D. Altman, Limor Helpman, Jacob McGee, Vanessa Samouëlian, Marie-Hélène Auclair, Harinder Brar and Gregg S. Nelson; on behalf of the Society of Gynecologic Oncology of Canada’s Communities of Practice in ERAS and Venous Thromboembolism
CMAJ April 29, 2019 191 (17) E469-E475; DOI: https://doi.org/10.1503/cmaj.180635

ERAS and Surgical Intensive Care

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Abstract

Patients are admitted to the surgical intensive care (SICU) unit after emergency and elective surgery. After elective surgery, for further support, or to manage coexisting comorbidities. The implementation of the ERAS (Enhanced recovery after surgery) protocols in surgery should decrease the need for ICU beds, but there will always be unpredicted complications after surgery. These will require individual management. What we can do for our surgical patients in ICU to further enhance their recovery? To promote early enhanced recovery in surgical intensive care—SICU, three areas need to be addressed, sedation, analgesia, and delirium. Tools for measurement and protocols for management in these three areas should be developed to ensure best practice in each SICU. The fourth important area is Nutrition. Preoperative screening and post-operative measurement of the state of nutrition also need to be developed in the SICU. The fifth important area is early mobilization. ERAS protocols encourage early mobilization of the critically ill patients, even if on mechanical ventilation. Early mobilization is possible and should be implemented by special multidisciplinary ICU team. All team members must be familiar with protocols to be able to implement them in their field of expertise. Personal and professional attitudes are critical for implementation. In the core of all our efforts should be the patient and his well-being.

2018; 5: 256.
Published online 2018 Oct 4. doi: 10.3389/fmed.2018.00256
PMCID: PMC6180254
PMID: 30338259

Enhanced Recovery Canada

Putting patients first, improving patient safety

Enhanced Recovery Canada is a project of the Canadian Patient Safety Institute leading the drive to improve surgical safety across the country and is based on Enhanced Recovery After Surgery – ERAS surgical best practices.
These evidence-based principles support better outcomes for surgical patients including: an improved patient experience, reduced length of stay, decreased complication rates and fewer hospital readmissions.
In partnership with: ERAS Society