Adam W. Beck, M.D. Associate Professor of Surgery - PowerPoint Presentation

Adam W. Beck, M.D.Associate Professor of SurgeryDivision of Vascular Surgery and Endovascular TherapyUniversity of Alabama at BirminghamJune 12th, 2019 Implementation of an Enhanced Recovery Program (ERP) for Lower Extremity Bypass

DisclosuresNo relevant Disclosures

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

How does eras work?Patients can drink up to 2hrs prior to surgeryRegular diet night of surgeryMobilize Day of SurgeryMinimize opioid useMinimize Intravenous FluidsOnly get 1 set of labs

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

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.

Themes of ERAS“Perioperative care, not the actual operation, can dictate outcomes”Minimize stress and improve response to stressPatient centered approachEvidence based, “best practice” medicineRelies on multidisciplinary team approach How does eras work?

ErP vascular? Vascular surgery patients often:Multiple medical comorbiditiesLower socioeconomic/educational levelHigh risk for perioperative complications High risk for SSIHigh risk for unplanned readmissionsLower extremity bypass patients perhaps highest risk...good population for ERP? Excluded patients undergoing open surgical inflow procedures as well as trauma patients.

Implementation Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: 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 Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? 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 in EMR Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: 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 Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessationAcknowledge that quitting is hard, do not trivializeExplain why tobacco is addicting, how medication can help and how it worksHelp to choose a low stress quit dateRecommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) MedicationFirst line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)Start Wellbutrin/NRT 7 days prior quit dayChantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit dateDiscuss side effects (if not discussed, patient is likely to stop medication)Provide written educational materials reinforcing discussion and medication regimenRecommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR 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

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 patientsReduction of the observed to expected LOS indexReduction in percentage of 30-day all cause readmission Reduction in SSI rate Reduction of variable cost per case.

UAB ERAS pathwaysExisting UAB ERAS pathways are based on ERAS society guidelines 2014- Colorectal2015- Surgical Oncology2016- Gynecology Oncology2018- Vascular

Implementation Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: 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 Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? 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 in EMR Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: 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 Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessationAcknowledge that quitting is hard, do not trivializeExplain why tobacco is addicting, how medication can help and how it worksHelp to choose a low stress quit dateRecommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) MedicationFirst line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)Start Wellbutrin/NRT 7 days prior quit dayChantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit dateDiscuss side effects (if not discussed, patient is likely to stop medication)Provide written educational materials reinforcing discussion and medication regimenRecommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR Transformational process! Plan-Do-Check-Adjust (PDCA) methodology Requires collaboration of teammates Repeated re-evaluation of initiatives: Redesign

ERAS Implementation

Preoperative phaseEmphasis on patient educationEarly mobilityPost-operative pain controlPlanned length of hospital stay

Smoking Cessation ProtocolInitial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: 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 Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? 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 in EMR Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: 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 Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessationAcknowledge that quitting is hard, do not trivializeExplain why tobacco is addicting, how medication can help and how it worksHelp to choose a low stress quit dateRecommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) MedicationFirst line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)Start Wellbutrin/NRT 7 days prior quit dayChantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit dateDiscuss side effects (if not discussed, patient is likely to stop medication)Provide written educational materials reinforcing discussion and medication regimenRecommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR

Perioperative phaseChlorhexidine showersPreoperative hair clippingNon-opioid analgesia in preoperative holding areaPlacement of fascia iliaca block by Inpatient Pain Service (IPS)Fascia Iliaca/Sciatic BlockAnesthesia 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 therapyAvoids use of an indwelling catheter which might limit early mobility

Intraoperative phaseAnesthesiologistsGoal directed fluid managementMaintain normothermiaNon-opioid pain adjunctsLung protective ventilationPost-operative nausea prophylaxisSurgeonsSkin closure protocolSeparate instrument set for skin closureChanging of gowns/gloves, and changing of the overhead operative light handlesTwo 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.

Postoperative phaseEarly mobilizationPOD0- Edge of bedPOD1- Out of bed, daily mobility milestones set by PTDietRegular diet immediately after arrival to surgical floorTobacco cessationConsult placed to UAB Tobacco Cessation team who visit the patient for bedside counseling typically on their second postoperative day

ERAS UAB Powerplan

DemographicsInitial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: 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 Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? 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 in EMR Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: 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 Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessationAcknowledge that quitting is hard, do not trivializeExplain why tobacco is addicting, how medication can help and how it worksHelp to choose a low stress quit dateRecommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) MedicationFirst line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)Start Wellbutrin/NRT 7 days prior quit dayChantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit dateDiscuss side effects (if not discussed, patient is likely to stop medication)Provide written educational materials reinforcing discussion and medication regimenRecommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR

Process Metric AssessmentInitial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: 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 Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? 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 in EMR Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: 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 Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessationAcknowledge that quitting is hard, do not trivializeExplain why tobacco is addicting, how medication can help and how it worksHelp to choose a low stress quit dateRecommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) MedicationFirst line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)Start Wellbutrin/NRT 7 days prior quit dayChantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit dateDiscuss side effects (if not discussed, patient is likely to stop medication)Provide written educational materials reinforcing discussion and medication regimenRecommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR 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

Team ComplianceInitial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: 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 Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? 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 in EMR Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: 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 Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient Education Supportive and empathetic discussion Discuss the importance of smoking cessationAcknowledge that quitting is hard, do not trivializeExplain why tobacco is addicting, how medication can help and how it worksHelp to choose a low stress quit dateRecommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) MedicationFirst line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)Start Wellbutrin/NRT 7 days prior quit dayChantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit dateDiscuss side effects (if not discussed, patient is likely to stop medication)Provide written educational materials reinforcing discussion and medication regimenRecommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR

Central Goals: Results to Date Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: 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 Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? 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 in EMR Initial Visit: Identify Patients who are currently smoking at intake Smoking Cessation Clinic Protocol: 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 Nurse/Quality Manager contact via phone once a month regarding smoking status Do they need refills or need to speak to a provider? Patient EducationSupportive and empathetic discussionDiscuss the importance of smoking cessationAcknowledge that quitting is hard, do not trivializeExplain why tobacco is addicting, how medication can help and how it worksHelp to choose a low stress quit dateRecommend elimination of cigarettes from home and remove potential triggers Encourage other family members to quite (especially if present) MedicationFirst line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)Start Wellbutrin/NRT 7 days prior quit dayChantix if patient prefers or if contraindication to Wellbutrin. No NRT while on Chantix, decrease cigarette consumption by half leading up to quit dateDiscuss side effects (if not discussed, patient is likely to stop medication) Provide written educational materials reinforcing discussion and medication regimenRecommend patients consult the 1-800-QUIT-NOW (800-784-8669) Document Smoking Cessation Intervention in EMR Document in EMR Baseline ERP P-value Eligible patients 189 57 ERAS % NA 69% Average LOS 11.1 ± 10.1 8.3 ± 8.4 0.056 Postop LOS 8.0 ± 7.5 6.1 ± 6.0 0.089 Observed:Expected LOS 1.8 ± 1.4 1.3 ± 0.7 <0.001 SSI % 5.8% 3.5% 0.499 Readmission % 21.6% 7.0% 0.012 Variable Cost/Case 18,777 ± 19,118 13,207 ± 9,930 0.004 Total Cost/Case 40,328 ± 37,820 29,865 ± 22,110 0.010 SSI

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

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

Successes Summary 68 patients have undergone through the ERP LEB pathway in the 10 months post implementationImprovement in observed to expected LOS: both total and post-operativeReduction in 30-day all cause readmissionReduction of surgical site infectionsDecrease of average cost per case

Ongoing ChallengesPoor compliance in certain metricsPACT visitCelebrex administration (Anesthesia)Day of surgery mobility Ordering of Pre-OP PowerPlan Proper documentation of metrics (mobility) Long term maintenance of reached goals Patient participation (crucial to success)

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