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Enhanced Recovery: Can We Really Have It All?
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Enhanced Recovery: Can We Really Have It All?


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This presentation was delivered at the BC Surgical Quality Action Network's 2013 annual meeting. …

This presentation was delivered at the BC Surgical Quality Action Network's 2013 annual meeting.

Olle Ljungqvist, MD PhD
Chairman of the International Enhanced Recovery After Surgery Society
Professor of Surgery at Örebro University Hospital, Sweden

Ron Collins, MD
Project Medical Director, Enhanced Recovery, Interior Health
Clinical Consultant, BCPSQC

Enhanced Recovery processes of care have repeatedly been demonstrated to improve surgical outcomes. Implementation of ERAS can be challenging. Recognizing some of the cultural barriers is important. We propose a data-rich, outcome driven process to support site-specific implementation of ERAS.

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  • We collect data on 20% of included cases from multiple specialties (ortho, gen, gyn, uro, plast, ENT: different depending on site). This represents 1680 cases per site for a total of 5040 cases authority wide (at 3 participating IHA sites). A unique benefit of NSQIP is that all cases are followed for 30 days postoperatively by contacting the patient and or physician.
  • Our Goal is to present the NSQIP data and best practices. One of the benefits of the NSQIP data are our Semi-annual and Interim Quarterly Reports. These reports are risk adjusted and allow us to share the data with surgeons and surgical teams to help identify areas for improvement. By participating in NSQIP and the BC Collaborative we are also able share recent best practices to help with quality improvement.
  • If we are at one (the gold bar) then we are doing as expected. Above the bar are opportunities for improvement and below the bar we are doing well. But that does not mean there aren’t ongoing opportunities for improvement and I believe that is an important take away. Again an Odds Ratio graph that identifies the 3 Island Health Authority sites that participate in NSQIP. This is an all site comparison of the key occurrences within NSQIP. The blue bar is NRGH, the red bar is RJH and the green bar is VGH. Of note, VGH was cited with a Meritorious Award this past SAR. Of the 374 eligible hospitals, VGH was sited in the TOP 10%.
  • This is an example of what we can do with the data. We can pull up an occurrence and compare it to cpt code for the procedure performed or rate by specialty. Unlike the previous two slides which were cumulative data and based on the semiannual reports - this slide is year by year comparison of UTI rates by all specialties and the top three specialties with high UTI rates at RJH. This slide also shows us how RJH is doing in comparison with the BC collaborative and the other NSQIP sites. We can also see that RJH’s UTI rates have increased significantly in the second year compared with the first year of data collection. As a result of the high UTI rates, RJH did a drilldown to find out what specialties would benefit from this data and where they needed to focus their attention to make improvements. As with the SAR this data reflects Risk Adjusted Data from July 1, 2011 to March 31, 2013 but unlike the SAR it includes Raw Non-Risk Adjusted Data from Apr 2013 to June 30, 2013. However, we have found the raw data if very indicative of the risk adjusted data and our current state.
  • The NSQIP Data tells usthat we have Missed Opportunities. For instance, all three sites have high Urinary Tract Infections rates. As well, all three sites are working to address Surgical Site Infections rates. This picture is a classic example of a missed opportunity. As a result of our data we are now poised to move forward. As stated earlier, our goal is to share the data with you. The question we need to ask is how can we all be a part of this authority wide quality improvement initiative?
  • SHN is one of the ways we can move forward. In June SHN presented a webex on preventing SSI (the link to this presentation is attached at the end of the slide). As well, Dr. Richard Bachand, who is a pharmacist and director of antimicrobial stewardship, was involved with NSQIP staff in drilling down on bariatric pts regarding antibiotic prophylaxis. That drill down along with SHN’s SSI bundle were the catalysts for our health authorities NSQIP team to create Custom Fields to help us see where we are in relation to preventing SSIs.
  • With Safer Health Care Now firmly in mind at Island Health Authority, we created (with ACS’s help) seven main custom fields (with 49 individual entries) in the workk station to assist us in identifying who our audiences need to include. We identified: Antibiotic dosing, wt based dosing and redosing, pre and intra op skin prep, ormothermia, glucose monitoring and post op instructions. We are also currently surveying our surgeons to identify pre and post op instructions so that we might know how else to convey key messages to our patients.This information has helped us to identify the low hanging fruit this is so ripe for the picking!
  • This slide speaks to me in so many ways. What a journey we are on! We know this is not a straight forward, guns ablazing journey! But a journey we can take together from the time a patient is identified as needing a procedure to the pinnacle of the mountain. A successful journey that sees our patients get the very best we all have to offer! As nurses and caregivers we can drive this change! How can you help?
  • Final Thoughts and questions????
  • Transcript

    • 1. Island Health Authority Nanaimo Regional General Hospital Victoria General Hospital Royal Jubilee Hospital
    • 2. Program Overview 40 cases 42 weeks 1680 40 cases Multispecialty 42 weeks X 3 sites 1680 X 3 sites VGH NRGH 5040 5040 20% 30 day RJH Ortho Ortho General Gyne 10 10 9 Ortho General Gyne 13 9 7 Urology 5 Plastics 5 Neuro ENT 4 2 Urology ENT 5 2 9 General Urology Vascular Cardiac ENT Plastics Thoracic 6 6 4 3 3 2 2
    • 3. Program Goals
    • 4. Island Health Cases Site Comparison 2.5 2 1.5 1 0.5 0 Jan-01-12 to Dec-31-12 Where we need to be NRGH RJH VGH
    • 5. RJH- Urinary Tract Infection Rates by Specialty First Year Second Year July 1, 2011 to June 30, 2012 July 1, 2012 to June 30, 2013 RJH BC NSQIP RJH BC NSQIP All Specialties 2.4% 2.8% 2.2% 4.2% 2.2% 2.2% ENT 1.7% 0.6% 0.8% 2.4% 0.3% 0.8% Urology 3.3% 4.1% 4.0% 6.2% 3.3% 3.3% General 3.3% 2.5% 1.8% 5.0% 1.7% 2.0%
    • 6. Resources The ‘How to’ Guide for Reducing Harm in Perioperative Care Updated Recommendations for Control of Surgical Site Infections. Annals of Surgery, Volume 253, No. 6. June 2011 Video presentation – ‘Cuts Like a Knife’, Safer Healthcare Now