Using Enhanced Recovery After Surgery (ERAS) to Enhance Postoperative Outcomes

Enhanced Recovery After Surgery (ERAS)
To Improve Recovery
Francesco Carli MD, MPhil
Professor of Anesthesia
McGill University
franco.carli@mcgill.ca

Improving Patient’s Recovery
What if surgery could be done without:
Metabolic stress response
Catabolism
Organ dysfunction
Complications
Pain
Fatigue…
…length of stay and costs will decrease too

We’re not there yet
• Complications: 21-45% of patients have
complications after cancer surgery and 1-4% die.
• Variations: Significant differences between and
within centers in perioperative processes,
complications and hospital stay
• Patient centered outcomes: Full recovery takes
longer than we think.

Colectomy outcomes remain poor
Schilling, Dimick, Birkmeyer JACS 2008. 207(5):698-704
Prioritizing quality improvement in general surgery

Cohen ME Ann Surg 2009
Variability in long length of stay after uncomplicated
colorectal surgery in NSQIP hospitals
87% had no complications: 6.1(3.8) days, median 5 days
13% had complications: 16.1(14.2) days, median 12 days

Variability in Processes of Care:
Responses (%) to questionnaire on perioperative care
in colonic resection in 5 northern European countries
Response Scotland Netherlands Sweden Norway Denmark Range
NG is removed in OR 75% 22% 83% 82% 85% 22-85%
Epidural analgesia is used
routinely on ward
11% 83% 93% 89% 96% 11-96%
Clear fluids day of surgery 38% 58% 71% 82% 96% 38-96%
Oral intake at will by POD1 27% 46% 44% 53% 85% 27-85%
Lassen K, BMJ, 2005
Based on traditions

Patients
(n=17)
Clinicians
(n=15)
Energy Level 88% 67%
Carrying out daily routine 76% 60%
General physical endurance 53% 53%
Sensation of pain 47% 87%
Recreational activities 47% 33%
Walking 41% 47%
Sleep functions 41% -
Appetite 35% 40%
Moving around 35% 47%
Defecation functions 18% 47%
Quality of consciousness - 60%
Doing housework - 47%
Family relationships - 40%
Informal social relationships - 40%
Lee L, Dumitra T, Fiore J Jr, Mayo NE, Feldman LS. How well are we measuring postoperative “recovery”? Qual Life Res, 2015
Outcomes that matter to patients recovering from GI surgery
Patients emphasized
energy level, functional
status (daily routine,
recreational activities,
endurance) and sleep
Compared to patients,
clinicians put more
emphasis on symptoms
(pain, cognition, bowel
function)

Patient Expectations:
What day do you tell patients to expect to be
discharged after uncomplicated colon resection?
0
10
20
30
40
50
60
70
POD 1 POD 2 POD 3 POD 4 POD 5 POD 6 POD 7
Responses
Keller DS, Delaney CP, Senagore AJ, Feldman LS. Surg Endosc 2016

Trajectory of functional ability throughout the
perioperative periodLevelofFunctional
ability
Preop Recovery
Recovery = time to recovery to baseline
Surgery

Decrease trauma of surgery  improve recovery

• How long
does it take
to recover
after a lap
chole?

How long to full recovery? longer than we think
>1 month to recover higher intensity physical activities after
ambulatory laparoscopic cholecystectomy
19
0
6
20
14
19
0
10
20
30
40
50
Baseline 1 week 1 month
kcal.kg-1.wk-1
higher intensity lower intensity
Feldman LS, Kaneva P, Demyttenaere S, Carli F, Fried GM, Mayo NE. Validation of a physical activity questionnaire (CHAMPS) as an
indicator of postoperative recovery after laparoscopic cholecystectomy. Surgery, 146 (1): 31-9, 2009.
p<0.05
p=0.68

Surgical stress:
pain, catabolism, fluid/salt
retention, immune dysfunction,
nausea/vomiting, ileus, impaired
pulmonary function, increased
cardiac demands,
hypercoaguability, sleep
disturbances, fatigue
Kehlet and Wilmore, Ann Surg 2008 (revised)
Approaches to reduce surgical stress and improving outcomes
Minimally Invasive Surgery
Afferent neural blockade:
thoracic epidural
local infiltration anesthesia
peripheral nerve blocks
Pharmacologic interventions:
non-opioid, multimodal analgesia
anti-emetics
glucocorticoids
systemic local anesthetics
insulin
β-blockers
α2-agonists
anabolic agents
Other interventions:
fluid balance
normothermia
preoperative carbohydrate
exercise

Perioperative care in GI Surgery:
• >20 elements
• “Strong” recommendations
• Several challenge traditions
• Multiple stakeholders
• How do we get all this into
practice?
Lots of evidence

“Health care historically has been a very siloed
field that’s organized around medical
specialties... The patient is the ping-pong ball
that moves from service to service”
-Michael Porter

Enhanced Recovery Pathway
• Integrated, evidence-based, multimodal, consensus
on perioperative care
• Goals:
– Support early return of function
– Reduce morbidity
– Improve efficiency
– Decrease variability
– Increase value (outcomes/cost)

CHO loading
Activation
Optimization
Reduced fasting
Fast acting anesthetics
Multimodal opioid
sparing analgesia
Fluid balance
Normothermia
Regional anesthesia
Periop nutrition
Early mobilization
Daily care maps
Discharge criteria
Early removal
catheters &
drains
PONV and Ileus
prophylaxis
Prehabilitation
?bowel prep
Components of an Enhanced Recovery Program
Preop
Intraop
Postop
No NG
Minimally Invasive

LevelofFunctional
ability
SurgerySurgery
ERP
Traditional
Preop Recovery
perioperative period

Ann Surg 2000
 60 patients (74 yo)
 Open colon resection + “accelerated
multimodal rehabilitation program”
 Epidural, early feeding and mobilization
 Median LOS 2 days (mean 3 days)
 15% readmissions

• Lap foregut pathway
• Started in 2001
• Nutrition management
• Limited investigations
• Excellent patient acceptance
• Colorectal fast track
• Started in 2006
• Laparoscopic cases only
• Surgeons selected patients
• Limited patient education

Mission: Implement multidisciplinary
ERPs across department
• Initiated by clinicians, supported by
Chair
• Started October 2008
• Target prevalent in-patient
procedures
• Pathways would be standard of care
(all start pathway)
• Full time coordinator as pilot
project (1 year)
• Multidisciplinary team with clinical
experts for each pathway
• Weekly meeting

ERP Team: Steering Group
• Pathway coordinator
• Surgeon lead
• Anesthesia lead
• Nurse manager surgery ward
• Clinical nurse specialist- pain
• Physiotherapist
• Nutritionist
• Pharmacist
• Librarian
PLUS Clinical Experts
for each pathway – surgical
lead, anesthesia, nursing

Literature review- guidelines, discharge target
Perioperative medical and pharmaceutical orders
ADL flowsheets and nursing documentation
External prescriptions
Pathway creation
Nurses: preoperative clinic and the recovery room
Surgeon staff and Surgical Residents
Launch date- “everyone starts the pathway”
MUHC Committees Reviews and Approvals
Personnel Training
Development of an ERP
Surgical Recovery team Review Committee
Nursing Clinical Practice Review Committee (NCPRC)
Pharmacy and Therapeutics (P&T) Committee
Form Committee (medical archives)
Audit and Revision
New Perioperative Pathway
Surgeons & nurses:
Standard orders
Patient:
Education & care map

The ”evidence” behind NPO
• Mendelson paper 1946
• Textbook ”thruth” from 1964
But:
• No true scientific backing
• Few aspirations in elective surgery
• Risk: associated with concomitant
disease
J R Maltby in Best Practice in Anaesthesia and Intensive Care 2006

Well known physiology:
Gastric emptying
Ljungqvist & Söreide, Br J Surg, 90: 400-406, 2003

Gastric emptyng after 400 cc of carbohydrate
MRI
Lobo et al. Clin Nutr 2009:28(6)636-41

Why challenge NPO?
• Normal physiology
• NPO is no guarantee of an empty stomach
• The same gastric volume with/without clear
fluids
• Improved well being: thirst (headaches,
hunger)

Modern fasting guidelines
Elective surgery
• Clear fluids
– water, coffee, tea (no milk), some juice
• 2 h before anaesthesia & surgery
• Exclusions
– Emergency surgery
– Upper GI symtoms, GI transit slow
Ljungqvist & Söreide Br J Surg 2003

Cochrane review 2003
• No evidence that liberal fasting guidelines had
negative impact on gastric volumes or pH
• Intake of water up to 90 mins preop resulted
in lower gastric volumes
• Clinicians should …. when necessary adjust
existing fasting policies
PC Stuart in Best Practice in Anaesthesia and Intensive Care 2006

Why carbohydrate treatment?
• Animal work showed survival benefit from fed
state in stress
• Short term fasting changes metabolic setting
• Un-natural way to prepare for stress
• Potential metabolic gains…..
Ljungqvist et al, Best Pract & Res Clin Anaesthiol 23 (2009) 401–409

• Reading level of patient education materials: Grade 11.5
Smith & Haggerty, 2003
• 1 out of 5 American adults reads at the 5th grade level or below, and the
average American reads at the 8th to 9th grade level, yet most health
care materials are written above the 10th grade level
National Patient Safety Foundation, 2011
• Printed materials should be accurate, easily accessible, and at a 6th to
7th grade reading level National Institutes of Health, 2011
• 800 studies between 1970 and 2006 indicate most health materials
exceed high-school graduate reading levels
Canadian Council for Learning, 2008
Patient Education Is An Important Element

What is Health Literacy?
The degree to which individuals can obtain, process and
understand basic health information and services they
need to make appropriate health decisions.
Institute of Medicine’s report Health Literacy: Prescription to End Confusion (2004) ;

Prevalence of low Health Literacy
• In the USA- 90 million people- nearly half of the
adult population have low health literacy.
• In Canada-
– 60% of adult Canadians have low health
literacy.
Canadian Council on Learning (2008).; IOM (2004)

Prevalence of low Health Literacy
The European Health Literacy Project. /The European Health Literacy Projec

How to get ready for your surgery
The evening before your surgery take a shower. The morning of your surgery
take another shower. On the day of your surgery do not put any makeup,
cream or lotions.
We strongly suggest you stop smoking completely before your surgery, as this
will reduce the risk of lung complications afterwards and help the incision to
heal. Doctors can help you stop smoking by prescribing certain medications.
Please discuss these options with your doctor.
Decrease your alcohol use. Alcohol can interact with medications. Do not drink
alcohol 24 hours before surgery. Please let us know if you need help
decreasing your alcohol use before surgery.
If you get sick before your surgery please phone the hospital to cancel.
Some pain medications can cause constipation. If constipation becomes a
problem, increase the amount of fluids you drink, add more whole grains,
fruits and vegetables to your diet and continue to exercise and walk regularly.

How to get ready for your surgery

www.muhcpatienteducation.ca
Why a patient version of pathway? Align expectations & empower patients to “speak up!”

Is achieved when a process or outcome, measured at least a year later,
has not returned to its past state. (Parsons & Cornett 2011)
Sustainability
Share Data Visual Cues
slide: Debbie Watson

1. Esophagectomy June 2010; revised 2014
2. Colorectal Aug 2010; RVH 2014
3. Prostatectomy Nov 2010 ; revised 2014
4. Lap chole Aug 2011; revised 2016
5. Thyroidectomy Oct 2011; revised 2014; revised 2016
6. Inguinal hernia Feb 2012
7. Lung resection Sept 2012
8. Hip and Knee Arthroplasty Sept 2013; hip revised 2016
9. Nephrectomy June 2014
10. Hepatectomy RVH June 2014
11. Spine (day surgery) Sept 2014
12. EVAR RVH march 2016
13. Cystectomy RVH Sept 2016
14. Bariatric March 2017
15. Hip fracture
16. Head and neck oncology
17. Gastrectomy
18. Video assisted Thoracic surgery
19. Kidney transplant
20. Gyne Oncology
21. Hysterectomy
22. Pancreatectomy
Implemented
In Development

Adherence to ERP: 23 elements
Preoperative Intraoperative Postoperative
Preadmission education 347 (100) Antibiotic prophylaxis 345 (99) Multimodal analgesia 241 (98)
Selective MBP 246 (71) Epidural analgesia 253 (73) Oral liquids on POD 0 209 (89)
Carbohydrate loading 213 (61) Laparoscopic approach 250 (72) Nutritional drink POD 0 146 (42)
No long-acting sedatives 347 (100) Balanced IV fluids 90 (26) Regular food on POD 1 282 (81)
PONV prophylaxis 320 (92) Early termination of IV 201 (58)
Normothermia 223 (64) Early mobilization 275 (79)
No abdominal drainage 298 (86)
Early termination of urinary
drainage
298 (86)
TED prophylaxis 346 (100) Chewing-gum 217 (63)
No nasogastric tube 344 (99) Laxative 210 (61)
Transition to oral analgesia on
POD 2
255 (73)
Mean overall adherence: 77% ± 11%

Predictors of “successful hospital recovery”
(LOS≤4d, no complications, no readmission)
ERP element OR 95% CI p-value
Laparoscopy 4.32 2.260 – 8.267 < 0.001
Early mobilization* 2.25 1.130 – 4.474 0.021
Early termination of IV fluids 1.99 1.158 – 3.445 0.013
Regular food on POD 1 2.37 0.952 – 4.393 0.067
Early termination of urinary drainage 2.05 0.956 – 5.854 0.063
Adjusted multivariate regression model (n=347)
*Early mobilization = out of bed at least once in first 24 hours
Pecorelli N, Fiore Jr J, Charlebois P, Liberman S, Stein B, Baldini G, Carli F, Feldman LS. Impact of adherence to care pathway
interventions on recovery following bowel resection within an established enhanced recovery program. Surg Endosc 2016

Relationship between overall adherence to enhanced
recovery pathway elements, successful recovery and 30-day
complications
Pecorelli N, Hershorn O, Baldini G, Fiore Jr JF, Stein BL, Liberman AS, Charlebois P, Carli F, Feldman S, Impact of adherence to
care pathway interventions on recovery following bowel resection within an established enhanced recovery program, Surgical
Endoscopy, April 2017, 31(4), 1670-71
n=347 elective colorectal surgery

Average LOS CUSM
2011-12 2012-13 2013-14 2014-15 2015-16
%difference 5% 2% 2% -2% -7%
-8%
-6%
-4%
-2%
0%
2%
4%
6%
Average LOS: % difference vs MSSS target for typical
cases

LOS as measure of recovery?
Fiore et al, WJS 2013
n=70 colorectal
54% lap
Traditional care
LOS = TRD + 1 day
No ERAS
Tolerance of oral intake 2 [1-3]
Recovery of lower GI function 1 [1-2]
Adequate pain control with oral analgesia 3 [2-3]
Ability to mobilize and self-care 3 [2-3]
No evidence of complications 2 [1-2.5]
Time to readiness for discharge 3 [2-4]
Length of hospital stay 3 [3-5]
Balvardi et al, SAGES 2017
n=100 colorectal
81% lap
Enhanced Recovery Pathway
LOS = TRD
+ ERAS

Conventional
Care (n=95)
Enhanced Recovery
(n=95)
p
Preoperative management
Written patient education 0 (0%) 95 (100%) <0.001
Mechanical bowel prep 63 (66%) 34 (36%) <0.001
Sedative 54 (57%) 0 (0%) <0.001
Carbohydrate drink 0 (0%) 46 (48%) <0.001
Intraoperative management
Antibiotic prophylaxis 95 (100%) 95 (100%) 1.000
Mean IV crystalloid, ml (SD) 2475 (1368) 1707 (1122) <0.001
Mean IV colloid, ml (SD) 429(405) 305(385) 0.038
Abdominal drain 13(14%) 4(4%) 0.022
NG tube left in situ 5(5%) 1(1%) 0.097
Normothermia 91 (96%) 91 (96%) 0.710
Thoracic epidural 61 (64%) 56 (59%) 0.456
Laparoscopic 45(47%) 71 (75%) <0.001
New stoma 33(35%) 22 (23%) 0.056
Cost-Effectiveness of Enhanced Recovery vs
Conventional Perioperative Management
Lee L, Mata J, Augustin B, Ghitulescu G,
Boutros M, Charlebois P, Stein B,
Liberman AS, Fried GM, Morin N, Carli F,
Latimer E, Feldman LS. Cost-Effectiveness
of Enhanced Recovery versus
Conventional Perioperative Management
for Colorectal Surgery. Ann Surg 2015
Dec; 262(6):1026-33

Postoperative Management Conventional
Care (n=95)
Enhanced
Recovery (n=95)
p
Median days to mobilization > 2h/day, days
[IQR]
2[1-2] 1[1-2] <0.001
Median days to discontinuation of IV fluids,
days [IQR]
3[2-5] 1[1-1] <0.001
Median days passage of first flatus, days [IQR] 3[2-3] 1[1-2] <0.001
Median days to receive oral fluids, days [IQR] 2[1-3.5] 0[0-0] <0.001
Median days to tolerate solid diet, days [IQR] 4[3-5] 1[1-2] <0.001
Median days to removal of bladder catheter,
days [IQR]
2[1-3] 1[1-1] <0.001
Enhanced Recovery met discharge milestones sooner and less variability

Postoperative Management Conventional
Care (n=95)
Enhanced
Recovery (n=95)
p
Median days to mobilization > 2h/day, days
[IQR]
2[1-2] 1[1-2] <0.001
Median days to discontinuation of IV fluids,
days [IQR]
3[2-5] 1[1-1] <0.001
Median days passage of first flatus, days [IQR] 3[2-3] 1[1-2] <0.001
Median days to receive oral fluids, days [IQR] 2[1-3.5] 0[0-0] <0.001
Median days to tolerate solid diet, days [IQR] 4[3-5] 1[1-2] <0.001
Median days to removal of bladder catheter,
days [IQR]
2[1-3] 1[1-1] <0.001
Median total hospital stay, days [IQR] 7 [5-9] 4 [3-7] <0.001
Results in decreased length of stay

Clinical outcomes
Total hospitalization, mean (SD): 9.8(12) vs 6.5(6)d*
60-d readmissions: 11 vs 13%
60-d complications: 43 vs 40%
Complication severity, mean (SD): 10.7(17) vs 10.2(14)
Postdischarge outcomes
Lost days from work: 35(20) vs 26(18)*
Caregiver lost days from work: 5(12) vs 1.3(2.6)*
Postoperative CLSC visits: 3.7(9) vs 1.4 (4.6)*
No difference in HRQoL (SF-6D)
Lee L, Mata J, Augustin B, Ghitulescu G, Boutros M, Charlebois P, Stein B, Liberman AS, Fried GM, Morin N, Carli F, Latimer E, Feldman LS. Cost-Effectiveness
of Enhanced Recovery versus Conventional Perioperative Management for Colorectal Surgery. Ann Surg 2015 Dec; 262(6):1026-33

Implementation Costs
Source What was included? Cost*
(2013 CAN$)
Roulin (BJS 2013)
Switzerland
“Implementation costs” 19 800
Travel and lunch of multidisciplinary team 5 423
Full-time nurse coordinator (6 mos) 36 300
Total 61 523**
Sammour (NZ Med J 2010)
New Zealand
Denmark visit (3 persons) 12 190
Research fellow salary (15 mos) 97 128
Total 109 318
Lee (Ann Surg 2014)
Canada
Booklet development 14 320
Pathway creation 19 340
Full-time nurse coordinator 81 225
Total 108 770
*Currency conversion using purchasing power parity from OECD
• Colorectal
• Esophagectomy/gastrectomy
• Pulmonary resection
• Thyroidectomy
• Laparoscopic cholecystectomy
• Inguinal hernia
• Prostatectomy
708 total patients 2012-2013
= $153 per patient

Mean difference in costs from
Different Perspectives (per patient)
Institutional cost saving
-$1,150 (-3487 to 905)
Health care system cost saving
-$1,602(-4,050 to 517)
Society cost saving
-$2,985(-5,753 to -373)*
Lee et al, Ann Surg 2015

Br J Surg 2013;100(10); 1326-34
Expected cost savings per patient: $2666
Average caseload: 50-60 per year
 $2666 savings/patient X 50
patients/year = $133,300 savings/year

Economic Impact of an Enhanced
Recovery Pathway for Lung Resection
Paci et al. STS 2017 (Submitted to Ann Thor Surg, in revisions)
CC (n=58 ) ERP (n= 75 ) p-value
Clinical outcomes
Any complication 30 (52) 24 (32) 0.022
Pulmonary complication 20 (34) 12 (16) 0.013
Minor (Clavien I-II) 20 (34) 17 (23) 0.13
Urinary tract infection 8 (14) 2 (3) 0.021
Major (Clavien III-V) 10 (17) 7 (9) 0.18
Mortality 0 1 (1) 1.00
Readmission 3 (5) 3 (4) 1.00
Emergency department visit 9 (16) 0 <0.001
Length of Stay
Overall 6 [4-9] 4 [3-6] 0.002
Discharged by target (POD#4) 16 (28) 39 (52) 0.005
Prolonged LOS (>14 days) 8 (14) 1 (1) 0.01

Adherence to elements of the standardized
postoperative pathway in the conventional care (CC)
and enhanced recovery pathway (ERP) groups

Zaouter C, Kaneva P, Carli F. Reg Anesth Pain Med 2009; 34:542-8
Early removal
(n=105)
Standard
removal
(n=110)
p
UTI 2% 17% 0.004
In and out catheterization 8% 2% 0.09
Reinsertion of Foley 3% 0 0.229
• Patients with continuous thoracic epidural at low risk for POUR
• RCT of early removal urinary catheter POD 1 vs standard
• Bladder scan every 3 hours if no void
Less urinary tract infection by earlier removal of bladder catheter in surgical patients
receiving thoracic epidural analgesia.

Economic Impact of an Enhanced
Recovery Pathway for Lung Resection
Mean difference in costs per patient from all perspectives
Favors ERP Favors Conventional Care
Institutional
Health care system
Societal
-8000 -4000 0 4000 8000
Mean difference (95% CI), CAN$
Institutional cost saving
-$2,580 (-6,245 to 576)
Health care system cost saving
-$2,850 (-6,380 to 244)
Societal cost saving
-$4,396 (-8,674 to -618)

LevelofFunctional
ability
SurgerySurgery
ERP
Traditional
Preop Recovery
perioperative period
Prehabilitation + ERP

Shifting role for preoperative team and
preoperative time
Risk stratification
Resource allocation (ICU)
“OK for OR”
Optimization
Metabolic preparation
Prehabilitation

Prehabilitation and functional capacity before and
after colorectal surgery: 5-years McGill experience
Minella et al Acta Oncol. 2017 Feb;56(2):295-300
n=185
+30(47)m*
-11(72)m*
17(84)m*
-5.8(40)m
-72(129)m
-9(74)m
* p <0.05

Recovered to baseline walking capacity 5-
9 wks post CRS
59 66 60
84
0%
20%
40%
60%
80%
100%
not recovered
recovered
1998-2000 2005-06 2009-11 2011-13
Laparosc. No 24% 93% 97%
ERP No - + +
Prehab No - - +
Moriello C Phys Med Rehab 2008;

Recovered to baseline walking capacity
5-9 wks post CRS
59 66 60
84
0%
20%
40%
60%
80%
100%
not recovered
recovered
Moriello C Phys Med Rehab 2008; Carli F BJS, 2010;
1998-2000 2005-06 2009-11 2011-13
ERP No No + +
Prehab No No - +

5-9 wks post CRS
59 66 60
84
0%
20%
40%
60%
80%
100%
not recovered
recovered
Moriello C Phys Med Rehab 2008; Carli F BJS, 2010; Li Surg Endosc, 2013;
1998-2000 2005-06 2009-11 2011-13
ERP No No Yes +
Prehab No No No +

5-9 wks post CRS
59 66 60
84
0%
20%
40%
60%
80%
100%
not recovered
recovered
Moriello C Phys Med Rehab 2008; Carli F BJS, 2010; Li Surg Endosc, 2013; Gillis C Anesthesiology 2014;
1998-2000 2005-06 2009-11 2011-13
ERP No No Yes Yes
Prehab No No No Yes

Summary: Pathway approach
• Need to change the culture
• Focus on patient’s recovery
• Get evidence into practice
• Improve interdisciplinary environment
• Applicable across procedures
• Decreases variability
Increase value* of what we do
*outcomes that matter to patients/ cost

Using Enhanced Recovery After Surgery (ERAS) to Enhance Postoperative Outcomes

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