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The pathways to improve patient care

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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The pathways to improve patient care

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  1. Enhanced Recovery After Surgery(ERAS) The pathways to improve patient care Presented by Deborah Bachand Manger of Surgical Service Project & Implementation for VIHA

  2. “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.

  3. ERAS programs follow well trodden paths… Evidence based, internationally proven to improve outcomes and patient satisfaction…

  4. 48/6 • Medication • Cognition • Pain • Mobility • Bowel/bladder • Nutrition/hydration

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

  6. 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

  7. Surgery is a Journey Think of ENHANCED SURGICAL PATHWAYS as the GPS to help our patients navigate the system…

  8. Colon (Bowel) Resection Surgery Your name: _____________________

  9. Changing traditional practice can be a tall order… Most of us are firmly rooted in our practice norms…

  10. Now Operating Room Before 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

  11. Now Care Post Operatively Before 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

  12. Now Care Post Operatively Before 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

  13. There will be obstacles…

  14. And some pitfalls…

  15. Mean LOS for Colorectal Surgery

  16. 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.

  17. 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. The Outcome…Everyone’s a Winner!

  18. Thank you

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