Adam W. Beck, M.D. Associate Professor of Surgery

1. Implementation of an Enhanced Recovery Program (ERP) for Lower Extremity Bypass Adam W. Beck, M.D. Associate Professor of Surgery Division of Vascular Surgery and Endovascular Therapy University of Alabama at Birmingham June 12th, 2019

2. Disclosures No relevant Disclosures

3. ERAS is not a new concept…1995 Dr. HenrikKehlet MD, PhD Considered the founder of ERAS

4. How does eras work? • Patients can drink up to 2hrs prior to surgery • Regular diet night of surgery • Mobilize Day of Surgery • Minimize opioid use • Minimize Intravenous Fluids • Only get 1 set of labs

5. ERAS is not a new concept…1995 • 8 patients • Laparoscopic approach • Epidural analgesia • Early oral nutrition • Early mobilization • 6 patients went home POD2 • 2 patients went home POD3 • Average LOS after a colectomy at the time was 5-10 days

6. What is Eras? • Reduce length of stay by up to 30-50%. • Reduce post-operative complications up to 50%. • Save up to $6,000 per patient for hospital stay. • Significantly reduces or eliminates racial disparities in LOS, readmissions, and POCs. • Reduces opioid use. • Strict adherence associated with reduction in 5 year mortality by 42% in cancer patients.

7. Themes of ERAS How does eras work? • “Perioperative care, not the actual operation, can dictate outcomes” • Minimize stress and improve response to stress • Patient centered approach • Evidence based, “best practice” medicine • Relies on multidisciplinary team approach

8. ErP vascular? • Vascular surgery patients often: • Multiple medical comorbidities • Lower socioeconomic/educational level • High risk for perioperative complications • High risk for SSI • High risk for unplanned readmissions • Lower extremity bypass patients perhaps highest risk...good population for ERP? • Excluded patients undergoing open surgical inflow procedures as well as trauma patients.

9. Initial Visit: Identify Patients who are currently smoking at intake Initial Visit: Identify Patients who are currently smoking at intake Implementation Smoking Cessation Clinic Protocol: Smoking Cessation Clinic Protocol: • Patient Education • Supportive and empathetic discussion • Discuss the importance of smoking cessation • Acknowledge that quitting is hard, do not trivialize • Explain why tobacco is addicting, how medication can help and how it works • Help to choose a low stress quit date • Recommend elimination of cigarettes from home and remove potential triggers • Encourage other family members to quite (especially if present) • Medication • First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) • Start Wellbutrin/NRT 7 days prior quit day • Chantix if patient prefers or if contraindication to Wellbutrin. • No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date • Discuss side effects (if not discussed, patient is likely to stop medication) • Provide written educational materials reinforcing discussion and medication regimen • Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) • Patient Education • Supportive and empathetic discussion • Discuss the importance of smoking cessation • Acknowledge that quitting is hard, do not trivialize • Explain why tobacco is addicting, how medication can help and how it works • Help to choose a low stress quit date • Recommend elimination of cigarettes from home and remove potential triggers • Encourage other family members to quite (especially if present) • Medication • First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) • Start Wellbutrin/NRT 7 days prior quit day • Chantix if patient prefers or if contraindication to Wellbutrin. • No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date • Discuss side effects (if not discussed, patient is likely to stop medication) • Provide written educational materials reinforcing discussion and medication regimen • Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) • UAB Care team • Care pathway transformation • Many previous ERAS/ERP programs with various disciplines (use your institutional knowledge) • Our team: vascular surgeons, anesthesiologists, rehabilitation physicians, physical therapists, wound care specialists, dieticians, pharmacists, pain management specialists, advanced practice providers, and nursing staff • Physician champions: Vascular surgeon & Anesthesiologist • Administrative support Document Smoking Cessation Intervention in EMR Document Smoking Cessation Intervention in EMR Follow up visit Follow up visit No Follow up Visit No Follow up Visit • Current smoking status identified at intake • Did the patient join any cessation programs? • Have they used medication? • If the patient did not quit, offer medication again and discuss importance again • If successfully quit, make sure to discuss and praise success • Current smoking status identified at intake • Did the patient join any cessation programs? • Have they used medication? • If the patient did not quit, offer medication again and discuss importance again • If successfully quit, make sure to discuss and praise success • Nurse/Quality Manager contact via phone once a month regarding smoking status • Do they need refills or need to speak to a provider? • Nurse/Quality Manager contact via phone once a month regarding smoking status • Do they need refills or need to speak to a provider? Document in EMR Document in EMR

10. Lower Extremity Bypass ERP Goals • Create and implement the ERP pathways for our lower extremity bypass population. • Identify patients who undergo Lower Extremity Bypass and track goal project outcomes of: • At least 80% use of ERP in eligible LEB patients • Reduction of the observed to expected LOS index • Reduction in percentage of 30-day all cause readmission • Reduction in SSI rate • Reduction of variable cost per case.

11. UAB ERAS pathways • Existing UAB ERAS pathways are based on ERAS society guidelines • 2014- Colorectal • 2015- Surgical Oncology • 2016- Gynecology Oncology • 2018- Vascular

12. Initial Visit: Identify Patients who are currently smoking at intake Initial Visit: Identify Patients who are currently smoking at intake Implementation Smoking Cessation Clinic Protocol: Smoking Cessation Clinic Protocol: • Transformational process! • Plan-Do-Check-Adjust (PDCA) methodology • Requires collaboration of teammates • Repeated re-evaluation of initiatives: Redesign • Patient Education • Supportive and empathetic discussion • Discuss the importance of smoking cessation • Acknowledge that quitting is hard, do not trivialize • Explain why tobacco is addicting, how medication can help and how it works • Help to choose a low stress quit date • Recommend elimination of cigarettes from home and remove potential triggers • Encourage other family members to quite (especially if present) • Medication • First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) • Start Wellbutrin/NRT 7 days prior quit day • Chantix if patient prefers or if contraindication to Wellbutrin. • No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date • Discuss side effects (if not discussed, patient is likely to stop medication) • Provide written educational materials reinforcing discussion and medication regimen • Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) • Patient Education • Supportive and empathetic discussion • Discuss the importance of smoking cessation • Acknowledge that quitting is hard, do not trivialize • Explain why tobacco is addicting, how medication can help and how it works • Help to choose a low stress quit date • Recommend elimination of cigarettes from home and remove potential triggers • Encourage other family members to quite (especially if present) • Medication • First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) • Start Wellbutrin/NRT 7 days prior quit day • Chantix if patient prefers or if contraindication to Wellbutrin. • No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date • Discuss side effects (if not discussed, patient is likely to stop medication) • Provide written educational materials reinforcing discussion and medication regimen • Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document Smoking Cessation Intervention in EMR Follow up visit Follow up visit No Follow up Visit No Follow up Visit • Current smoking status identified at intake • Did the patient join any cessation programs? • Have they used medication? • If the patient did not quit, offer medication again and discuss importance again • If successfully quit, make sure to discuss and praise success • Current smoking status identified at intake • Did the patient join any cessation programs? • Have they used medication? • If the patient did not quit, offer medication again and discuss importance again • If successfully quit, make sure to discuss and praise success • Nurse/Quality Manager contact via phone once a month regarding smoking status • Do they need refills or need to speak to a provider? • Nurse/Quality Manager contact via phone once a month regarding smoking status • Do they need refills or need to speak to a provider? Document in EMR Document in EMR

13. ERAS Implementation

14. Preoperative phase • Emphasis on patient education • Early mobility • Post-operative pain control • Planned length of hospital stay

15. Initial Visit: Identify Patients who are currently smoking at intake Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Protocol Smoking Cessation Clinic Protocol: Smoking Cessation Clinic Protocol: • Patient Education • Supportive and empathetic discussion • Discuss the importance of smoking cessation • Acknowledge that quitting is hard, do not trivialize • Explain why tobacco is addicting, how medication can help and how it works • Help to choose a low stress quit date • Recommend elimination of cigarettes from home and remove potential triggers • Encourage other family members to quite (especially if present) • Medication • First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) • Start Wellbutrin/NRT 7 days prior quit day • Chantix if patient prefers or if contraindication to Wellbutrin. • No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date • Discuss side effects (if not discussed, patient is likely to stop medication) • Provide written educational materials reinforcing discussion and medication regimen • Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) • Patient Education • Supportive and empathetic discussion • Discuss the importance of smoking cessation • Acknowledge that quitting is hard, do not trivialize • Explain why tobacco is addicting, how medication can help and how it works • Help to choose a low stress quit date • Recommend elimination of cigarettes from home and remove potential triggers • Encourage other family members to quite (especially if present) • Medication • First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) • Start Wellbutrin/NRT 7 days prior quit day • Chantix if patient prefers or if contraindication to Wellbutrin. • No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date • Discuss side effects (if not discussed, patient is likely to stop medication) • Provide written educational materials reinforcing discussion and medication regimen • Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document Smoking Cessation Intervention in EMR Follow up visit Follow up visit No Follow up Visit No Follow up Visit • Current smoking status identified at intake • Did the patient join any cessation programs? • Have they used medication? • If the patient did not quit, offer medication again and discuss importance again • If successfully quit, make sure to discuss and praise success • Current smoking status identified at intake • Did the patient join any cessation programs? • Have they used medication? • If the patient did not quit, offer medication again and discuss importance again • If successfully quit, make sure to discuss and praise success • Nurse/Quality Manager contact via phone once a month regarding smoking status • Do they need refills or need to speak to a provider? • Nurse/Quality Manager contact via phone once a month regarding smoking status • Do they need refills or need to speak to a provider? Document in EMR Document in EMR

16. Perioperative phase • Chlorhexidine showers • Preoperative hair clipping • Non-opioid analgesia in preoperative holding area • Placement of fascia iliaca block by Inpatient Pain Service (IPS) Fascia Iliaca/Sciatic Block • Anesthesia of the anterior and medial thigh (femoral nerve) as well as the anterolateral thigh (lateral femoral cutaneous nerve) • Able to be placed in patients receiving antiplatelet therapy • Avoids use of an indwelling catheter which might limit early mobility

17. Intraoperative phase Anesthesiologists • Goal directed fluid management • Maintain normothermia • Non-opioid pain adjuncts • Lung protective ventilation • Post-operative nausea prophylaxis Surgeons • Skin closure protocol • Separate instrument set for skin closure • Changing of gowns/gloves, and changing of the overhead operative light handles • Two wound closure methods • Interrupted vicryl sutures with staples on the skin and a sterile occlusive dressing (OPSITE Post op, Smith & Nephew, London, UK) or • Interrupted vicryl sutures with subcuticular moncryl and skin glue.

18. Postoperative phase • Early mobilization • POD0- Edge of bed • POD1- Out of bed, daily mobility milestones set by PT • Diet • Regular diet immediately after arrival to surgical floor • Tobacco cessation • Consult placed to UAB Tobacco Cessation team who visit the patient for bedside counseling typically on their second postoperative day

19. ERAS UAB Powerplan

20. Initial Visit: Identify Patients who are currently smoking at intake Initial Visit: Identify Patients who are currently smoking at intake Demographics Smoking Cessation Clinic Protocol: Smoking Cessation Clinic Protocol: • Patient Education • Supportive and empathetic discussion • Discuss the importance of smoking cessation • Acknowledge that quitting is hard, do not trivialize • Explain why tobacco is addicting, how medication can help and how it works • Help to choose a low stress quit date • Recommend elimination of cigarettes from home and remove potential triggers • Encourage other family members to quite (especially if present) • Medication • First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) • Start Wellbutrin/NRT 7 days prior quit day • Chantix if patient prefers or if contraindication to Wellbutrin. • No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date • Discuss side effects (if not discussed, patient is likely to stop medication) • Provide written educational materials reinforcing discussion and medication regimen • Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) • Patient Education • Supportive and empathetic discussion • Discuss the importance of smoking cessation • Acknowledge that quitting is hard, do not trivialize • Explain why tobacco is addicting, how medication can help and how it works • Help to choose a low stress quit date • Recommend elimination of cigarettes from home and remove potential triggers • Encourage other family members to quite (especially if present) • Medication • First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) • Start Wellbutrin/NRT 7 days prior quit day • Chantix if patient prefers or if contraindication to Wellbutrin. • No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date • Discuss side effects (if not discussed, patient is likely to stop medication) • Provide written educational materials reinforcing discussion and medication regimen • Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document Smoking Cessation Intervention in EMR Follow up visit Follow up visit No Follow up Visit No Follow up Visit • Current smoking status identified at intake • Did the patient join any cessation programs? • Have they used medication? • If the patient did not quit, offer medication again and discuss importance again • If successfully quit, make sure to discuss and praise success • Current smoking status identified at intake • Did the patient join any cessation programs? • Have they used medication? • If the patient did not quit, offer medication again and discuss importance again • If successfully quit, make sure to discuss and praise success • Nurse/Quality Manager contact via phone once a month regarding smoking status • Do they need refills or need to speak to a provider? • Nurse/Quality Manager contact via phone once a month regarding smoking status • Do they need refills or need to speak to a provider? Document in EMR Document in EMR

21. Initial Visit: Identify Patients who are currently smoking at intake Initial Visit: Identify Patients who are currently smoking at intake Process Metric Assessment Smoking Cessation Clinic Protocol: Smoking Cessation Clinic Protocol: • Manual process audit • Process metrics audited and measured: • scheduling of the surgery as ERP • completion of patient education • diabetes patient optimization process • multimodal medications • regional block • tobacco cessation process • early diet • early mobility. • Automated monthly using Vizient (UHC) quality data • Readmission, LOS, LOS index, SSI, %ERP enrolled, variable cost • Patient Education • Supportive and empathetic discussion • Discuss the importance of smoking cessation • Acknowledge that quitting is hard, do not trivialize • Explain why tobacco is addicting, how medication can help and how it works • Help to choose a low stress quit date • Recommend elimination of cigarettes from home and remove potential triggers • Encourage other family members to quite (especially if present) • Medication • First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) • Start Wellbutrin/NRT 7 days prior quit day • Chantix if patient prefers or if contraindication to Wellbutrin. • No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date • Discuss side effects (if not discussed, patient is likely to stop medication) • Provide written educational materials reinforcing discussion and medication regimen • Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) • Patient Education • Supportive and empathetic discussion • Discuss the importance of smoking cessation • Acknowledge that quitting is hard, do not trivialize • Explain why tobacco is addicting, how medication can help and how it works • Help to choose a low stress quit date • Recommend elimination of cigarettes from home and remove potential triggers • Encourage other family members to quite (especially if present) • Medication • First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) • Start Wellbutrin/NRT 7 days prior quit day • Chantix if patient prefers or if contraindication to Wellbutrin. • No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date • Discuss side effects (if not discussed, patient is likely to stop medication) • Provide written educational materials reinforcing discussion and medication regimen • Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document Smoking Cessation Intervention in EMR Follow up visit Follow up visit No Follow up Visit No Follow up Visit • Current smoking status identified at intake • Did the patient join any cessation programs? • Have they used medication? • If the patient did not quit, offer medication again and discuss importance again • If successfully quit, make sure to discuss and praise success • Current smoking status identified at intake • Did the patient join any cessation programs? • Have they used medication? • If the patient did not quit, offer medication again and discuss importance again • If successfully quit, make sure to discuss and praise success • Nurse/Quality Manager contact via phone once a month regarding smoking status • Do they need refills or need to speak to a provider? • Nurse/Quality Manager contact via phone once a month regarding smoking status • Do they need refills or need to speak to a provider? Document in EMR Document in EMR

22. Initial Visit: Identify Patients who are currently smoking at intake Initial Visit: Identify Patients who are currently smoking at intake Team Compliance Smoking Cessation Clinic Protocol: Smoking Cessation Clinic Protocol: • Patient Education • Supportive and empathetic discussion • Discuss the importance of smoking cessation • Acknowledge that quitting is hard, do not trivialize • Explain why tobacco is addicting, how medication can help and how it works • Help to choose a low stress quit date • Recommend elimination of cigarettes from home and remove potential triggers • Encourage other family members to quite (especially if present) • Medication • First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) • Start Wellbutrin/NRT 7 days prior quit day • Chantix if patient prefers or if contraindication to Wellbutrin. • No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date • Discuss side effects (if not discussed, patient is likely to stop medication) • Provide written educational materials reinforcing discussion and medication regimen • Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) • Patient Education • Supportive and empathetic discussion • Discuss the importance of smoking cessation • Acknowledge that quitting is hard, do not trivialize • Explain why tobacco is addicting, how medication can help and how it works • Help to choose a low stress quit date • Recommend elimination of cigarettes from home and remove potential triggers • Encourage other family members to quite (especially if present) • Medication • First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) • Start Wellbutrin/NRT 7 days prior quit day • Chantix if patient prefers or if contraindication to Wellbutrin. • No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date • Discuss side effects (if not discussed, patient is likely to stop medication) • Provide written educational materials reinforcing discussion and medication regimen • Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document Smoking Cessation Intervention in EMR Follow up visit Follow up visit No Follow up Visit No Follow up Visit • Current smoking status identified at intake • Did the patient join any cessation programs? • Have they used medication? • If the patient did not quit, offer medication again and discuss importance again • If successfully quit, make sure to discuss and praise success • Current smoking status identified at intake • Did the patient join any cessation programs? • Have they used medication? • If the patient did not quit, offer medication again and discuss importance again • If successfully quit, make sure to discuss and praise success • Nurse/Quality Manager contact via phone once a month regarding smoking status • Do they need refills or need to speak to a provider? • Nurse/Quality Manager contact via phone once a month regarding smoking status • Do they need refills or need to speak to a provider? Document in EMR Document in EMR

23. Initial Visit: Identify Patients who are currently smoking at intake Initial Visit: Identify Patients who are currently smoking at intake Central Goals: Results to Date Smoking Cessation Clinic Protocol: Smoking Cessation Clinic Protocol: • Patient Education • Supportive and empathetic discussion • Discuss the importance of smoking cessation • Acknowledge that quitting is hard, do not trivialize • Explain why tobacco is addicting, how medication can help and how it works • Help to choose a low stress quit date • Recommend elimination of cigarettes from home and remove potential triggers • Encourage other family members to quite (especially if present) • Medication • First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) • Start Wellbutrin/NRT 7 days prior quit day • Chantix if patient prefers or if contraindication to Wellbutrin. • No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date • Discuss side effects (if not discussed, patient is likely to stop medication) • Provide written educational materials reinforcing discussion and medication regimen • Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) • Patient Education • Supportive and empathetic discussion • Discuss the importance of smoking cessation • Acknowledge that quitting is hard, do not trivialize • Explain why tobacco is addicting, how medication can help and how it works • Help to choose a low stress quit date • Recommend elimination of cigarettes from home and remove potential triggers • Encourage other family members to quite (especially if present) • Medication • First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use) • Start Wellbutrin/NRT 7 days prior quit day • Chantix if patient prefers or if contraindication to Wellbutrin. • No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date • Discuss side effects (if not discussed, patient is likely to stop medication) • Provide written educational materials reinforcing discussion and medication regimen • Recommend patients consult the 1-800-QUIT-NOW (800-784-8669) SSI Document Smoking Cessation Intervention in EMR Document Smoking Cessation Intervention in EMR Follow up visit Follow up visit No Follow up Visit No Follow up Visit • Current smoking status identified at intake • Did the patient join any cessation programs? • Have they used medication? • If the patient did not quit, offer medication again and discuss importance again • If successfully quit, make sure to discuss and praise success • Current smoking status identified at intake • Did the patient join any cessation programs? • Have they used medication? • If the patient did not quit, offer medication again and discuss importance again • If successfully quit, make sure to discuss and praise success • Nurse/Quality Manager contact via phone once a month regarding smoking status • Do they need refills or need to speak to a provider? • Nurse/Quality Manager contact via phone once a month regarding smoking status • Do they need refills or need to speak to a provider? Document in EMR Document in EMR

24. Length of Stay: Results to Date P=0.056 P=0.089

25. Cost per case: Results to Date *P=0.010 *P=0.004

26. Successes Summary • 68 patients have undergone through the ERP LEB pathway in the 10 months post implementation • Improvement in observed to expected LOS: both total and post-operative • Reduction in 30-day all cause readmission • Reduction of surgical site infections • Decrease of average cost per case

27. Ongoing Challenges • Poor compliance in certain metrics • PACT visit • Celebrex administration (Anesthesia) • Day of surgery mobility • Ordering of Pre-OPPowerPlan • Proper documentation of metrics (mobility) • Long term maintenance of reached goals • Patient participation (crucial to success)

28. Thank You