2017 ANNUAL CONGRESS OF

ENHANCED RECOVERY AND PERIOPERATIVE MEDICINE

6737 W. Washington St., Suite 4210 • Milwaukee, WI 53214 (P) 414-389-8610 • (F) 414-276-7704 • www.aserhq.org • info@aserhq.org

APRIL 27TH–29TH, 2017HYATT REGENCY WASHINGTON ON CAPITOL HILL400 NEW JERSEY AVE NW, WASHINGTON, D.C. 20001

SYLLABUS

2

Invited Faculty

Welcome to Washington D.C. and to the 5th Annual Congress of the American Society for Enhanced Recovery (ASER). This is the third year we are co-hosting the event with Evidenced Based Perioperative Medicine (EBPOM). This unique partnership provides a wonderful opportunity for attendees to stay abreast of the most recent scientific information on enhanced recovery and topics related to perioperative medicine, and an opportunity for colleagues and associates from different specialties and healthcare sectors to meet and enjoy a pleasant venue in Washington D.C.

We are grateful to this year’s Scientific Program Chair, Dr. Timothy Miller, assisted by Dr. Julie Thacker and Robin Anderson, RN. They have done an incredible job in selecting the speakers and the wide variety of topics for the meeting, from prehabilitation and exercise programs, perioperative pain and fluid management, to wearable technologies and digital innovations for Enhanced Recovery Program. Fascinating topics in Perioperative Medicine will also be covered by national and international experts, as well as procedure specific enhanced recovery case discussions.

Dr. Henrik Kehlet, the plenary speaker, will discuss his vision for the future of Enhanced Recovery. Other speakers include leaders and experts in surgery, anesthesiology and nursing, both at home and abroad. We also look forward to the scientific abstract session and the discussion with the presenters.

We would like to thank the corporate sponsors for their generous support, without which this meeting would not be possible. We encourage all attendees to visit the exhibits, learn what is available and offer insights to the exhibitors.

Tony J. Gan, MD, MHS President American Society for Enhanced Recovery (ASER)

Monty G. Mythen, MD, FRCA Evidence Based Perioperative Medicine (EBPOM)

Anoushka Afonso, MDMemorial Sloan Kettering

Cancer CenterNew York, NY USA

Robin Anderson, RN, BSNDuke HealthDurham, NC USA

Solomon Aronson MD, MBA, FACC, FCCP, FAHA, FASE

Duke University School of Medicine

Durham, NC USA

Syed A. Azim, MDStony Brook University

Medical CenterStony Brook, NY USA

Kristen Ban, MDLoyola University Medical

CenterMaywood, IL USA

Elliot Bennett-Guerrero, MDStony Brook School of

MedicineStony Brook, NY USA

Maxime Cannesson, MD, PhD

UCLAIrvine, CA USA

Desiree Chappell, CRNA, MSNA

Norton Audubon AnesthesiaLouisville, KY USA

Mark Edwards, MRCP, FRCA, MD(Res)

University Hospital Southampton, UK

Hampshire, UK

Lee Fleisher, MDUniversity of PennsylvaniaPhiladelphia, PA USA

Jeff Gadsden, MD, FRCPC, FANZCA

Duke University Medical Center

Durham, NC USA

Tong J. Gan, MD, MHS, FRCA

Stony Brook UniversityStony Brook, NY USA

Mike Grocott, MD, FFCIM, MBBS, FRCP, FRCA, BSc

University of SouthamptonSouthampton, UK

Ruchir Gupta, MDStony Brook UniversityStony Brook, NY USA

Traci Hedrick, MDUniversity of VirginiaCharlottesville, VA USA

Mitchell T. Heflin, MDDuke University School of

MedicineDurham, NC USA

Deborah Hobson, RN, BSNJohns Hopkins HospitalBaltimore, MD USA

Margaret Holtz, MDWellStar Kennestone

Regional Medical CenterMarietta, GA USA

Stefan Holubar, MD, MS, FACS, FASCRS

Geisel School of Medicine at Darthmouth

Lebanon, NH USA

David Hoyt, MD, FACSAmerican College of

SurgeonsChicago, IL USA

Welcome

DEAR COLLEAGUES,

3

Meeting Accreditation Information

LEARNING OBJECTIVES• Discuss the various elements of an enhanced recovery

pathway• Explain the current evidence base, as well as gaps in

understanding and controversies• Describe new care delivery models and approaches, and

how to apply these models in their hospital to improve outcomes

ACCREDITATION STATEMENTThis activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Amedco and Sexual Medicine Society of North America (SMSNA). Amedco is accredited by the ACCME to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT (CME)

Amedco designates this live activity for a maximum of 17.75 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

APPROVAL STATEMENT (AANA)

This program has been prior approved by the American Association of Nurse Anesthetists for 17.75 Class A CE credits; Code Number 1034556; Expiration Date 4/29/2017

APPROVAL STATEMENT (ANCC)

Amedco is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This course is co-provided by Amedco and American Society for Enhanced Recovery. Maximum of 17.75 contact hours.

Robert Isaak, DOUNC School of MedicineChapel Hill, NC USA

Henrik Kehlet, MD, PhDRigshospitalet Copenhagen

UniversityCopenhagen, DENMARK

Michael Kelly, MDHackensack UMCHackensack, NJ USA

Adam King, MDVanderbilt UniverstyNashville, TN USA

Clifford Y. Ko, MD, MS, MSHS, FACS, FACRS

UCLA Schools of Medicine and Public Health

Los Angeles, CA USA

Lindsey Koshansky, RN, BSNLocus HealthCharlottesville, VA USA

Terrence Loftus, MDLoftus HealthTempe, AZ USA

Christopher Mantyh, MDDuke HealthDurham, NC USA

Amy McCutchan, MDIndiana UniversityIndianapolis, IN USA

Matthew D. McEvoy, MDVanderbilt UniversityNashville, TN USA

Frederic Michard, MD, PhDRyan-KayLausanne, Switzerland

Timothy Miller, MDDuke UniversityDurham, NC USA

Vicki Morton, DNP, AGNP-BCProvidence Anesthesiology

AssociatesCharlotte, NC USA

James Nicholson, MDStony Brook Medical CenterStony Brook, NY USA

Rupert Pearse, MD, FRCA, FFICM

Queen Mary University of London

London, UK

Bethany Sarosiek, RN, MSN, MPH, CNL

UVA Health SystemCharlottesville, VA USA

Michael Scott, MDVirginia Commonwealth

University Health SystemRichmond, VA USA

Anthony Senagore, MD, MBAUniversity of Texas Medical

Branch at GalvestonGalveston, TX USA

Daniel Sessler, MDThe Cleveland ClinicCleveland, OH USA

Andrew Shaw, MB, FRCA, FCCM, FFICM

Vanderbilt UniversityNashville, TN USA

Roy Soto, MDOakland University William

Beaumont School of MedicineRoyal Oak, MI USA

Julie Thacker, MDDuke University Durham, NC USA

Robert Thiele, MDUniversity of Virginia School of

MedicineCharlottesville, VA USA

Paul Wischmeyer, MDDuke University School of

MedicineDurham, NC USA

Sabino Zani Jr., MDDuke HealthDurham, NC USA

Invited Faculty continued

4

Schedule of Events

THURSDAY, APRIL 27TH 20170630 – 0800 Registration

0645 – 0745 BREAKFAST & Nestle Health Science Symposia:The Role of Immunonutrition in the Enhanced Recovery Protocol (ERP) Bundle

SESSION 1: ENHANCED RECOVERY – INTRODUCTION SESSION Moderator: Timothy Miller, MD

Location: Regency A

0800 – 0810 Introduction Timothy Miller, MD

0810 – 0825 ERAS and ASER in 2016 Tong J. Gan, MD, MHS, FRCA

0825 – 0840 Perioperative Medicine – A Global Perspective Mike Grocott, MD, FFCIM, MBBS, FRCP, FRCA, BSc

0840 – 0900 ERAS – Results, Successes and Challenges Julie Thacker, MD

0900 – 0930 System Wide Implementation Clifford Y. Ko, MD, MS, MSHS, FACS, FACRS

0930 – 1000 Break with Sponsors and Exhibitors Location: Regency BCD

SESSION 2: ASER AND POQI CONSENSUS STATEMENTS – PATIENTS FOCUSED AND SCIENCE BASED

Moderators: Andrew Shaw, MB, FRCA, FCCM, FFICM; Anthony Senagore, MD, MBA

Location: Regency A

1000 – 1020 Perioperative Fluid Management within ERPs Robert Thiele, MD

1020 – 1040 Perioperative Analgesia within ERPs Matthew D. McEvoy, MD

1040 – 1100 Prevention of Postoperative Infection within ERPs Stefan Holubar MD, MS, FACS, FASCRS

1100 – 1120 Patient Reported Outcomes Elliot Bennett–Guerrero, MD

1120 – 1200 Panel Discussion

1200 – 1330 LUNCH & Edwards Lifesciences Symposia: Preventable Hypotension – Know More. Act Early. Location: Regency A

SESSION 3: OPTIMIZATION PROGRAMSModerators: Solomon Aronson, MD, MBA, FACC, FCCP, FAHA, FASE;

Matthew McEvoy, MD Location: Regency A

1330 – 1350 Perioperative Nutrition Paul Wischmeyer, MD

1350 – 1410 POSH – Perioperative Optimization of Senior Health Mitchell T. Heflin, MD

1410 – 1430 Fit – 4 – Surgery School Mark Edwards, MRCP, FRCA, MD(Res)

1430 – 1450 Prehabilitation and Exercise Programs Mike Grocott, BSc, MBBS, MD, FRCA, FRCP, FFICM1450 – 1515 Panel Discussion

1515 – 1545 Break with Sponsors and Exhibitors Location: Regency BCD

SESSION 4: INNOVATIONS TO IMPROVE QUALITYModerators: Maxime Cannesson, MD, PhD;

Stefan Holubar, MD, MS, FACS, FASCRSLocation: Regency A

1545 – 1605 Wearable Technologies and Digital Innovations for ERPs Frederic Michard, MD, PhD

1605 – 1625 Measurement to Maintain and Improve Quality of ERPs Mike Grocott, BSc, MBBS, MD, FRCA, FRCP, FFICM

1625 – 1645 EHRs and ERAS: The Challenges of Data Collection and Automation Julie Thacker, MD

1645 – 1705 There’s an App for That: Connecting with Patients Where They Are Bethany Sarosiek, RN, MSN, MPH, CNL

1705 – 1715 Panel Discussion

1715 – 1730 Annual Business Meeting

1730 – 1900 Opening Reception and Poster Presentations Location: Regency BCD

FRIDAY, APRIL 28TH 2017

0630 – 0800 Registration

0645 – 0745 BREAKFAST & Medtronic Symposia: The New ESA Policy on Guideline Development and What it Means for Everyday Practice: Examples from the 2017 Guidlines

SESSION 5: ERAS RESCUE: CONTINGENCY PLANS TO KEEP PATIENTS ON TRACKModerators: Julie Thacker, MD; Roy Soto, MD

Location: Regency A

0800 – 0820 Postoperative Ileus Traci Hedrick, MD

0820 – 0840 Should We Be Obsessed with Readmissions? Christopher Mantyh, MD

0840 – 0900 Discharge Criteria Kristen Ban, MD

0900 – 0930 Panel Discussion

0930 – 1000 Break with Sponsors and Exhibitors Location: Regency BCD

SESSION 6: THE FUTUREModerators: Tong J. Gan, MD, MHS, FRCA; Timothy Miller, MD

Location: Regency A

5

Schedule of Events continued

1000 – 1005 Poster Winner Announcement

1005 – 1040 Plenary Lecture – Enhanced Recovery in 2020 Henrik Kehlet, MD, PhD

1040 – 1110 Volume to Value Transition in the USA Lee Fleisher, MD

1110 – 1140 Five Phases of Care for Best Surgical Outcomes David Hoyt, MD, FACS

1140 – 1200 Panel Discussion

1200 – 1330 LUNCH & Mallinckrodt Pharmaceuticals Symposia: Multimodal Analgesia in the Era of Enhanced Recovery and the Perioperative Surgical Home

SESSION 7A: EBPOM 1 – BIG DATA AND BIG TRIALS Moderators: Andrew Shaw, MB, FRCA, FCCM, FFICM;

Lee Fleisher, MDLocation: Regency A

1330 – 1355 Large Trials in Perioperative Medicine in the UK: What’s New and What’s in the Pipeline Rupert Pearse, MD, FRCA, FFICM

1355 – 1420 Perioperative Myocardial Injury – Can it be Prevented? Recent Evidence from Large Trials Daniel Sessler, MD

1420 – 1455 Challenges of Big Data – The NSQIP Experience Julie Thacker, MD

1455 – 1515 Panel Discussion

1515 – 1545 Break wtih Sponsors and Exhibitors Location: Regency BCD

SESSION 7B: MAKING IT ALL HAPPENModerator: Bethany Sarosiek, RN, MSN, MPH, CNL

Location: Regency A

1330–1350 Implementation Basics: It’s More Than Just an Order Set Robin Anderson RN, BSN

1350–1410 The Change Adoption Triad – A Straightforward Approach for the Enhanced Recovery Multi–Discipinary Team Desiree Chappell, CRNA, MSNA

1410–1430 Innovative & Engaging Approaches for Educating Patients Lindsey Koshansky, RN, BSN

1430–1515 Q&A/Panel Discussion

1515–1545 Break with Sponsors and Exhibitors Location: Regency BCD

SESSION 8A: EMERGENCY SURGERYModerator: Mike Grocott, MD, FFCIM, MBBS, FRCP, FRCA, BSc

Location: Regency Foyer

1545–1610 Fractured Neck of Femur Jeff Gadsden, MD, FRCPC, FANZCA

1610–1635 Emergency Laparotomy Rupert Pearse, MD, FRCA, FFICM

1635–1715 Surgery May Not be the Right Option – The Elephant in the Room Panel Discussion Jeff Gadsden, MD, FRCPC, FANZCA; Terrence Loftus, MD; Rupert Pearse, MD, FRCA, FFICM; Julie Thacker, MD

SESSION 8B: THEN WHAT? – HOW DO WE KEEP MOVING FORWARD?Moderator: Robin Anderson RN, BSN

Location: Regency Foyer

1545–1610 Tracking Process Measure Compliance – Does it Help with Sustainability? Deborah Hobson, RN, BSN

1610–1635 Nursing Led Research and Enhanced Recovery Vicki Morton, DNP, AGNP–BC

1635–1715 Panel Discussion: Sustainability and Growth – Managing the Spread Robin Anderson RN, BSN; Deborah Hobson, RN, BSN; Bethany Sarosiek, RN, MSN, MPH, CNL; Vicki Morton, DNP, AGNP–BC

SATURDAY, APRIL 29TH 2017

0700 – 0800 Registration & Breakfast

SESSION 9: PROCEDURE SPECIFIC CASE DISCUSSIONS

Time BreakoutRoom 1

BreakoutRoom 2

BreakoutRoom 3

BreakoutRoom 4

0800 – 1000 HPB OrthopedicReal–life

challenges with implementation

Colorectal/cystectomy

1000 – 1030 BREAK BREAK BREAK BREAK

1030 – 1230 HPB OrthopedicReal–life

challenges with implementation

Colorectal/cystectomy

FACULTY:HPB – Moderator: Michael Scott, MB, ChB, FRCP, FFICM

Panelists: Robert S. Isaak, DO; Adam King, MD; Sabino Zani Jr., MD

Orthopedic – Moderator: Jeff Gadsden, MD, FRCPC, FANZCAPanelists: James Nicholson, MD; Syed A. Azim, MD; Margaret Holtz, MD;

Michael Kelly, MD

Implementation – Moderator: Julie Thacker, MDPanelists: Robin Anderson, RN, BSN; Terrence Loftus, MD; Amy McCutchan, MD

Colorectal/Cystectomy – Moderator: Stephan Holubar, MD, MS, FACS, FASCRS

Panelists: Anoushka Afonso, MD; Desiree Chappell, CRNA, MSNA; Ruchir Gupta, MD

1230 – 1330 LUNCH

SATURDAY AFTERNOON WORKSHOPS

1330–1630 Ultrasound - Guided Infiltration Workshop

1330–1630 Fluid Optimization for Every Patient: A Noninvasive Solution

Sponsored by:

Sponsored by:

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ABSTRACT #

FULL ABSTRACT TITLEPRESENTING

AUTHORINSTITUTION PAGE

1 Programmatic challenges in eras compliance reduce stressPatrick Shanahan, MD, MBA

Anesthesiology Consultants Enterprises

10

2 Enhanced recovery after surgery (eras): a systemic review of perioperative care for patients undergoing obstetric surgery

Jeffrey Huang, MD

Anesthesiologists of Greater Orlando & University of Central Florida

12

3 Evaluating the implementation of an enhanced recovery after surgery protocol: a consensus building approach Nathan Hieb, MD Akron General

Medical Center 14

4Institution of an enhanced recovery after surgery protocol for colorectal surgery in a large teaching community hospital decreases length of stay, improves functional status on discharge and lower cost

Opeyemi Popoola, BSC, MD

Saint Barnabas Medical Center 16

5Anesthesia process measure compliance correlates with reduced length of stay: results from an enhanced recovery after surgery (eras) for colorectal surgery cohort

Michael C. Grant, MD

Johns Hopkins University 18

6 Enhanced recovery pathway for colorectal pediatric surgery: initial experience

Jessica A. George, MD, Med

Johns Hopkins University 20

7Decreased complications with enhanced recovery after surgery protocol in children undergoing urologic reconstructive operations

Kyle O. Rove, MD

Washington University in St. Louis

22

8 Enhanced recovery after surgery implementation strategy: a systematic review of barriers and facilitators

Alexander B. Stone, BA

Johns Hopkins Medical Institutions 24

9 Impact of preoperative education on patient empowerment and surgical experience in a colorectal eras program Roy Soto, MD Beaumont Health 26

10 Impact of adherence levels to eras protocol for elective colorectal surgery

Kelly Mayson, MD, FRCPC

Vancouver General Hospital, University of British Columbia

28

11 Implementation of eras pathway cuts length of stay in half Kelly Bahr, BSN, RN

Cleveland Clinic Akron General 30

12Utilization of a phone and computer-based application to optimize surgical preparedness and decrease post-surgical readmissions

Karin Montgomery, RN

St. Joseph Mercy Hospital 32

13 Impact of total joint eras program implementation on same-day discharge/readmission rates and satisfaction Roy Soto, MD Beaumont Health 35

14 How adherence to enhanced recovery after surgery protocols impacts on patient outcomes post radical cystectomy surgery

Tracey Hong, RN, BScN

Vancouver General Hospital 37

15 Development of a web-based smartphone app: a sustainable measure to enable accessibility of pathway details

Ravindra Prasad, MD

University of North Carolina 39

16Preoperative mental health optimization in an eras pathway leads to increased rate of same- day discharge for laparoscopic hysterectomy patients

Lyla Hance, MPH University of North Carolina 41

Abstract Table of Contents

9

Abstract Table of Contents

ABSTRACT #

FULL ABSTRACT TITLEPRESENTING

AUTHORINSTITUTION PAGE

17 Advancing surgical outcomes by providing patients with core elements and standardized pre- operative wellness education

Baotram Tran, MD

Indiana University School of Medicine 43

18Immunonutrition and pre surgical wellness, critical elements in the pathway improved outcomes, reduced surgical site infection, length of stay, and readmission independents of enhanced recovery enhancing a proactive culture of safety

Baotram Tran, MD

Indiana University School of Medicine 45

19 An enhanced recovery program in colorectal surgery has the power to decrease a broad range of complications

Alexander Hawkins, MD, MPH

Vanderbilt University 47

20Eras multimodal analgesia protocols result in marked reduction in opioids with associated improved pain scores, decreased los and accelerated return of gut function

Patricia Ahlquist, RN Middlesex Hospital 49

21 Enhanced recovery to improve outcomes in pancreaticoduodectomy

Vicki Morton, DNP, AGNP-BC

Medical University of South Carolina 50

22An evaluation of patients’ perceptions regarding use of the acs nsqip surgical risk calculator during preoperative risk discussion

Britany L. Raymond, MD

Vanderbilt University Medical Center

52

23 Implementing an eras protocol: our journey toward excellence Geri Johnston, MSN, RN

Medical University of South Carolina 54

24Dynamic risk profiling for postoperative nausea and vomiting after implementation of an enhanced recovery pathway for surgical weight loss patients

Krishnan Ramanujan, BA

Vanderbilt University School of Medicine

55

25Early success in implementation of a division-wide eras program utilizing an outcomes manager-led interdisciplinary team

Emily Saeler, MSN, RN, CRNI, CNL

Baylor University Medical Center 57

26 Development of a novel enhanced recovery after surgery pathway for major lower extremity amputation Sara Scarlet, MD University of North

Carolina 59

27 Capturing real-time eras milestones: an integrative project management tool

Elizabeth Pratt, DNP, RN, ACNS-BC

Barnes-Jewish Hospital 61

28 Enhanced recovery after surgery (eras) – an assessment at six months post discharge

Thomas Deiss, BA

University of California-San Francisco

63

29 Enhanced recovery and outcomes in pancreatic cancer surgeryVandana Agarwal, MD, FRCA

Tata Memorial Hospital 66

30 Maintaining compliance and ongoing support for a successful long-term enhanced recovery program

Desiree Chappell, CRNA Norton Healthcare 68

31 Immunonutrition within enhanced recovery after surgery (eras): an unresolved matter

Ruchir Gupta, MD

Stony Brook School of Medicine 70

10

Programmatic challenges in eras compliance reduce stress

Authors: Patrick Shanahan, MD, MBA1, Carrie Chesher, APRN, APN-C2 1Anesthesiology Consultants Enterprises 2 First Urology Background Change based healthcare that utilizes evidence-based medicine as a foundation continues to meet resistance. The ERAS programmatic development at our institution overcame several hurdles and required repeated attempts with phoenix-like rebirth to finally become an accepted practice in our hospital system. Methods Educational effort by change leaders in a department is manageable but requires traction in other departments to become adopted. Moving from the anesthesiology department to surgery required evidence based discussions and more importantly a scheme and strategy to implement easily the changes for surgeons. Busy practitioners cannot easily undergo major disruptions in their practices without assistance from a transition team with a plan. Plan in hand the practitioner will adopt the positive change. Once these two key players were on board the proof or projection for a reasonable return on investment (ROI) for management without data from our institution was a major hurdle. Securing financial and staff support from management for a program that was new to the C suite hinged upon a composite presentation of the ROI, potential competitive advantages and finally improved patient outcomes demonstrated in the literature. Positive team based presentations to the hospital management, nursing and surgical staffs solidified a change environment. Like being cheerleaders the team set about creating a story for the late adopters and skeptics that encouraged participation. Welcome to the change, move to better care, and revitalize yourself with better patient outcomes were themes for the participants. These themes were implied in all interaction by the development team. Adoption became the idea of the individual, who underwent the change with information (evidence based) and peer (team based) interaction, learning a new care pattern. This switch from the theme of “change” to learning something new was an epiphany for the ERAS team. We all did change, however, that change became learning something new, which was far less threatening. Results Results in the initial year were impressive for the entire team. As time passed adherence to the care path declined, as has been reported from multiple programs. Excuses based upon anecdotal events further impacted compliance. Messaging and reinvigorating team leadership are also obstacles in the midpoint of adoption. An example of the length of stay change and variable cost change for one service are presented in the graphic.

11

12

Enhanced recovery after surgery (eras): a systemic review of perioperative care for patients undergoing obstetric surgery Authors: Jeffrey Huang, MD1, Cathy Cao, MD2

1 Anesthesiologists of Greater Orlando & University of Central Florida, Orlando, FL 2 Department of Anesthesiology, Medstar Washington Hospital Center, Washington DC Background There has been an exponentially accumulative of evidence to support the clinical success of ERAS for a wide range of surgical procedures. There has been little implementation of ERAS in obstetric surgery. Recent study demonstrated that an enhanced recovery pathway can be successfully integrated into labor delivery unit. The aim of the review is to provide an evidence-based protocol for optimal perioperative care of patients undergoing obstetric surgery. Methods We review the recent literatures on enhanced recovery, fast track surgery of obstetric surgery. These studies included randomized controlled studies, prospective cohort studies, nonrandomized controlled studies, Meta analyses, systematic reviews, reviews, and case. Results Many ERAS elements can be or have been applied to obstetric surgery. These elements include patient education, preoperative optimization, prophylaxis against thromboembolism, antimicrobial prophylaxis, postop nausea vomiting prevention, hypothermia prevention perioperative fluid management, postoperative analgesia, prevention of Ileus, breast feeding promotion, and early mobilization. The available evidence supported that ERAS can enhance recovery, reduce length of stay, and lower the cost. Conclusions Based on the evidences for each element, ERAS can be implemented in obstetric surgery. The implementation depends on multidisciplinary coordination at preoperative, intraoperative and postoperative phases.

13

Figure 1. ERAS elements for cesarean section

DuringDelivery

PostDelivery

Pre-de

livery •PatientEducation

•Preoperativeoptimization

•Preoperativefastingandcarbohydratetreatment

•Timingofsurgery

Durin

gDe

livery •Thromboembolism

prevention•Antimicrobialprophylaxisandskinpreparation

•AnestheticChoice•Fluidoptimization•Prophylaxisagainstnauseaandvomiting

•Preventionofhypothermia

•Oxytocindose•Baby-friendlyskin-to-skincontact

PostDelivery •Multimodal

analgesia•Earlydrinkingandeating

•Earlyremovalurinarycatheter

•Earlymobilization•Earlybreastfeeding•PreventionofIleus•Post-dischargerehabilitationandcommunitycare

14

Evaluating the implementation of an enhanced recovery after surgery protocol: a consensus building approach Authors: Nathan Hieb, MD1, Mark Horattas, MD1, Stephen Brandstetter, MD1

1 Akron General Medical Center Background Enhanced Recovery After Surgery (ERAS) programs have been adopted to improve a number of outcomes following colorectal surgery, including decreased length of hospital stay, increased patient satisfaction, fewer complications, and decreased costs. These programs utilize multiple modalities and practices such as reduced narcotic usage and preoperative nerve blocking for pain control as well as early PO nutrition and preoperative patient education to achieve these improved outcomes. The implementation of these programs however, requires a cultural and systematic shift in caregiver perceptions and many customary practices. This study attempted to identify opportunities for more effective implementation of our ERAS protocol via feedback from those involved with the different components of the program. The results from the caregivers were used to modify the program for more efficient patient management. Methods An anonymous survey was sent out to the members of the departments responsible for developing and implementing our ERAS program. The survey was sent to preadmission testing, the presurgical unit, PACU, surgical floor, anesthesia, and the members of the general surgery department. The survey consisted of multiple choice and ranking questions, which assess staff perception of the program’s success and its efficacy for patients and to determine opportunities to facilitate adoption of the program. Results Forty-three surveys were completed for analysis. Respondents’ view of the purpose of the ERAS program ranged from very specific goals to more global thoughts on improving the patient experience and length of stay via numerous interventions. Adequate pain control viewed as the most important aspect of the ERAS program while some of the other features of an ERAS program such as limiting IV fluids and beginning early PO intake were not viewed as contributing as much. Poor patient education was felt to be the most significant social factor impeding patient recovery and thus was seen as a significant opportunity for caregiver impact. Many respondents indicated that the most important role of an ERAS program nursing coordinator would be to provide education to all staff about the different components of the ERAS program. The majority of respondents felt that there would be little resistance to successful ERAS program implementation and but that a standardized order set would facilitate compliance with the program. Respondents felt that patients were approximately 50% prepared for surgery with the current educational resources provided.

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Conclusions Enhanced recovery after surgery protocols have been demonstrated to be effective in reducing patient length of stay, costs and complications while improving overall patient satisfaction; however, their implementation can be more difficult to accomplish with many pitfalls. Analysis of the responses from our surveys revealed several opportunities for improvement regarding many aspects including patient and staff education, pain management, anesthesia, and nutrition. Several educational opportunities facilitated refinement of our ERAS program and successful implementation. One such refinement was the creation of a standardized order set for patients in the ERAS program, which has been met with positive reception. Our preliminary results indicated that our ERAS program resulted in dramatic improvement in patient satisfaction scores (HCAHPS), decreased average length of stay to 2.5 days, and over $3500 per average patient in cost savings.

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Institution of an enhanced recovery after surgery protocol for colorectal surgery in a large teaching community hospital decreases length of stay, improves functional status on discharge and lower cost. Authors: Opeyemi Popoola, BSC, MD1, R. Pitera1, M. Gilder1, L. Mullman1, S. Lew1, V. Chakravorty1

1 Saint Barnabas Medical Center, Livingston, New Jersey Background The Comprehensive Recovery Pathway (CRP) is an Enhanced Recovery After Surgery (ERAS) protocol for colorectal surgery. The anesthesia and surgery departments implemented the CRP as part of the PSH in April, 2015. To improve patient outcomes and patient experience in individuals undergoing colorectal surgery with the primary endpoint of reducing the length of stay and decreasing the rate of discharge to other skilled nursing facilities (SNF). Methods A multidisciplinary team of physicians, nurses and the ancillary staff were educated about the program. The main components include patient education including a patient guidebook, peri-operative nutritional support, multi-modal pain management, early ambulation and early feeding. Surgeons were encouraged to place patients on the pathway by utilizing a CRP order set which included the post-operative elements of ERAS. We performed a prospective one-year comprehensive analysis of the outcomes for patients undergoing colon and rectal resection surgeries, stratified by CRP enrollment, open versus minimally invasive surgical approach, and surgeries performed by colorectal fellowship trained versus general surgeons. Results A total of 219 patients underwent elective colorectal surgery at our institution from April 2015 to March 2016. Baseline characteristics did not differ in terms of age, gender, comorbidities, primary diagnosis, smoking status and BMI in patients who were enrolled in the CRP versus those that were not (all p>0.05). Among 104 patients who underwent minimally invasive surgery, 59 patients were enrolled in CRP. Of the 115 patients who underwent open colorectal surgery, 54 patients were enrolled in CRP. Overall, a 1.3-day reduction in length of stay (LOS) was observed in patients who were enrolled in CRP compared to non-CRP enrolled patients regardless of the surgical approach (p=0.001). Additionally, results indicated patients enrolled in CRP had better functional status at the time of discharge, reflected by increased rates of discharge home (p=0.005), and decreased rates of discharge to SNF (p=0.05). Additionally, lower rates of post-operative infection (p=0.037), 30-day and 90-day readmission (p=0.023 and p=0.002 respectively) were observed. When stratified by surgical approach, there was about a 2-day reduction in LOS for patients enrolled in CRP undergoing open procedures (p=0.003). There were also statistically significant reductions in post-operative infection, post-operative ileus and 90-day

17

readmission rate (all with p<0.05). Moreover, there was an observed $3,000 reduction in the direct cost associated with each admission for patients undergoing open procedures that were enrolled in the CRP (p=0.043). For minimally invasive procedures, more patients were discharged home rather than SNF (p=0.029) and 90-day readmission rates were reduced (p=0.047). When the level of training of the surgeons was investigated, a reduction in LOS was observed for both minimally invasive (11 hrs, p=0.02) and open procedures (1.4 day, p=0.010) performed by colorectal trained surgeons when patients were enrolled in CRP. Significant LOS reduction was observed for open procedures performed by general surgeons that enrolled their patients in CRP (2.8 day, p=0.05) Conclusions The implementation of a CRP for patients undergoing colorectal surgery is an effective strategy to improve patient outcomes while simultaneously reducing length of stay and costs associated with admission. The CRP was more effective in open surgical cases, and utility of the CRP was more pronounced for colorectal fellowship trained surgeons. Further analysis of the subtype of the minimally invasive procedures (robotic versus laparoscopic surgery) and the outcome differences by the level of compliance with the protocol will be performed in future investigation.

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Anesthesia process measure compliance correlates with reduced length of stay: results from an enhanced recovery after surgery (eras) for colorectal surgery cohort Authors: Michael C. Grant, MD1, Claro Pio Roda, MHS1, Daniel Galante, MD1, Philip Sommer, MD1, Deborah Hobson, BSN1, Susan Gearhart, MD1, Christopher L. Wu, MD1, Elizabeth Wick, MD2

1 Johns Hopkins University 2 University of California-San Francisco Background Enhanced Recovery After Surgery (ERAS) programs are designed to add value to the perioperative care experience through mitigation of surgical insult and reduction in hospital length of stay (LOS). While numerous surgical interventions have been examined, it remains unclear how a focused effort on improving compliance with the anesthesia-based protocol elements impacts care in the setting of an ERAS for colorectal surgery program. Methods From January 2013 – April 2015, compliance and outcome data was collected and analyzed for all patients prior to (pre-ERAS) and following (ERAS) implementation of an ERAS for colorectal surgery program at a single institution. Compliance with ten specific process measures that were mainly influenced by the anesthesiologist or acute pain service (APS) was analyzed to determine the collective impact on subsequent index hospitalization LOS as well as direct variable and total hospital charges. Results A total of 1,140 patients were included in the study, divided among pre-ERAS (n=512) and ERAS (n=628) groups. Implementation of ERAS resulted in significantly increased compliance of the designated anesthesiology process measures (5.3±2.1 vs. 2.6±1.3 process measures per patient; p<0.001). Increased compliance was associated with a stepwise reduction in LOS (Figure 1) and patients who received greater than 5 process measures (annotated as “High” compliance group) had a significantly shorter LOS (Inverse Risk Ratio [IRR] 0.78; 95% Confidence Interval [CI] [0.71 – 0.87]; p<0.001) compared to lower compliance counterparts. Multivariate regression suggests that utilization of multimodal PONV prophylaxis (IRR 0.78; 95% CI [0.68 – 0.89], p<0.001), scheduled postoperative NSAID use (IRR 0.76; 95% CI [0.68 – 0.85], p<0.001), and adherence to less than three days of postoperative opioids (IRR 0.58; 95% CI [0.51 – 0.67]; p<0.001) were independently associated with reduced LOS (Table 1). High compliance was also associated with a significant reduction in direct variable (p<0.001) and total hospital charges (p<0.001) compared to lower compliance groups. Conclusions ERAS for colorectal surgery relies upon a transdisciplinary approach to perioperative care, which increases the relative scrutiny to each involved provider type. Our study suggests there is added value to a concerted anesthesia-based protocol with anesthesia provider participation both in the operating room and as part of the post-operative care. Further

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investigation is warranted to develop tools to maximize compliance with anesthesia process measures in order to optimize the patient care experience. Figure1:NumberofanesthesiaprocessmeasuresandindexhospitalizationLOS

LOS=lengthofstay;graphsexpressedasmeans+95%confidenceinterval;numbersabovegraftscorrespondtonumberofpatientsineachcategoryTable1:UnivariateandmultivariatecorrelatesofindexhospitalizationLOS Univariate MultivariateProcessMeasure IRR(95%CI) p-value IRR(95%CI) p-valueERASProvider 0.83(0.74–0.94) 0.003 0.98(0.87–1.10) 0.68PreopCHODrink 0.72(0.61–0.86) <0.001 0.97(0.81–1.15) 0.70PreopPainMeds 0.65(0.58–0.74) <0.001 0.96(0.83–1.10) 0.54Epidural/TAP 0.85(0.76–0.95) 0.003 0.96(0.86–1.07) 0.44ForcedWarming 1.07(0.96–1.20) 0.19 - -TIVA/Noinhaled 0.67(0.60–0.75) <0.001 0.91(0.79–1.05) 0.19PONVProphylaxis 0.64(0.56–0.73) <0.001 0.78(0.68–0.89) <0.00124HourFluids 0.84(0.75–0.95) 0.004 1.006(0.89–1.13) 0.91PostopNSAID 0.65(0.58–0.73) <0.001 0.76(0.68–0.85) <0.001OpioidAvoidance 0.51(0.45–0.59) <0.001 0.58(0.51–0.67) <0.001Preop=preoperative;CHO=carbohydrate;TAP=transversusabdominusplane;TIVA=totalintravenousanesthesia;PONV=postoperativenauseaandvomiting;postop=postoperative;NSAID=non-steroidalanti-inflammatorydrug;IRR=incidencerateratio;CI=confidenceinterval

0 1 2 3 4 5 6 7 8 9 100

5

10

15

Number of Process Measures Recieved

Inde

x H

ospi

taliz

atio

n LO

S

n=31 n=98 n=208 n=198 n=153 n=119 n=126 n=112 n=67 n= 26 n=2

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Enhancedrecoverypathwayforcolorectalpediatricsurgery:initialexperienceAuthors:JessicaA.George,MD,MEd1,IraLeeds,MD,MBA1,RahulKoka,MD,MPH1,EmilyF.Boss,MD,MPH1,EricJelin,MD1,ChristopherL.Wu,MD11JohnsHopkinsUniversity BackgroundPost-surgicalenhancedrecoverypathwayshavedemonstratedbenefitstopostoperativeoutcomes;however,thesepathwayshavenotbeendevelopedoremployedinpediatricsurgeryuntilrecently.Wereportourpreliminarydatafromanewlyimplementedmultidisciplinarypediatriccolorectalenhancedrecoveryaftersurgery(ERAS)program.MethodsAfteranenhancedrecoverypathwaywascreated,revisedandimplemented,colorectalsurgerypatientswerefollowedprospectivelyusinganinstitutionalqualitydatabaselinkedtoNationalSurgicalQualityImprovementProgram30-daypostoperativeoutcomes.Patientdatacollectedincludeddemographics,comorbidities,operativecourse,ERASprocessmeasures,andpost-operativeoutcomes.ResultsWefollowedsevenpatients(6males,1female)foreightsurgicaladmissionsfrompreoperativeconsultationto30-daysaftersurgeryfromJanuary1st2016toJuly31st2016.Sixoftheoperationsincludedcolonresections(4laparoscopic,2open),andtwooperationswereforisolatedostomyreversals.Patientshadnomajorcomorbidities,and43%wereonsteroidsforinflammatoryboweldisease.ERASprocessmeasuresforthisearlygroupwereintermittentlyadherent(37%)withtheleastadherenceseenwithearlymobilization(20%)andearlyoralnutritionadvancement(0%).100%percentofpatientsreceivedmultimodalanesthesiawithanepidural,foropenprocedures,ortransversusabdominisplaneblock,forlaparoscopicprocedures.100%receivedpreoperativeeducationandamechanicalbowelprepwithoralantibiotics.Therewerenosurgicalsiteinfectionsinthisgroup.Thisresultcomparesfavorablywithour2014-2015surgicalsiteinfectionrateinpediatriccolorectalsurgeryof10.8%.CasesbyYear Pre-ERAS

(2014-2015)2016(Allpediatriccolorectalcases)Through11/1

2016(ERAS)

Total#ColorectalCases

103

165 8

SSI/WoundOccurrenceRate

NSQIP–10.8% JHHQITeam–3.6% 0%

ConclusionsMultidisciplinarypediatricsurgicalcarecanbefurtherstandardizedwiththeuseofbundledevidence-basedinterventionssuchasenhancedrecoverypathways.Measuringadherenceis

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importantforcontinuousqualityimprovement.Standardizationofcareinpediatricsurgerymayleadtoimprovedpostoperativeoutcomes.

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Decreased complications with enhanced recovery after surgery protocol in children undergoing urologic reconstructive operations Authors: Kyle O. Rove, MD1, Amanda F. Saltzman, MD2, Muhammet İrfan Dönmez, MD, FEBU3, Megan A. Brockel, MD4, Brian T. Caldwell, MD2, Vijaya M. Vemulakonda, MD, JD2, Duncan T. Wilcox, MD, MBBS2

1 Division of Urology, St. Louis Children’s Hospital, Washington University in St. Louis 2 Department of Pediatric Urology, Children’s Hospital Colorado 3 Department of Urology, Istanbul University Istanbul Faculty of Medicine 4 Department of Anesthesiology, Children’s Hospital Colorado Background ERAS is well established in adults but has not been well studied in pediatric patients. Previous work shows that ERAS is a safe alternative to standard care, but its precepts remain controversial among some pediatric urologists. The purpose of this study is to assess the association of ERAS with risk of complications in patients undergoing urologic reconstructive surgery that required a bowel anastomosis. We hypothesized that ERAS would decrease complications as compared to historical controls. Methods IRB approval was obtained to prospectively enroll patients <18 years in ERAS if they were undergoing urologic reconstruction that included a bowel anastomosis. ERAS protocol entailed 16 unique items, including: no bowel prep, pre-op oral liquid carbohydrate, minimization of opioids in favor of non-opioid analgesia, regional anesthesia, laparoscopy when feasible, no excess drains, no post-operative nasogastric tube (NG), early enteral feeding, and early removal of intravenous fluids (IVF). Recent (2009-2014) historical controls were propensity matched in a 2:1 ratio on age, sex, ventriculoperitoneal (VP) shunt status and whether patient was undergoing bladder augmentation. Patients were analyzed for ED visits, re-admission within 30 days, re-operation within 90 days and adverse events occurring within 90 days of surgery. Given the matched nature of the two cohorts, continuous variables were compared using logistic regression using generalized estimating equations and categorical variables were compared using the Mantel-Haenszel test. All tests were two-sided and p-values < 0.05 were considered significant. Results 26 historical and 13 ERAS patients were included. Median ages were 10.4 (IQR 8.0-12.4) and 9.9 years (IQR 9.1-11), respectively (p=0.94). There were no significant differences in prior abdominal surgery (38% vs 62%) or primary diagnosis of spina bifida (62%) between groups. Median ERAS protocol items achieved per patient was 8 of 16 (IQR 4–9) historically vs 12 of 16 (IQR 11–13) in the ERAS cohort. ERAS significantly improved use of pre-op liquid load (p<0.001), minimization of opioids (p=0.046), early discontinuation of IVF (p<0.001), and early feeding (p<0.001). Length of stay decreased from 8 days (range 3–41 days) for historical patients to 5.7 days (range 2–22 days). This difference was not significant. There was an inverse correlation between number of ERAS items achieved per patient and length of stay

23

(adjusted R2=0.25). 90-day complications per patient decreased from 2.1 to 1.3 (OR 0.71, 95% CI 0.51-0.97). There were fewer complications per patient across all grades with ERAS. Most complications were grades 1 (20 vs 7 total complications) or 2 (22 vs 9 complications). Grades 3 (10 vs 1 complications) and 4 (4 vs 0 complications) were less common. No differences were seen in ED visits, re-admissions or re-operations. Conclusions Implementation of ERAS in a pediatric urology population undergoing urologic reconstructive operations with a bowel anastomosis is feasible, safe and appears to decrease 90-day complications. Multicenter study will be required to confirm the potential benefits of adopting ERAS on complications, length of stay, and cost.

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Enhanced recovery after surgery implementation strategy: a systematic review of barriers and facilitators Authors: Alexander B. Stone BA1, Christina Yuan PhD2, Michael Rosen MA, PhD 2, Michael Grant MD, Lauren Benishek PhD 2, Elizabeth Hanahan MPH2, Lisa Lubomski PhD2, Christopher Wu MD1, Elizabeth Wick, MD3

1 Johns Hopkins Medical Institutions, Baltimore, MD 2Armstrong Institute for Patient Safety and Quality, Baltimore, MD 3 University of California San Francisco, San Francisco, CA Background Enhanced Recovery After Surgery (ERAS) pathways are being increasingly adopted throughout the world based upon their success in reducing length of hospital stay, costs and complications following surgery. Implementation of ERAS programs is challenging because they are complex quality improvement interventions that involve a wide-range of healthcare providers. Few publications describe ERAS implementation in detail. We examined the body of published ERAS literature to assess how authors describe barriers and facilitators of their ERAS implementation strategy to identify, in aggregate, best practices that should be considered. We utilized the Consolidated Framework for Implementation Research (CFIR) framework to extract these elements and summarize common barriers and facilitators of ERAS implementation. CFIR has five major domains: (1) intervention characteristics; (2) inner setting; (3) outer setting; (4) characteristics of the individuals; and (5) the process of implementation and is a validated tool for studying implementation of quality improvement projects.

Methods A systematic review of was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) statement. An ERAS pathway was defined as, a bundle of multiple perioperative interventions that involve a multidisciplinary team, was labeled as something different than traditional care, and had a formal way of measuring outcomes. Included papers had to both specifically address barriers and facilitators of ERAS implementation and had to provide sufficient detail that the CFIR domain could be identified. Any discrepancy was settled by discussion and consensus. Data was extracted by two independent researchers using an agreed upon standardized extraction form.

Results The initial search strategy returned 4563 results. By screening titles and abstracts we eliminated 3883 studies leaving 680 articles for full text screening. Of these, 53 studies were included in our review. In brief, the broad facilitator themes identified by the CFIR framework were; 1. Adaptability of the program and ability to have and demonstrate early “wins” 2. Gaining buy in from both frontline providers as well has hospital leadership 3. having a strong ERAS team that met regularly 4. Utilization of champions and full time ERAS staff when possible 5. Having formal implementation framework when possible. The broad barriers identified were 1. Meeting with resistance to change from frontline providers 2. Not having

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enough resources for implementation 3. External factors such as patient complexity or rural hospital location.

Conclusions The majority of ERAS literature focuses on the efficacy, safety, or cost effectiveness of these protocols. However, most clinicians are left wondering about how to implement these programs and whether or not it would be effective in the context of their home institution. In order to promote the spread of ERAS programs, more high quality studies on the implementation process itself are needed.

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Impact of preoperative education on patient empowerment and surgical experience in a colorectal eras program Authors: Roy Soto, MD1, Larry Manders, MD1, Rebekah Kelly, MPH1, Michael Schostak, MD1

1Beaumont Health, Department of Anesthesiology Background Managing expectations of patients undergoing complex surgical procedures can be challenging. Although preoperative education has been shown to improve satisfaction and outcomes in small case series, no literature exists demonstrating the role of education on patient empowerment or experience/satisfaction in an ERAS protocol. Methods Patients undergoing non-emergent colorectal surgery were asked to participate in this study. A convenience-based sample of 1yr was used to survey patients completing a preoperative optimization class (as part of a broader ERAS program) and case-matched controls: that is, patients that were having similar procedures but not in an ERAS protocol. The optimization class included education about multiple aspects of the pre/intra/post-operative period, and focused on appropriate expectation management, especially as it pertained to pain control. The survey (Table 1) assessed patient preparation, education, and empowerment, and was graded on a 100mm VAS. Results of individual questions were compared using unpaired t-test. Results 329 patients completed the survey. (250 ERAS, 79 non-ERAS). Although our goal was to recruit 250 patients in each group, recruiting non-ERAS patients became difficult due to increased activity of our ERAS team. Table 1 lists mean VAS responses for each question, and p-values reveal significant differences for each question. Furthermore, individual responses were more variable for the non-ERAS patients and correlated less closely around mean/median values for each question (not shown below due to space constraints). Conclusions Our results suggest that participation in a preoperative optimization class can improve feelings of preparedness for surgery, resulting in improved patient empowerment. Appropriate expectation management can lead to improved patient-centered care.

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Table 1: Question Prehabilitation

Class Participant (Mean)

Non-Prehabilitation Participant (Mean)

P-Value

I feel I was adequately prepared for my colorectal surgery

91.4 80.5 0.001

I feel I can actively participate in my own recovery

91.2 82.3 0.001

I feel my expectations for surgery were adequately met

90.6 82.3 0.005

I feel encouraged and enabled about my recovery

93.7 81.4 0.003

I feel I was physically/mentally prepared for my surgery

88.3 81.0 <0.001

I feel I was involved in the decision making about my surgical care

89.9 81.2 0.007

I understood the health information provided to me about my surgery

91.3 82.3 <0.001

I feel I had the access to the information I needed about my surgery

91.0 81.8 <0.001

I feel prepared to care for my own health after my surgery

89.1 81.1 0.001

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Impact of adherence levels to eras protocol for elective colorectal surgery Authors: Kelly Mayson, MD, FRCPC1, 3, Liam Stobart, MD2, XinYang Huang, MD3, Andrea Bisallon, RN, BScN1, Tracey Hong, RN, BScN1

1Vancouver General Hospital, Vancouver, B.C., Canada 2University of Northern Ontario, Sudbury, Ontario, Canada 3 University of British Columbia, Vancouver, B.C., Canada Background Prior studies have shown adherence to a multimodal Enhanced Recovery After Surgery (ERAS) protocol is associated with improved outcomes, indicating a dose-response relationship. We studied the impact of the adherence level, after implementing our ERAS protocol following elective colorectal surgery (CRS). Methods A multidisciplinary team implemented an ERAS protocol at our centre in November 2013. The charts of 369 consecutive elective CRS performed since implementation to December 2015, were audited. 12 ERAS process measures were assessed: pre-operative counseling, pre-operative anesthesia consultation, CHO loading, maintenance of normothermia, timely administration of antibiotics, the use of multimodal analgesia, adequate PONV prophylaxis, use of a monitor to direct GDFT, mobilization on POD 0 and 1, introduction of fluids on POD 0 and solids on POD 1. ACS NSQIP defined post-operative 30-day complications, and length of stay (LOS) was determined. The complication rate was compared between two cohorts, those that had a > 75% compliance and those than had < 75%, as well as to our pre-implementation cohort (2011-2013 N=99). Univariate analysis was performed to assess the significance of each of the process measures. Results Since implementation of our ERAS protocol 43% (158/369) of our patients have obtained > 75% compliance to the ERAS protocol process measures. Patient demographics with respect to age, gender, and ASA status were comparable in the pre, and two post implementation cohorts as seen attached table. 71.3% of patients had a minimally invasive procedure, with a slightly higher percentage in > 75% adherence cohort (82.3% vs. 63%) but this did not reach statistical significance. Greater than 75% adherence resulted in a significance decrease in LOS, mean 5.81 days vs. 8.46 days (p<0.05), a decrease in overall pulmonary complications: pneumonia 1.3% vs. 5.7%, ventilation > 48 hrs 0.6% vs. 3.3%, re-intubation 0.0% vs. 4.7%. Overall complication rate decreased from 27.8% prior to implementation of ERAS to 15.2% with > 75% adherence to ERAS components (p<0.05). Univariant logistic regression analysis demonstrated pre-operative counseling was an independent predictor of “no complications” Exp (B) 2.181, 95% CI 1.058-4.496 (p<0.05).

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Pre-ERAS (N=99)

<75% adherence (N=211)

>75% adherence (N=158)

P values

Age (mean) 65+/-15.3 66.6+/-14.36 67.6+/-12.7

Female/Male 48/52 44.5/55.5 43/57

ASA 1 7.1% 4.3% 5.1%

ASA 2 52.5% 57.8% 60.8%

ASA 3 38.4% 35.5% 32.3%

ASA 4 2.0% 2.4% 1.9%

All complications

*27.8%

18% *15.3%

*p<0.05

Pneumonia 5.1% 5.7% 1.3% p<0.05

Ventilation > 48hrs

5.1% 3.3% 0.6% p=0.078

Reintubation 4.7% 5.7% 0.0% p<0.05

LOS (mean) 10.7 8.46 5.81 p<0.05

Conclusions A high adherence to the ERAS process measures is associated with decreased LOS, and complications. Our adherence to pre-operative and intraoperative components was high, but postoperative components still requires improvement as well as clear documentation regarding these process measures. Adequate patient counseling is an integral component in the ERAS pathway.

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Implementation of eras pathway cuts length of stay in half Authors: Kelly Bahr, BSN, RN1, Mark Horattas, MD1, Nathan Hieb, MD1

1 Cleveland Clinic Akron General Background Postoperative hospital average length of stay (ALOS) is a major factor contributing to the high cost of surgery. Enhanced Recovery After Surgery (ERAS) pathways have been shown to improve postoperative recovery and lower healthcare costs. This is evidenced by more effective pain control with markedly reduced narcotic usage and quicker return of bowel function, which together result in a decreased length of stay. The development and effectiveness of ERAS protocols require the participation and commitment of a dedicated multidisciplinary team. Methods A multidisciplinary team was formed to develop our ERAS protocol. This cohesive team created a balanced, perioperative care pathway for colorectal surgical patients. Our ERAS protocol is based both on our colorectal SSI (Surgical Site Infection) prevention bundle, as well as information from several other published ERAS protocols. Each department’s input facilitated its widespread adoption. The impact of our ERAS pathway on patient ALOS was assessed. All patients undergoing colorectal resection with anastomosis in 2015 (pre-ERAS) were compared to all of our ERAS patients in 2016. Results A total of 65 ERAS colectomies with anastomosis were performed at Cleveland Clinic Akron General in 2016 by eight different general surgeons. These patients had an average length of stay of 2.5 days. Ten patients were discharged on POD (Post-operative Day) #1 and 31 patients on POD #2. In 2015, 83 patients undergoing colorectal resection with anastomosis had an average length of stay of 5.7 days. None of the pre-ERAS patients were discharged home in less than three days postoperatively. In addition, other metrics including HCAHPS scores, narcotic usage, and return of GI function were also noted to be improved as well. Conclusions The success of our program is attributed to several unique features. We engaged an ERAS Nurse Navigator to educate this patient group pre-operatively through discharge and beyond. Interdepartmental ownership of our ERAS program occurred as we solicited input and also shared our successes collectively. There was 100% surgeon participation. A collaborative relationship with our anesthesia colleagues helped refine our unique ketamine-based, non-narcotic general anesthetic. It is believed that our use of long acting liposomal TAP nerve blocks for additional prolonged pain control significantly reduced narcotic administration, facilitating a more rapid return of GI function. There was a >50% reduction in postoperative ALOS for this colorectal surgical patient population. In addition, the HCAHPS scores for that same population improved and our institution had a cost savings of greater

31

than $3,200 per patient. The multidisciplinary approach to creating our protocol helped to achieve its widespread adoption and the program’s success exceeded our expectations.

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Utilization of a phone and computer-based application to optimize surgical preparedness and decrease post-surgical readmissions Authors: Karin Montgomery, RN1, Olivia Ajja, CRNA1, Karen Emery, RN1, Robert Cleary, MD1, 2

1St. Joseph Mercy Hospital 2Internal Health Associates Introduction Enhanced Recovery After Surgery (ERAS) has improved perioperative care by standardization of processes developed by a multidisciplinary team, utilization of evidence-based practices, and patient feedback for the efficacy of educational materials and methods. In addition, cost and quality of care have been optimized by implementing ERAS. Unplanned readmissions have not been positively impacted by ERAS in most cases (Adamina et al., 2011; Greco et al., 2014; Hendren et al., 2011; Khreiss et al., 2014; Martin et al., 2016; Thiele et al., 2015). We designed a pilot implementing Twistle, a perioperative communications platform, to optimize perioperative outcomes, decrease unplanned readmissions to the hospital after discharge, and decrease readmissions length of stay. The workflows and prompts for specific benchmarks will be embedded in Twistle to address each of the identified perioperative risk factors.

Methods Our ERAS lead surgeon completed an in-depth chart review on all ERAS readmissions between January 1, 2014 and December 31, 2016. These data were then reviewed by the ERAS multidisciplinary team for accuracy. Preventable readmissions fell into four categories; dehydration, pain management, ileus, and surgical site infection. Workflows and educational materials were developed to address these four issues as well as a prehabilitation component for preoperative patient engagement. The pilot was initiated January 2017 and is ongoing with all colorectal ERAS patients with the capability of using a phone or computer-based application. All colorectal ERAS patients were given the information on the Twistle application by their surgeon. Patients were invited to download the application during the ERAS preoperative education class. Patients willing and able to participate were then given verbal and written instructions on the use and purpose of the application.

Results To date, 19 patients have participated in the perioperative Twistle pilot. Two patients initially accepted the invitation and then declined to participate with the application. Two patients with redness around their incisions, were instructed to keep their discharge clinic appointment, small areas were opened and the patients were not readmitted to the hospital with subsequent good reports per the application. One patient reported nausea, was instructed to reduce his diet to clears for a couple days and drink protein supplements and resolved at home. One patient reported dark urine and feeling full; he/she was coached that fluids were more important that full meals and resolved within 48 hours. Subsequent Twistle prompts revealed resolution of the situation. Average cost reduction for each avoided readmission is $15,366 (Sutherland et al., 2015) for an average length of stay of 3.3 days. To

33

date, four readmissions have been avoided ($61,464). One patient was readmitted for less than 24 hours for observation for a potential leak but was then cleared. Readmission rate for all participating perioperative colorectal patients has decreased from 14.6% to 9.1% with Twistle and other readmission reduction initiatives.

Conclusions Preliminary data indicates utilization of Twistle for perioperative communication, monitoring, and education for the pilot has proven, to date, to decrease hospital readmissions. In addition, anecdotal findings suggest that use of Twistle increases patient and staff satisfaction, and optimizes outcomes for perioperative patients. Final data will analyzed at the conclusion of the pilot.

References

Adamina, M., Kehlet, H., Tomlinson, G. A., Senagore, A. J., & Delaney, C. P. (2011). Enhanced recovery pathways optimize health outcomes and resource utilization: A meta-analysis of randomized controlled trials in colorectal surgery. Surgery, 149(6), 830-840. Greco, M., Capretti, G., Beretta, L., Gemma, M., Pecorelli, N., & Braga, M. (2014). Enhanced recovery program in colorectal surgery:A meta-analysis of randomized controlled trials. World Journal of Surgery, 38, 1531-1541. Hendren, S., Morris, A. M., Zhang, W., & Dimick, J. (2011). Early discharge and hospital readmission after colectomy for cancer. Diseases of the Colon & Rectum, 54(11), 1362-1367. Khreiss, W., Huebner, M., Cima, R. R., Dozois, E. R., Chua, H. K., Pemberton, J. H., . . . Larson, D. W. (2014). Improving conventional recovery with enhanced recovery in minimally invasive surgery for rectal cancer. Diseases of the Colon & Rectum, 57(5), 557-563. Martin, T. D., Lorenz, T., Ferraro, J., Chagin, K., Lampman, R. M., Emery, K. L., . . . Cleary, R. K. (2016). Newly implemented enhanced recovery pathway positively impacts hospital length of stay. Surgical Endoscopy, 30(9), 4019-4028. Sutherland, T., David-Kasdan, J. A., Beloff, J., Mueller, A., Whang, E. E., Bleday, R., & Urman, R. (2015). Patient and provider-identified factors contributing to surgical readmission after colorectal surgery. Journal of Investigative Surgery, 29(4), 195-201. http://dx.doi.org/10.3109/08941939.2015.1124947 Thiele, R. H., Rea, K. M., Turrentine, F. E., Friel, C. M., Hassinger, T. E., Goudreau, B. J., . . . McMurry, T. L. (2015). Standardization of care: Impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. Journal of the American College of Surgeons, 220, 430-443.

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Acknowledgements The Saint Joseph Mercy Hospital, Ann Arbor, Enhanced Recovery Multidisciplinary Team – Robert Cleary, MD; John Eggenberger, MD; Amanda McClure, MD; Beth-Ann Shanker, MD; Olivia Ajja, CRNA; Sandra Basch, RN; Barbara Boylen-Lewis, RN; Jami Boyd, RN, Kara Brockhaus, PharmD; Timothy Cahill, MD; Traci Coffman, MD; Karen Emery, RN; Jane Ferraro, RN; Cheryl Genord, BSPharm; Laurie Kadish, RN; Susan Kheder, LMSW; Theodore Kinard, RN; Sally Knight, RN; Robert Macdonell; Danielle Martin, RN; Yvonne Reed, RN; Diana Rego, NP; Kristine Ryan, RN; Joan Zurkan, RD

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Impact of total joint eras program implementation on same-day discharge/readmission rates and satisfaction Authors: Roy Soto, MD1, Michael Schostak, MD1, Scott Nemitz, PA-c1, Carol Schmidt, CRNA1, Alison Havens, RN1, Maureen Cooper, RN1

1Beaumont Health, Department of Anesthesiology Background ERAS protocols allow for standardization of care with an emphasis on a number of controllable, evidence-based factors, including patient education and opioid avoidance. Following demonstrable improvements in patient care and cost savings with ERAS programs for colorectal and cystectomy surgery, we were asked by the orthopedic service to implement a similar program for same-day total joint replacement. Methods In January of 2016, patients scheduled to undergo elective total hip or knee replacement were sent to a new anesthesia-run ERAS clinic. Changes made with ERAS implementation are listed in table 1 below. Length of stay, 30d readmission, and HCAHPS satisfaction data were collected. Note that this was a trial program which ran for 2 months. Results Length of stay for knee replacement decreased from 2.48 to 1.06 days (n=1028 prior to and 17 after implementation). 30 day readmissions decreased from 8 to 0. Length of stay for hip replacement decreased from 2.27 to 1.00 days (n=852 prior to and 41 after implementation). 30 day readmissions decreased from 14 to 0. 74% of ERAS patients were discharged on day 0 compared to none previously. Average all-domain HCAHPS percentile scores increased from 66% to 98.6% after program implementation. Conclusions LOS, readmissions, and satisfaction all improved following implementation of a total joint ERAS program. While numbers were low given the brevity of the program trial, we have demonstrated the value of local change implementation and its ability to drive future change (ie. justifying/validating need for increased level of clinic staffing). Table 1:

Intervention Pre-ERAS Post-ERAS PreOp Class large group individual Expectation Management

ambulation, safety ambulation, safety, length of stay, analgesia, appropriate opioid risks/benefits

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Exercise pre/postop exercise discussed pre/postop exercise discussed, PT/OT visit preop

Nutrition N/A preop albumin measured, if low or clinical signs of malnutrition patients given Impact AR for 5 days preop

Carbohydrate loading N/A Clearfast – 1 bottle on morning of surgery

Block Anesthesiologist administered fascia iliaca block

surgeon administered intraarticular block

Multimodal analgesia At discretion of provider, +/- preop oxycontin

preop Neurontin, acetaminophen, celecoxib. No oxycontin given

PONV prophylaxis At discretion of provider preop oral ondansetron, scopolamine patch if high risk

Lung health N/A incentive spirometer given/taught, and instructed to use 30x prior to DOS

Glycemic management At discretion of provider A1C drawn in preop clinic. Referral to endocrinology if >6.0 if undiagnosed diabetic

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How adherence to enhanced recovery after surgery protocols impacts on patient outcomes post radical cystectomy surgery Authors: Tracey Hong, RN, BScN1, Andrea Bisaillon, RN, BScN1, Kelly Mayson, MD, FRCP1

1Vancouver General Hospital, Vancouver, Canada Background Enhanced Recovery after Surgery (ERAS) protocols have been shown to improve patient outcomes after major surgeries. It has been validated in the elective radical cystectomy (RC) in our hospital with overall morbidity, as defined by the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP), initially decreasing by 40% post implementation. Prior studies have demonstrated that increase adherence to the ERAS components was associated with improved outcomes. We studied the impact of adherence to our ERAS protocol following elective RC on patient outcomes. Methods A multidisciplinary team implemented an ERAS protocol in October 2014. A project charter and an implementation plan were initiated. The adherence to 12 key ERAS components was measured in 152 consecutive cases (October 2014-September/2016). The 12 ERAS components included: preoperative counselling & anesthesia consultation, carbohydrate loading, maintenance of normothermia, timely antibiotics administration, use of multimodal analgesia & goal-directed fluid therapy, adequate postoperative nausea and vomiting prophylaxis, mobilization on POD 0 & 1, oral nutrition on POD 1 & 4. ACS NSQIP defined 30-day postoperative complications, length of stay (LOS) and readmissions were assessed and were compared between two cohorts, those who had ≥ 75% compliance and < 75%, as well as to our pre-implementation cohort (May 2011-September 2014 n=90). Results Post-implementation, 52% of patients achieved ≥75% adherence to the 12 ERAS components. Process measures showed that the preoperative and intraoperative components (except use of goal directed fluid therapy) had met our goal of a minimum of 80% compliance. Postoperative components have been the slowest to change, but they are heading towards our goal. Patient demographics in both cohorts were comparable. Postoperative outcomes for 90 patients pre-ERAS were compared with 152 patients post-ERAS implementation. Post-ERAS implementation, rates of overall morbidity fell from 31.1% to 21.1 % (p=0.09), a 32% reduction. Patients with ≥75% adherence had a lower morbidity rate (15.2% vs 27.4%) as compared to those with <75%, a 51% reduction in morbidity from the pre-implementation results. We have moved from decile 8-10th before ERAS to 1st decile with odds ratio for morbidity is now at 0.58 (CI 0.35-0.95). (See Table 1 below).

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Table 1: Patient Demographics and Outcomes

Pre ERAS Post ERAS <75%

Adherence ≥75% Adherence

Number of cases 90 152 73 79 Age (mean) 69 67 66.7 67.3 NSQIP Co-morbidity Count (mean)

1.1 1.05 1.11 1

Cases with ≥ 1 Postoperative Complications 31.1% 21.1% 27.4%

15.2% (51 % reduction from Pre ERAS)

Superficial Surgical Site Infection

12.2% 5.9% 9.6% 2.5%

Urinary Tract Infection 10% 5.5% 5.1% 5.3% Sepsis/Septic Shock 14.4% 6.6% 9.6% 3.8% Transfusions 43.3% 25.7% 27.4% 24.1% Ileus 10% 10.5% 13.7% 5.1% Readmission 16.7% 13.2% 13.7% 12.7% Median LOS (days) 7.5 7 8 7 Conclusions Adoption of ERAS pathways had resulted in 32% reduction in postoperative complications following RC in our hospital. Increased adherence (≥ 75%) to ERAS components was associated with a further improvement in patient outcomes. Further work is needed to foster the adherence to the intraoperative and postoperative components. Ongoing auditing & repetitive education are also vital to increase adherence and sustain the improved outcomes.

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Development of a web-based smartphone app: a sustainable measure to enable accessibility of pathway details Authors: Ravindra Prasad, MD1, Lyla Hance, MPH1, Lakhesh Khullar, MSIS1, Lavinia Kolarczyk, MD1, Rob Isaak, DO1 1University of North Carolina Department of Anesthesiology Background Included amongst the many challenging aspects to management of a large, multidisciplinary Enhanced Recovery After Surgery (ERAS) program at an academic medical center is accessibility to pathway information to ensure compliance. ERAS pathways should be readily available for reference in a variety of geographic locations for all team members including surgery, anesthesiology, and nursing staff. Many institutions utilize an online, secure database repository that requires the end user to access a website, login, and click through several screens to find pathway-specific information. This could lead to user frustration or confusion, which might decrease buy-in and compliance with pathway elements. We sought to develop a smartphone app providing streamlined elements of each active pathway that can be accessed easily and quickly from anywhere that has Wi-Fi access. We offered this app as an alternative to options already available to our department, which included some less readily available formats such as a password-protected database containing PDFs of the full pathways accessible via computer and e-mails containing pathway details sent to the anesthesia care teams the day before ERAS cases. Methods Two commercial developers specializing in apps for ERAS programs were found by word-of-mouth and a Google search. Initial quotes were deemed too expensive (range: $25,000-$90,000) to be cost-effective for our program. The high initial costs, along with contracts requiring yearly maintenance fees (maximum: $10,000), was not sustainable, and the apps contained features that were more complex than those needed to address our main need for improving pathway accessibility. Our department’s IT division created a simple webpage-based pathway repository that met all of our desired features including (i) custom display of pathway elements, (ii) ease of navigation, (iii) minimal user log-ins, and (iv) easy maintenance. A unique icon was created for the webpage so that it appears as a discrete app to the end user on their smartphone. Six months after the launch of the app, an optional and anonymous survey was administered to anesthesiologists, residents, and CRNAs in the department who managed ERAS cases since the time the app has been active. Results The internal department app was introduced in August 2016 and supports seven different ERAS pathways, with the option to easily add new pathways as the program expands. The

40

app is available to all 79 attending anesthesiologists, 87 CRNAs, and 55 resident physicians in the department. Internal set-up required 160 man-hours and necessitates an average of 3 hours of in-kind work per month for ongoing support. Responses (n=40) to the usage survey revealed that 63% (n=25/40) find the app easy to use, 25% (n=10/40) are undecided on ease of use, and the remaining 13% (n=5/40) did not find the app easy to use. 28% (n=11/40) of respondents report using the app at some point while managing their cases in the OR, 43% (n=17/40) use the app when reviewing their ERAS cases the day before, and 43% (n=17/40) use the app as a general reference. Only 38% (n=15/40) reported not using the app at all. A common reason for not using the app was a stated preference to access the pathways using one of the two original methods. Conclusions The development of an internal webpage smartphone app allows perioperative clinicians to access pathway details quickly and from a variety of locations. The internal webpage app saved external costs by not relying on externally-hosted commercial apps, and provides a low-maintenance solution to an accessibility issue. Areas of future research include investigating the impact of this technology on compliance with ERAS pathway elements.

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Preoperative mental health optimization in an eras pathway leads to increased rate of same-day discharge for laparoscopic hysterectomy patients Authors: Lyla Hance, MPH1, Amy Goetzinger, PhD1, Seema Patidar, PhD1, Jay Schoenherr, MD1, Lavinia Kolarczyk, MD1, Robert Isaak, DO1, Dayley Keil, BA2, Larry Michael, MPH MS1, Erin Carey, MD3, Lauren Schiff, MD3, Janelle Moulder, MD3 1 University of North Carolina Department of Anesthesiology 2 University of North Carolina School of Medicine 3 University of North Carolina Department of Obstetrics and Gynecology Background A large proportion of women (27-62%) undergoing elective laparoscopic hysterectomy for benign indications also have a chronic pain condition.1-4 One of the fundamental components of an Enhanced Recovery After Surgery (ERAS) pathway is preoperative patient education and expectation management. The ERAS pathway for laparoscopic hysterectomy at our institution was designed to optimize mental health and empower patients to be active participants in the recovery process. The elective mental health optimization component includes a targeted pain-coping skills counseling session by a pain psychologist. Because inadequate pain control is a common reason for hospital admission following laparoscopic hysterectomy, we hypothesized that ERAS patients who receive pain-coping skills counseling would be more likely to be discharged on the same day of their surgery than ERAS patients who do not. Methods An ERAS pathway for laparoscopic hysterectomy was implemented in September 2015. The mental health optimization component of the ERAS pathway was developed and carried out by pain psychologists, who provided both a (i) comprehensive pain coping skills workbook and (ii) phone consultation. The workbook included lessons in cognitive behavioral therapy, diaphragmatic breathing, and progressive muscle relaxation training. The phone consultation included screening for risk factors of poor post-operative pain coping, including symptoms of anxiety, depression and baseline pain intensity. The primary reason for missing the session was no response after multiple attempts to reach the patient. A retrospective chart review was conducted for all patients who underwent laparoscopic hysterectomy on an ERAS pathway (September 2015-August 2016). Patients who underwent the same surgery with the same group of surgeons prior to the ERAS pathway (April 2014-September 2015) served as controls. There were 165 patients in the ERAS group, and 90 in the control group. ERAS and control groups were not statistically different in terms of mean age, BMI, race, or ASA status. Data collected included patient demographics, presence of a comorbid chronic pain syndrome, completion of the counseling session, and length of stay. Results Over half of all patients in both groups had a chronic pain condition at the time of surgery (55.8% (n=92/165) ERAS and 51.1% (n=46/90) controls, p=0.478). 56.4% (n=93/165) of ERAS patients were discharged on the same day of their surgery compared to 8.9% (n=8/90) of patients in the control group (p<.0001).

42

Disposition data was analyzed according to four groups based on the patient’s status of pre-existing chronic pain and completion of the counseling skills session: non-chronic pain patients who received counseling, chronic pain patients who received counseling, non-chronic pain patients who did not receive counseling, and chronic pain patients who did not receive counseling. See Table 1 for results. Table 1: Rates of same-day discharge among ERAS patients based on chronic pain and counseling status

Group n Same-day discharge p-value

1= Non-chronic pain patients who received counseling

15 66.7% (n=10/15)

0.327 2= Chronic pain patients who received counseling 27 59.3% (n=16/27) 3= Non-chronic pain patients who did not receive counseling

58 56.9% (n=33/58)

4= Chronic pain patients who did not receive counseling

65 52.3% (n=34/65)

Conclusions Rate of same-day discharge improved after implementation of an ERAS pathway for laparoscopic hysterectomy overall. Among patients in the ERAS group, those who received mental health optimization prior to surgery were more likely to be discharged on the day of surgery compared to those who did not, but this trend was not statistically significant. Larger sample sizes and higher patient compliance with mental health optimization are needed to better determine the impact of this preoperative ERAS component. Areas for further research include investigating potential confounding variables and disparities in compliance among different demographic groups. References 1. Hartmann KE, Ma C, Lamvu GM, et al. Quality of life and sexual function after hysterectomy in women with preoperative pain and depression. Obstet Gynecol. 2004 Oct;104(4):701-9. 2. Pinto PR, McIntyre T, Nogueira-Silva C, et al. Risk factors for persistent postsurgical pain in women undergoing hysterectomy due to benign causes: a prospective predictive study. J Pain. 2012 Nov;13(11):1045-57. doi: 10.1016/j.jpain.2012.07.014. Epub 2012 Oct 12. 3. Lassen PD, Moeller-Larsen H, de Nully P. Same-day discharge after laparoscopic hysterectomy. Acta Obstet Gynecol Scand. 2012;91: 1339–1341. 4. Brandsborg B, Nikolajsen L, Hansen CT, et al. Risk factors for chronic pain after hysterectomy: a nationwide questionnaire and database study. Anesthesiology. 2007 May;106(5):1003-12.

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Advancing surgical outcomes by providing patients with core elements and standardized pre-operative wellness education Authors: Baotram Tran, MD1, Vinayak Gupta1, Nancy Strange, RD, CNSC, CLT, CD1, William Wooden, MD, FACS1

1Indiana University School of Medicine, Indianapolis, IN

Background Twenty to 50% (1) of surgical patients experience post-operative complications, resulting in prolonged length of stays (2), increased morbidity and mortality (3), infections and decreased quality of life. Infections are the most common complication (4) and are estimated to cost $10 billion per year to the healthcare industry (5). In 2011 IU Health initiated efforts to improve pre-surgical wellness by expanding our pre-surgical assessment and interventions program. The initial step was to prescribe an immunonutrition drink which has arginine, omega 3 fatty acids, and nucleotides, not glutamine, which have demonstrated a 41% reduction in infectious complications4 (4), decreased mortality, infections, and length of stay in patients6(6). The patient was required to purchase the product as no insurance program would cover the cost of a short term oral nutrition drink. The results of the initial program were consistent with the evidence based literature and showed significant improvement in wound healing, LOS and infection rates. Using the initial data, we obtained executive level support and an IU Health financial grant to refine a standard IU Health POWERR (Peri-Operative Wellness Enhanced Rapid Recovery) education process and a POWERR “Tool Kit”. The tool kit includes a 5 day supply of the immunonutrition drink, incentive spirometer, chlorhexidine soap bath, and Mupirocin and is provided to the patient without charge along with education in the PAT (Pre-Admission Testing) clinic. This trial was conducted in 2015 to 2016 and included 6834 elective adult surgical patients treated at University and Methodist hospitals on our academic health campus. We have tracked compliance and outcomes and identified that providing a pre-surgical wellness kit with the immunonutrition, at no cost to the patient, has further improved the surgical outcomes and engagement with providers and patients. Methods A retrospective chart review of the patients at Methodist and University Hospitals in Indianapolis, IN who participated in the PAT clinic between late 2015 and all of 2016. The PAT clinic staff (RNs) encouraged exercise, smoking cessation, and provided a pre-surgical education package with the POWERR tool kit, prior to an elective surgery. Patients were queried about compliance with the POWERR tool kit components on the day of surgery during the admission nursing assessment. A review of LOS, SSI, CAUTI, CLABSI, MRSA, VAE and CDIFF infection was done. Statistical analysis was conducted through Fisher exact test with a two sided p-value <.05. Results The percentage of the patients receiving at least 1 component of the POWERR program is 91.1%. The patient overall compliance rate is 57% with 47.1% for immunonutrition, 49.5% for

44

IS, 52.8% for chlorhexidine bathing and 68% for Mupirocin. A global analysis of the data indicates a statistically significant decrease in the post-surgical complication rates for patients who were compliant with the pre-surgical components. The global harm event rate was reduced by 39% with POWERR compliance. Conclusion At our institution initiation of the POWERR program and patient compliance with the interventions, the global harm event was found to be significantly decreased. Therefore, all patients who are undergoing elective surgery will benefit from immunonutrition, pre-surgical education and interventions that will significantly decrease their risk of post-operative complications.

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Immunonutrition and pre surgical wellness, critical elements in the pathway improved outcomes, reduced surgical site infection, length of stay, and readmission independents of enhanced recovery enhancing a proactive culture of safety Authors: Baotram Tran, MD1, Vinayak Gupta1, Nancy Strange, RD, CNSC, CLT, CD1, William Wooden, MD, FACS1 1Indiana University School of Medicine, Indianapolis, IN

Background As Health Care providers we have now become keenly aware of need and opportunity to improve outcomes and reduce cost to the patients and the health care system at larger. Based on our NSQP data, 75% of the surgical patients treated at the IU Health Adult Academic Health Center have three or more risk factors for complications. To address the need to improve outcomes, we initiated OR Pre Surgical Wellness program. The core element was introduction Pre Surgical Immunonutrition in 2010-2011. We also enhanced our Pre Surgical medical and anesthesia optimization program, standardizing education on pre-surgical physical activity, general nutrition, 5 days pre-surgical imunonutrion supplement, smoking cessation, Chlorohexidine soap bathing, and Mupirocin pre-treatment. This formed the foundation of POWERR (P-re O-perative W-ellness, E-nhanced, R-apid R-ecovery) program. Carbohydrate loading and ERAS elements were added in 2014-2015 , expanding our progress. This base program dramatically improves surgical outcome providing a foundation for surgical engagement and collaboration to add additional elements of ERAS. Methods A retrospective chart review of the patients at our institution who had received the POWERR intervention tool kit was performed. Review of length of stay, length of ICU stay, mortality, and surgical site infection were assessed. Results Consistent decreased in length of stay index for all surgical services was demonstrated after the implementation of POWERR compared to pre-implementation from 2010 to 2013, we recovered over 8 thousands days and reducing our LOS (length of stay) index from 1.142 in 2013 to 1.32 in 2014, 1.064 in 2015, and 1.063 in 2016. Over 8 thousand opportunity days were saved from 2013 to 2016, translating to a significant amount of cost saving in our health system. Our mean ICU days has decreased from 6.22 days in 2012 to 5.99 in 2015. Mortality index has decreased from 1.33 in 2012, to 1.11 in 2013 and 2014, and to 0.97 in 2015. Superficial surgical site infection (SSI) has decreased as well: after colectomy decreased from 7.89% in 2010 to 1.72% in 2016, after enterectomy from 6.25% to 0%, after gastrectomy from 17.14 to 7.14%, after hepatectomy from 6.74% to 2.33%, after pancreatectomy from 5.15% to 1.75%, after proctectomy from 11.11% to 0%. There was also a decrease in deep SSI after hepatectomy from 1.12% in 2010 to 0% in 2016 and after pancreatectomy from 1.03% to 0.58%.

46

Conclusions All health care systems strive to achieve superior patient’s safety and surgical outcome. We have dramatically improved our outcomes with a simple direct. Immunonutrition and wellness based program. This is easy to implement with fewer steps than Enhanced recovery and provides very tangible results for providers, patients and administration. This can rapidly build collaboration and engagement to advance progressive improvements with ERAS and other process.

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An enhanced recovery program in colorectal surgery has the power to decrease a broad range of complications Authors: Alexander Hawkins, MD, MPH1, Timothy Geiger, MD1, Jonathan Wanderer, MD,

MPhil1, Adam King, MD1, Roberta Muldoon, MD1, Molly Cone, MD1, M. Benjamin Hopkins, MD1, Matthew McEvoy, MD1 1Vanderbilt University Background Historically, perioperative care has been uncoordinated and lacked standardization throughout the service spectrum. Enhanced recovery programs (ERP) have been shown to decrease aggregate complications across surgical specialties. However, studies examining ERPs have traditionally shown improvement in composite complication outcome measures rather than specific organ system based complication rates. We hypothesize that the sustained implementation of a multi-modality ERP will be associated with a decrease in a broad range of organ system complications. Methods Adult patients undergoing elective colorectal procedures at a single institution between 1/2011 and 10/2016 were included. Patients were stratified based on exposure to an ERP (7/2014-10/2016) after an 18 months wash out period in a pre-post analysis. The primary outcome was 30 day complication rate by organ system as collected by National Surgical Quality Improvement Program (NSQIP) abstractors. Demographic and other patient level data was collected. Complication rates were compared using both Fisher’s exact test and multivariable logistic regression models including all predictive variables. Results A total of 1,182 patients were included in this study, with 47% (N=550) treated in an ERP. The two groups were similar in age, gender, race, BMI, comorbidity index and procedure type. Significant reductions were seen in surgical site infection, postoperative pulmonary complications, transfusion, urinary tract infections, sepsis, and cardiac complications. A reduction in 30-day readmission was also noted. Length of stay decreased from median 5.2 to 3.5 days. These reductions persisted in a multivariable analysis. No significant changes occurred for acute kidney injury and hematologic complications. Conclusions An ERP was associated with reduced complication rates across a wide range of organ systems and >1.5 day reduction in length of stay in a colorectal surgery population.

Incidence Unadjusted model for Post Adjusted Model for Post

Outcome Pre Post OR (95% CI)

Wald P-Value

OR (95% CI) Wald P-

Value

48

SSI 21.05 7.4%

0.30 (0.21-0.44)

<0.001 0.30 (0.20-

0.43) <0.001

Pulmonary 4.9% 2.4%

0.47 (0.24-0.91)

0.02 0.45 (0.23-

0.89) 0.02

Transfusion 7.9% 2.5%

0.30 (0.16-0.56)

0.0001 0.28 (0.15-

0.52) <0.001

AKI 1.4% 2.0%

1.41 (0.58-3.43)

0.44 1.43 (0.59-

3.49) 0.43

UTI 5.8% 2.4%

0.39 (0.20-0.74)

0.004 0.37 (0.19-

0.71) 0.003

Sepsis 7.7% 3.4%

0.42 (0.25-0.73)

0.002 0.43 (0.25-

0.74) 0.002

Cardiac 1.5% 0.2%

0.11 (0.01-0.88)

0.03 0.11 (0.01-

0.90) 0.03

Heme 2.7% 2.2%

0.80 (0.38-1.70)

0.57 0.80 (0.30-

2.66) 0.58

Readmission 16.1% 11.3%

0.66 (0.47-0.92)

0.01 0.67 (0.47-

0.94) 0.02

Return to ED 4.7% 4.4%

0.92 (0.53-1.59)

0.75 0.95 (0.55-

1.64) 0.84

β (SE) P-value β (SE) P-value LOS (median)

5.2 d 3.5 d -1.45 (0.28) <0.001 -1.51 (0.29) <0.001

An enhanced recovery program in colorectal surgery has the power to decrease a broad range of complications Authors: Alexander Hawkins, MD, MPH1, Timothy Geiger, MD1, Jonathan Wanderer, MD,

MPhil1, Adam King, MD1, Roberta Muldoon, MD1, Molly Cone, MD1, M. Benjamin Hopkins, MD1, Matthew McEvoy, MD1 1Vanderbilt University Background Historically, perioperative care has been uncoordinated and lacked standardization throughout the service spectrum. Enhanced recovery programs (ERP) have been shown to decrease aggregate complications across surgical specialties. However, studies examining ERPs have traditionally shown improvement in composite complication outcome measures rather than specific organ system based complication rates. We hypothesize that the sustained implementation of a multi-modality ERP will be associated with a decrease in a broad range of organ system complications. Methods Adult patients undergoing elective colorectal procedures at a single institution between 1/2011 and 10/2016 were included. Patients were stratified based on exposure to an ERP (7/2014-10/2016) after an 18 months wash out period in a pre-post analysis. The primary outcome was 30 day complication rate by organ system as collected by National Surgical Quality Improvement Program (NSQIP) abstractors. Demographic and other patient level data was collected. Complication rates were compared using both Fisher’s exact test and multivariable logistic regression models including all predictive variables. Results A total of 1,182 patients were included in this study, with 47% (N=550) treated in an ERP. The two groups were similar in age, gender, race, BMI, comorbidity index and procedure type. Significant reductions were seen in surgical site infection, postoperative pulmonary complications, transfusion, urinary tract infections, sepsis, and cardiac complications. A reduction in 30-day readmission was also noted. Length of stay decreased from median 5.2 to 3.5 days. These reductions persisted in a multivariable analysis. No significant changes occurred for acute kidney injury and hematologic complications. Conclusions An ERP was associated with reduced complication rates across a wide range of organ systems and >1.5 day reduction in length of stay in a colorectal surgery population.

Incidence Unadjusted model for Post Adjusted Model for Post

Outcome Pre Post OR (95% CI)

Wald P-Value

OR (95% CI) Wald P-

Value

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Eras multimodal analgesia protocols result in marked reduction in opioids with associated improved pain scores, decreased los and accelerated return of gut function Authors: Patricia Ahlquist, RN1 1Middlesex Hospital, Middletown, CT Background Implementation of multimodal pain management protocols is known to reduce opioid consumption in postoperative patients. Our study correlates decreased reliance on opioid analgesics postoperatively, due to the use of multimodal strategies, with a positive impact on patient reported pain scores, LOS and return of gut function. Methods Forty-six consecutive elective colon resection cases were reviewed as a baseline cohort and entered into the ERAS Encare database. Subsequently, forty-seven colon resection patients that underwent surgery under ERAS care pathways were entered. Opioid consumption, LOS and return of gut function were compared for pre and post ERAS implementation. Results Nineteen ERAS pathway patients received no opioid medication following elective colon resection. Of those, fourteen patients received no opioid medication in either PACU or postop. This contrasted with two patients in the pre-ERAS group receiving no opioid medication postop. Return of gut function decreased by one day for passage of flatus and two days for stool. Patients were able to tolerate solids three days earlier. Maximum daily reported pain scores were all significantly less in ERAS patients. Conclusions A dramatic reduction in opioid use did not result in any negative patient experience outcomes and patients left the hospital more quickly due to earlier resumption of GI function, tolerance of diet and avoidance of the side effects of opiate pain medications.

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Enhanced recovery to improve outcomes in pancreaticoduodectomy Author: Vicki Morton, DNP, AGNP-BC1 1Medical University of South Carolina Background Enhanced recovery programs (ERPs) have been applied to a multitude of surgical procedures in an effort to enhance care by reducing postoperative complications, decreasing hospital length of stay, reducing readmission rates, improving patient outcomes, and enhancing pa-tient experience. ERPs are multimodal and involve defined preoperative, intraoperative, and postoperative elements that when collectively applied improve clinical outcomes. Pancreati-coduodenectomy, otherwise known as the Whipple Operation, is a complex, costly procedure performed for pancreatic cancer and chronic pancreatitis. Typically, the operation involves re-section of the pancreatic head, distal stomach, duodenum, bile duct and gallbladder, and is associated with high post surgical morbidity rates. Methods The quality improvement project included 56 adult patients undergoing pancreaticoduode-nectomy due to either a pancreatic carcinoma or life-altering chronic pancreatitis. A team was developed for the project. Our ERP was developed based on existing evidence-based pathways and reviewed by the team’s surgeon and anesthesiologist. Education was provided to all anesthesia care providers and printed pathways were placed within the operating rooms. All adult patients scheduled to have pancreaticoduodenectomy received two 355ml carbohydrate drinks that contained 50g of carbohydrates, 3 g L-citrulline, and maltodextrin. The patients were instructed to drink one bottle the night before surgery and the second three hours prior to surgery. Patients were educated on the benefits of the carbohydrate-rich drink by the clinical educator during their preadmission testing appointment. Intraoperative goal directed fluid therapy was achieved using a modified Ramsingh protocol during all open phases of surgery. During the laparoscopic portions, fluid optimization was per the NHS NICE protocol. All patients also attended a preoperative class where they were educated on pre-operative nutrition, exercise, smoking cessation, alcohol cessation, early mobilization, postop-erative pain medication, and postoperative nutrition Results Overall, outcomes improved following implementation of our ERP. Prior to implementation, our overall complication rate associated with pacreaticoduodenectomy was 70%. Following ERP implementation, our complication rate rate decreased to 46%. The most prevalent com-plications included delayed gastric emptying (DGE) nausea, respiratory insufficiency, SSI, and wound dehiscence. Prior to this quality improvement project, the two most prevalent compli-cations were DGE and SSI (53% and 40%, respectively). Following implementation of the ERP, our DGE rates decreased to 47% and SSI to 12%. This improvement was reflected in readmis-sion rates. Prior to this implementation, our 30-day readmission rate for this procedure was 28%. This was decreased to 25% following implementation. Lengths of stay decreased by 14.02% following the ERAS pathway implementation, from 14.19 days to 12.2 days.

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Conclusions Pancreatic surgery is associ-ated with poor survival rates. Outcomes research involving Enhanced Recov-ery in pancreaticodudenec-tomy is lacking, however, ERAS guidelines for patients undergoing pacreaticoduo-denectomy exist. Although the literature and this qual-ity improvement project supports the use of an En-hanced Recovery pathway in patients undergoing pancre-aticoduodenectomy, appro-priately powered random-ized controlled trials will be needed to prove the benefit of ERPs in this surgical popu-lation.

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An evaluation of patients’ perceptions regarding use of the acs nsqip surgical risk calculator during preoperative risk discussion Authors: Britany L. Raymond, MD1, Jonathan P. Wanderer, MD, MPhil1, Jesse M. Ehrenfeld, MD, MPH1, Lane Stiles, BA, BS, MA2, John Stokes, MD1, Matthew D. McEvoy, MD1 1Vanderbilt University Medical Center, Department of Anesthesiology 2Vanderbilt University Medical Center, Department of Patient Education Background A critical component of an informed surgical consent is the discussion of potential perioperative risks. National healthcare institutions, such as Centers for Medicare and Medicaid Services, have begun advocating for surgeons to provide patients with personalized risk estimates of perioperative complications. In response, the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) developed a risk calculator that can provide numerical estimates of empirically-derived, patient-specific risks for common adverse perioperative outcomes. This risk calculator was promoted as a validated tool to improve shared decision-making and informed consent for patients undergoing elective operations. To our knowledge, no data is available regarding the use of this calculator in preoperative risk discussions with patients. Our objective was to evaluate patient perceptions of the calculator and the impact of reviewing their personalized risk estimates from the risk calculator in a preoperative clinic setting. Methods Patients presenting to a preoperative clinic during a one-month period completed an initial survey that inquired about their understanding of their perioperative risks. Participants were asked to predict their hospital length of stay and to estimate their personal risks of the 12 postoperative complications that are computed by the ACS NSQIP surgical risk calculator. Risk calculation was performed by entering patient-specific variables/demographics into the ACS NSQIP surgical risk calculator. An anesthesiologist reviewed the predicted risk results with the patients. A follow-up survey was administered to evaluate patients’ attitudes and perceptions regarding use of the calculator in discussion of perioperative risks. Patients were given a $25 gift card as remuneration for participation in they study. Average time for completing study procedures was 30 minutes. Results Of the 157 patients approached, 150 consented to and completed participation in the study. Of these, zero (0%) claimed familiarity with or previous exposure to the ACS NSQIP surgical risk calculator. A majority of participants (89%) felt that doctors should share their personalized risks before agreeing to surgery. High-risk patients, defined as ≥10% risk of serious complication by the ACS NSQIP calculator, were more likely to underestimate their risk of complications as compared to low risk patients (see Figure, P<0.0001). Knowledge of personalized risk estimates had no effect on anxiety levels in 20% of patients, and decreased anxiety in 71%. After reviewing their predicted risks, 77% of patients stated they would consider participating in a structured pre-habilitation program in order to decrease their

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perioperative risk of complications, and 38% of patients would delay their surgery in order to do so. Conclusions In modern medicine, the practice of informed consent is designed to equip the patient with knowledge to participate in and contribute to shared decision-making. The relational nature of this process is intended to promote the coordination between the medical care delivered and patient values. Although the ACS NSQIP calculator was marketed specifically to aid preoperative consent discussions, it is unclear if the calculator is being used as intended. Based upon our sample, it appears that the ACS NSQIP risk calculator is an underutilized resource that patients feel should be incorporated into the surgical consent process. Participants viewed estimation of their personalized risks to be an important part of the consent process, and an overwhelming majority expressed a desire to see their results prior to consenting for surgeries in the future. Our study has also shown that insight and awareness of one’s perioperative risks may reduce anxiety. Knowledge of individualized risk may provide motivation for patients to participate in a structured prehabiliation program, which has important implications to the future of perioperative medicine.

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Implementing an eras protocol: our journey toward excellence Author: Geri Johnston, MSN, RN1

1Medical University of South Carolina Background The Medical University of South Carolina is a level 1 trauma center and comprehensive academic medical center that provides care to a large population within the southeast. The mission of MUSC is to improve health and maximize quality of life through education, research and patient care. A pilot project using Enhanced Recovery After Surgery principles was undertaken with pancreatobiliary surgery in 2014 and 2015, with impressive results. Hospital leadership made the decision to hire a nurse navigator and pursue implementation of ERAS throughout most elective surgical specialties, beginning with colorectal surgery. Methods My poster will outline the process that was taken to develop and create all the elements and infrastructure needed before implementing an ERAS protocol. Our journey began with a review of the literature and evidence-based best practice. An interdisciplinary ERAS Oversight Committee was brought together which included a range of clinicians interested in this project. Executive and clinical leadership and support were crucial to start the program. A committee charter and guiding principles for the committee were developed and approved. A summary of the committee charter will be presented on the poster. One of the initial steps was to create a detailed process map so that our medical record IT team understood the patient flow and could develop tools that needed to be built into the medical record to track compliance with the protocol and patient outcomes. Poster will show part of the process map. Baseline data were compiled to assess current outcomes, including length of stay, complications and readmissions in the first 30 days post operatively. Poster will show baseline data summary. Order sets for the initial surgery consult, day of surgery admission and for inpatient post-operative stay were written and reviewed by the Oversight Committee. Patient education tools were written and incorporated into the medical record based on orders placed. All staff involved in the care of the patient from surgical consult visit in clinic through discharge was educated on ERAS principles, with focus on the particular part of the protocol that their patient interaction takes place. This involved clinic staff, pre-op day of surgery staff, OR and PACU staff, and inpatient unit staff. Residents and PAs were educated on order sets as well as attending surgeons. Results Protocols began in early February, and preliminary results are favorable. Consistent real-time monitoring will be needed, especially early in the project. Outcomes at 30 days will be reviewed by the Oversight Committee on a monthly basis. Conclusion: With many infrastructure elements now in place, a similar process will be followed with other surgery specialties, beginning with gynecologic surgery.

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Dynamic risk profiling for postoperative nausea and vomiting after implementation of an enhanced recovery pathway for surgical weight loss patients Authors: Krishnan Ramanujan, BA1, Jon Wanderer, MD2, Patrick Jablonski, PhD2, Adam B. King, MD2, Matthew Spann, MD3, Brandon Williams, MD3, Wayne English, MD3, Matthew McEvoy, MD2 1Vanderbilt University School of Medicine 2Vanderbilt University Medical Center, Department of Anesthesiology 3Vanderbilt University Medical Center, Department of Surgery Introduction Enhanced recovery pathways (ERP) have been shown to reduce postoperative length of stay (LOS) without increasing morbidity in surgical weight loss (SWL) patients.1 We implemented an ERP for SWL patients that resulted in >80% of patients being discharged on postoperative day 1.2 Despite the incorporation of risk-based prophylaxis into this ERP,3 postoperative nausea and vomiting (PONV) continues to be an issue. The goal of this study was to identify areas for improvement with dynamic risk profiling a population at high-risk for PONV. Methods An ERP was implemented in January 2015. Records were obtained for patients undergoing robotic or laparoscopic gastric bypass/sleeve gastrectomy (1/28/15 – 11/7/16). Baseline characteristics, Apfel scores, and number of anti-emetics administered in the PACU and inpatient unit were obtained. Postoperative LOS was determined by calculating the time from surgery start to hospital discharge and subtracting the operative time, with prolonged LOS defined as one that spans two midnights. Causes of prolonged LOS were determined via manual review of daily progress notes and discharge summaries. Multiple logistic regression, analysis of variance with Tukey follow-up, and Kruskal-Wallis tests were used where appropriate. P<0.05 was considered significant. Results A total of 767 charts were reviewed. Patient demographics, stratified by Apfel score, are shown in Table 1. Almost half of patients (46.2%) required at least one anti-emetic in the PACU. Higher Apfel score was associated with increased anti-emetic use in the PACU (H=21.4; p<.0001). Among patients who received anti-emetics in the PACU or inpatient unit, receiving at least one anti-emetic in the PACU was associated with an increased frequency of further postoperative administration (F=61.55; p<.0001). Tukey follow-up showed that significant changes in dosing frequency occurred when patients required 2-3 PACU anti-emetics (rescue dosing needed q8-10h) or 4 PACU anti-emetics (rescue dosing needed q6h) (P<0.05). Requiring PACU anti-emetics increased the odds of a prolonged LOS due to PONV (OR 1.7 for each dose; p<0.0001). Apfel score was not associated with increased frequency of anti-emetic administration or prolonged LOS. Conclusions

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As previously reported, patients with higher Apfel scores required more anti-emetics in the PACU. Interestingly, regardless of Apfel score, PACU anti-emetic administration was associated with increased frequency of administration during the inpatient stay and a prolonged LOS. These findings show that while the Apfel score is important for determining appropriate PONV prophylaxis and PACU risk of PONV, administration of rescue anti-emetics in the PACU can help determine whether SWL patients will experience persistent PONV requiring ongoing treatment and predict an increased risk of prolonged LOS due to PONV. Taken together, these findings may allow for dynamic risk profiling such that patients who require PONV treatment in the PACU receive more aggressive, and possibly scheduled, anti-emetic therapy as an inpatient in order to improve patient satisfaction and reduce risk of prolonged LOS. References 1. Lemanu DP, et al. BJS. 2013;100:482-9. 2. McEvoy MD, et al. ASA Symposium 2015. 3. Gan TJ, et al. Anesth Analg. 2014;118:85-113.

Dynamic risk profiling for postoperative nausea and vomiting after implementation of an enhanced recovery pathway for surgical weight loss patients Authors: Krishnan Ramanujan, BA1, Jon Wanderer, MD2, Patrick Jablonski, PhD2, Adam B. King, MD2, Matthew Spann, MD3, Brandon Williams, MD3, Wayne English, MD3, Matthew McEvoy, MD2 1Vanderbilt University School of Medicine 2Vanderbilt University Medical Center, Department of Anesthesiology 3Vanderbilt University Medical Center, Department of Surgery Introduction Enhanced recovery pathways (ERP) have been shown to reduce postoperative length of stay (LOS) without increasing morbidity in surgical weight loss (SWL) patients.1 We implemented an ERP for SWL patients that resulted in >80% of patients being discharged on postoperative day 1.2 Despite the incorporation of risk-based prophylaxis into this ERP,3 postoperative nausea and vomiting (PONV) continues to be an issue. The goal of this study was to identify areas for improvement with dynamic risk profiling a population at high-risk for PONV. Methods An ERP was implemented in January 2015. Records were obtained for patients undergoing robotic or laparoscopic gastric bypass/sleeve gastrectomy (1/28/15 – 11/7/16). Baseline characteristics, Apfel scores, and number of anti-emetics administered in the PACU and inpatient unit were obtained. Postoperative LOS was determined by calculating the time from surgery start to hospital discharge and subtracting the operative time, with prolonged LOS defined as one that spans two midnights. Causes of prolonged LOS were determined via manual review of daily progress notes and discharge summaries. Multiple logistic regression, analysis of variance with Tukey follow-up, and Kruskal-Wallis tests were used where appropriate. P<0.05 was considered significant. Results A total of 767 charts were reviewed. Patient demographics, stratified by Apfel score, are shown in Table 1. Almost half of patients (46.2%) required at least one anti-emetic in the PACU. Higher Apfel score was associated with increased anti-emetic use in the PACU (H=21.4; p<.0001). Among patients who received anti-emetics in the PACU or inpatient unit, receiving at least one anti-emetic in the PACU was associated with an increased frequency of further postoperative administration (F=61.55; p<.0001). Tukey follow-up showed that significant changes in dosing frequency occurred when patients required 2-3 PACU anti-emetics (rescue dosing needed q8-10h) or 4 PACU anti-emetics (rescue dosing needed q6h) (P<0.05). Requiring PACU anti-emetics increased the odds of a prolonged LOS due to PONV (OR 1.7 for each dose; p<0.0001). Apfel score was not associated with increased frequency of anti-emetic administration or prolonged LOS. Conclusions

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Early success in implementation of a division-wide eras program utilizing an outcomes manager-led interdisciplinary team Authors: Emily Saeler, MSN, RN,  CRNI, CNL1, Katerina Wells, MD, MPH1, James Fleshman, MD, FACS, FASCRS1, Walter Peters, MD, MBA1

1Baylor University Medical Center Background Enhanced Recovery after Surgery (ERAS) programs improve postoperative outcomes and decrease overall recovery time. While awareness of the benefits provided by these programs has grown, there is little formal understanding of the implementation strategies and auditing processes undertaken by adopting institutions. Outcome Managers (OM) that are formally trained with a master’s degree in Clinical Nurse Leadership are paramount to the early success of the implementation process due to their ability to apply process-improvement strategies. An OM facilitates collaboration of stakeholders to participate in root-cause analysis to identify specific interventions. Key interventions are then prioritized using an impact and frequency matrix, and are incorporated into an ERAS intervention program. Duties of an OM include developing strategic implementation methods, collecting data through chart abstraction, and continuous auditing for quality improvement. Our goal is to (1) demonstrate that OM oversight of an interdisciplinary team to implementing a division-wide colorectal ERAS program accelerates success, (2) describe the obstacles encountered with implementation and (3) offer strategies for implementation and long-term success. Methods This is a retrospective review of colorectal surgery patients undergoing major abdominal surgery over a five-month OM-led implementation period. Data for the post-intervention group was prospectively collected. A matched cohort of pre-intervention colorectal surgery patients were retrospectively collected by chart review using a defined set of standards and definitions for abstraction. All elective colorectal cases were eligible for the study. The institutional ERAS program is comprised of 22 care components spanning preoperative, intraoperative and postoperative periods for elective colorectal resections. The primary endpoint is compliance to bundle variables, considered the measure of success attributed to having an OM in a longitudinal role for implementation of the ERAS program. Secondary endpoints included length of stay (LOS) and readmission rates. Descriptive statistics and student’s t-test were used for analysis. Results 358 patients were included in the analysis, pre-intervention (n=183) and post-intervention (n=175). The median age was 59.5 years (range: 21-95 years) and the median ASA score was 3. Mean compliance of ERAS interventions increased from 41% to 65% over the study period, (p= 0.001). Length of stay decreased to 5.2 days from 6.0 days over a five-month period, (p=0.0445). Readmission rates remained stable (4.42% and 4.04%). Bundle variables that were least adhered to included carbohydrate loading (29%), transversus abdominus plane (TAP) block placement (48%) and patient ambulation day of surgery (31%). To improve

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compliance with these variables, prescreening phone calls were initiated to ensure patient understanding of surgery expectations and carbohydrate loading, and TAP block education with appropriate staff members was initiated. Awareness of compliance with all variables was publicly reviewed at team meetings and with leadership staff of each department. Conclusions An OM-lead multidisciplinary team for implementation of ERAS results in accelerated compliance to bundle variables with a resultant decrease in postoperative LOS. The role of an OM is a novel consideration that is instrumental in both intervention inception and continuous real-time auditing to improve intervention compliance and patient outcomes over an accelerated time period. Application of an OM in other specialties and service lines may be considered to enhance adoption of new programs and achieve early success.

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Development of a novel enhanced recovery after surgery pathway for major lower extremity amputation Authors: Sara Scarlet, MD1, Lavinia Kolarczyk, MD1, Robert Isaak, DO1, Katharine L. McGinigle, MD, MPH1

1University of North Carolina Background Patients undergoing major lower extremity amputation typically have significant postoperative pain and delayed return to baseline level of functioning. Despite these perioperative issues, the utilization of enhanced recovery after surgery (ERAS) pathways has been limited for patients undergoing major lower extremity amputation. We aimed to develop an ERAS pathway for the treatment of patients undergoing above- or below-knee amputation in an attempt to improve the quality of care for this at-risk patient population. Methods We conducted a literature review to identify and characterize ERAS pathways used in the context of amputation. Our search was performed using Medline and Cochrane databases. Search terms included ‘ERAS’ ‘enhanced recovery’, ‘fast-track recovery,' ‘recovery pathway,' ‘postoperative care,' ‘multi-modal analgesia,' ‘amputation,' ‘postoperative pain,' ‘phantom limb pain,' and ‘length of stay.' We used this data to develop a novel ERAS pathway for patients undergoing major lower extremity amputation. Results Literature review of ERAS pathways specific to vascular surgery resulted in no relevant publications. Universal ERAS concepts including preoperative education, multimodal analgesia, antibiotic prophylaxis, and early postoperative physical mobility were used as a starting point for the development of a novel ERAS pathway for limb amputation. Key elements of our pathway included: 1) detailed preoperative patient education on perioperative expectations and the typical recovery process 2) preoperative oral analgesics (acetaminophen, pregabalin, duloxetine) and placement of peripheral nerve catheters in the lower extremity on the day of surgery 3) pre-incision antibiotic prophylaxis 4) intraoperative multi-modal, opioid sparing anesthesia technique while avoiding general anesthesia when possible 5) postoperative multimodal analgesic regimen, limited opioid use, and consultation of our anesthesiology acute pain management team 6) early nutrition, mobility, and evaluation by our physical medicine and rehabilitation team postoperatively 7) education regarding limb guard, stump shrinkers and prosthetics follow-up and 8) evaluation for phantom limb pain prior to hospital discharge. Conclusions We developed a novel ERAS pathway for treatment of patients undergoing major lower extremity amputation. This protocol has been implemented at our institution. Future studies will compare pre- and post-ERAS protocol implementation periods to examine outcomes of length of stay, surgical pain, phantom limb pain, and time to ambulation. We will continue to

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refine and adapt our pathway to meet the needs of patients undergoing major lower extremity amputation.

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Capturing real-time eras milestones: an integrative project management tool Authors: Elizabeth Pratt, DNP, RN, ACNS-BC1, Melissa Schmidt, MSN, RN, CCRN, CNRN, ACCNS-AG1, Kara Vyers, BS, Julie Griffin, MHA, RN, CENP, Patricia Potter, PhD, RN, FAAN, Neil Wright, MD2, Ian Dorward, MD2 1Barnes-Jewish Hospital 2Washington University School of Medicine Background The inpatient innovation unit at a large academic hospital tests evidence-based practices and technology to enhance care delivery. The team designed a quality improvement method to capture postoperative ERAS milestones with live data using an existing rounding platform, driving consistency, accountability, and trending for patient experience. The goal was to determine if this technology was a viable solution as a project management tool for collecting post-surgical outcomes. Patient care milestones, or points in time when desired clinical outcomes are met, are often identified but rarely captured in real time in the hospital setting. Methods Patient navigators, or assistant nurse managers, rounded each shift to identify if neurosurgery spine patients achieved their milestones. They alerted team members to help the patient achieve missed outcomes. Data was entered on a mobile device or computer. Each patient had a single file on the protected data collection website. Multiple navigators can work on the same patient, and ERAS milestones are collected throughout the entire patient stay. Results All neurosurgery spine patients (n=436) admitted in February 2016 – January 2017 were placed on the postoperative pathway to achieve clinical milestones. Surgery type, surgeon, and critical care stays were captured in the data. Foley catheters are removed within six hours for 68% of the patients, with one unit-acquired CAUTI in 2016. Intravenous fluids are discontinued and PO intake initiated within 12 hours on 59% of the patients, and the unit had zero CLABSIs in 2016. Patients following a progressive mobility protocol reached the highest mobility level, independent ambulation, within an average of 14 hours of arrival to the floor. Sequential devices are on the 97% of the patients 18 hours or greater each day, with a DVT rate of 0.005 (2 events). Pain goals are achieved 93% of the time within 12 hours of arrival to the floor. Patients and family verbalized their discharge plan 91% of the time within the first 24 hours. Teamwork, nurse responsiveness, and nurses’ management of pain are key drivers for patient satisfaction, achieving 95.2 percentile ranking, exceeding the hospital and national benchmarks. Conclusions By utilizing a real-time project management tool for ERAS milestones, the navigator identified if patients were on target for expected recovery from neuro-spine surgery. Understanding the impact of integrative technology can transform care practices and improve work flow in the

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hospital setting. Researchers will continue to analyze data and evaluate the success in meeting achieved milestones to determine if there is an association with patient outcomes, such as length of stay, readmissions, and nursing sensitive indicators. References Jones, Wainwright, Foster, Smith, Middleton, & Francis (2014). A systematic review of patient reported outcomes

and patient experience in enhanced recovery after orthopaedic surgery. Ann R Coll Surg Engl. 96(2), 89–

94. doi: 10.1308/003588414X13824511649571 Paton, Chambers, Wilson, et al. (2014). Effectiveness and implementation of enhanced recovery after surgery

programmes: a rapid evidence synthesis. BMJ Open 2014;4:e005015. doi:10.1136/bmjopen-2014-005015 Sibbern, Sellevold, Steindal, Dale, Watt-Watson, & Dihle (2016). Patients' experiences of enhanced recovery after

surgery: a systematic review of qualitative studies. J Clin Nurs. doi: 10.1111/jocn.13456. Wainwright, Immins, & Middleton (2016) Enhanced recover after surgery (ERAS) and its applicability for major

spine surgery. Best Pract Res Clin Anaesthesiol. 30(1), 91-102. doi: 10.1016/j.bpa.2015.11.001.

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Enhanced recovery after surgery (eras) – an assessment at six months post discharge Authors: Thomas Deiss, BA1, Ankit Sarin, MD1, Ramana Naidu, MD1, Lee-Lynn Chen, MD1

1Department of Anesthesia and Perioperative Care, University of California-San Francisco, San Francisco, CA Background Enhanced Recovery After Surgery (ERAS) programs have been established as perioperative strategies associated with improved outcomes. Long-term results for patients undergoing ERAS interventions remain limited. This study collected prospective telephone questionnaire data six months post-colorectal surgery from patients who participated in an ERAS program at University of California, San Francisco (UCSF). Our goal was to detect previously unreported issues and associated predictive factors in patient outcomes. Methods We conducted a prospective observational study at UCSF, using an automated telephone survey six months after patients underwent abdominal colorectal surgery. All patients from February 2015 to June 2016 in the ERAS program were included in this post-discharge survey. Prior IRB approval was obtained. Patients who responded to the survey received a follow up call for clarity and accuracy. Six month significant outcomes were defined by persistent pain, hospital readmission, and/or patient satisfaction. Patients reporting these outcome variables were compared with patients who met none of these criteria. These patients were categorized by age, gender, diagnoses (cancer/non-cancer), ASA rating, use of an epidural, and type of procedure (Open vs Minimally Invasive) to determine what variables correlate with the six-month outcomes. Preoperative and postoperative pain scores, length of procedure, and length of hospital stay were also analyzed. A chi-square test was used to determine any relationship for categorical variables, a two independent samples t-test for length of procedure/stay and a Wilcoxon-Mann-Whitney test for pain scores. Results 154 of 324 patients contacted six months after surgery completed the telephone survey (47.53%). There was no statistical difference between the patient populations of those completing and not completing the survey (Figure 1). 30 of 154 (19.48%) reported surgical pain, 31 of 154 (20%) reported hospital readmission, and 21 of 154 (13.6%) reported less than complete satisfaction with their stay (Figure 2). Hospital readmission was associated with patients with a cancer diagnosis (P=.049) and those that had a longer mean length of procedure (282 vs. 206 minutes, P=.006) (Figure 3). Median six-month pain scores were significantly higher for patients that underwent an open procedure compared to laparoscopic (Z=-2.06, P=.04). No relationship between pre/postoperative pain and six month outcomes was found. Of the patients reporting surgical pain at six months, 10 out of 30 (33.3%) reported using opiods to manage their pain. Postoperative pain (9 of 21, 43%) was the most common reason for patient dissatisfaction. Epidural use suggested a beneficial trend to decreased six-month pain scores, though this was not statistically significant.

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Conclusions A six-month postoperative telephone survey was an adequate tool to assess outcome measures of interest. Long-term benefits of an ERAS program were mostly confirmed. However, longer procedure time and patients with cancer correlated with an increased likelihood of hospital six-month readmission. Type of procedure also had a significant effect on six-month pain score outcomes. Further studies are needed to identify long-term outcomes of ERAS patients.

Figure 1

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Figure 2

Figure 3

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Enhanced recovery and outcomes in pancreatic cancer surgery

Authors: Vandana Agarwal, MD, FRCA1, Riddhi Joshi, MBBS1, Martin Thomas, MD1, Vikram Chaudhari, MS2, Abhishek Mitra, MS2, Manish Bhandare, MS2, Ashwin Desouza, MS, FRCS2, Karuna Panhale3, Vincent Parmanandam4, Reshma Ambulkar, MD, FRCA1, Mahesh Goel, MS2, Shailesh Shrikhande, MS, MD, FRCS2 1Dept of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Mumbai, India. 2Division of Gastrointestinal Surgical Oncology, 3Research Nurse, 4Physiotherapy Dept, Tata Memorial Hospital, Mumbai, India. Introduction Enhanced Recovery after Surgery (ERAS) pathway accelerates recovery and reduces morbidity. Evidence regarding ERAS in pancreatic cancer surgery is still evolving. It has been found to be associated with reduced length of stay, morbidity and costs. We implemented ERAS in patients undergoing pancreatic cancer resections. The objective was to assess compliance with various components of ERAS and evaluate the impact on outcomes. Methods Study design: Institutional Review Board approved Prospective observational audit. The team was educated prior to implementation of ERAS. Patients were followed up till 30 days postoperatively. Clavien Dindo (C&D) classification was used to grade complications (1, 2 – Minor, 3,4 - Major). Data was recorded regarding the compliance with the protocol and outcomes in terms of postoperative morbidity and mortality. In addition, we compared year 1 vs year 2 and year 3 to explore the temporal effect of implementation. Results 392 patients underwent pancreatic resections (Feb 2014 - Dec 2016). Median age was 56 years (IQR 46 -62). Overall compliance with ERAS elements was 84% and compliance of individual variables is listed in Table 1. Major complications occurred in 119 patients (30.3%) and 13 patients died (3.3%). Major complications decreased over a period of time from 45% in the first year to 31.2% in the third year after implementation. There was a similar reduction in mortality (4.1% vs. 1.4%). ERAS elements didn’t influence postoperative stay. Table 1: Compliance with individual ERAS elements and Outcomes (overall and change over time). Variables Overall

N = 392(%) 2014

N =97(%) 2015

N = 151 (%) 2016

N = 144 (%) Preoperative Counselling 375 (95.6) 93(98.9) 144(98.6) 139 (96.5) VTE prophylaxis 355 (90.5) 76(81.7) 139(95.2) 140 (97) Preoperative Carbohydrate load 346 (88.2) 83(89.2) 137(93.8) 126 (88.1) Selective Bowel preparation 57 (14.5) 12 (12.3) 30 (19.8) 16 (11.1)

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Selective Sedation 5 (1.2) 2 (2) 1 (0.6) 2 (1.4) Intraoperative Mid thoracic Epidural 369 (94.1) 91(94.8) 142(94) 136 (95.1) Antibiotic prophylaxis 386 (98.4) 93(98.9) 150(99.3) 143 (99.3) Antiemetic prophylaxis 365 (93.1) 84(89.4) 149(98.7) 132 (91.7) Temperature management 248 (100) 97(100) 151(100) 144 (100) Postoperative Adhered to Structured mobilisation

350 (89.2) 76(80.9) 142(94.7) 132 (91.7)

Mobilisation started POD# 1 (1 -1) 1 (1-1) 1 (1-1) 1 (1-1) Target achieved POD# (Ability to perform activities of daily living)

4 (3-6) 5 (4-7) 4 (3-5) 5 (3-7)

Complications Major C &D (grade 3-4) 119 (30.3) 41 (45) 42(27.8) 45(31.2) Mortality 13(3.3) 4 (4.1) 7(4.6) 2 (1.4) Postop stay (Median, #) 12 (9-18) 11 (10-20.5) 13 (10-20) 12 (9-17) Readmissions (days) 23 (5.8) 10(10.3) 3(1.9) 10 (6.9) N - Number of patients we were compliant. POD-Postoperative day, #-Interquartile range. Conclusions ERAS pathway is associated with reduced incidence of major complications and mortality suggesting that implementation of ERAS is safe in pancreatic cancer resections.

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Maintaining compliance and ongoing support for a successful long-term enhanced recovery program Authors: Desiree Chappell, CRNA1, Patrick Shanahan, MD1

1Norton Healthcare, Louisville, KY Background Over the past two years, our facility has maintained an Enhanced Recovery After Surgery program (ERAS) for colorectal and urological patients. The anesthesia group designed the program based upon the ERAS society guidelines1 and instituted utilizing a multidisciplinary team approach. Within the first year of implementation, a significant reduction of length of stay (LOS) and variable direct costs (VDCs) occurred. It was during the second year of the program that a reversal in the LOS data and VDCs were observed. We did not have specific compliance data to explain the divergence; therefore, the initial team leaders performed a root-cause analysis directed at determining a correlation between the program evolution and the decline in the results. Objective Determine the factors affecting the program resulting in increased LOS and VDCs from initial outcomes. Results Initial results over year 1 of ERAS implementation showed a significant decrease in LOS and VDCs for colorectal and urology patients (Fig. 1). Over year 2, the LOS for colorectal cases, although significantly decreased from baseline, gained a day and a half and costs started to climb (Fig. 2). More apparent was the increase in LOS and VDCs for urosurgical cases (Fig. 2) The root cause analysis resulted in five predominant factors pointing to the diminished success:

1. A decline in leadership from the initial start-up team 2. Waning of communication and engagement of the multidisciplinary team 3. Lack of process auditing 4. Inherent turnover of nursing creating a lack of consistency 5. The heuristic and cognitive biases of program providers affecting their judgment and long-

term acceptance of the evidence based practices of ERAS Conclusions Compliance within Enhanced Recovery programs is not well documented in professional healthcare literature. The lack of data and information may well be because the program demonstrates initial success; but often, a report of a back slide in data may be interpreted as

1U.O.Gustafsson,M.J.Scott,W.Schwenk,N.Demartines,D.Roulin,N.Francis,etal.Guidelinesforperioperativecareinelectivecolonicsurgery:enhancedrecoveryaftersurgery(ERAS®)societyrecommendationsWorldJ.Surg.,Volume37,2012,pp.259–284,doi:10.1007/s00268-012-1772-0

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program failure. As part of the ER initiatives in this country, an emphasis in the sustainability and long-term compliance should be addressed. The beginning stages of the program development should include a framework to prevent the previously mentioned issues. Suggested interventions to improve compliance within an existing program include the utilization of software and APPS for auditing providers and tracking the surgical patient, development of provider education and team engagement strategies, as well as strengthening of administrative support for the ER coordinator/navigator. The cost-prohibitive nature of these interventions may prevent early adoption by hospital organizations even though the potential return on investment exists. Business plans for ER programs should address these needs for longevity as well as a detailed, comprehensive picture regarding the loss in savings as compliance drops off year to year. The hospital multi-disciplinary team has a responsibility to create a program with these issues in mind to ensure the long-term sustainability of ER initiatives.

Figure 1. Enhanced Recovery Outcomes for Colorectal Surgery in 2015 and 2016

Figure 2. Enhanced Recovery Outcomes for Urosurgery in 2015 and 2016

Avg.perpatient Stddev #Discharges AVG. Stddev #Discharges AVG. Stddev #Discharges

LengthofStay 11.13 7.69 159 5.14 3.68 66 6.2 4.45 69

Avg.PerPatient Stddev #Discharges AVG. Stddev #Discharges AVG. Stddev #Discharges

$10,729 $8,590 159 $6,261 $2,951 66 $7,087 $4,780 69

Improvement2016

VariableDirectCost

Baseline2014 Improvement2015

Avg.perpatient Stddev #Discharges AVG. Stddev #Discharges AVG. Stddev #Discharges

LengthofStay 6.37 4.37 47 3 0.55 14 5.44 5.84 34

Avg.PerPatient Stddev #Discharges AVG. Stddev #Discharges AVG. Stddev #Discharges

$6,464 $3,038 47 $4,850 $1,850 14 $6,656 $5,565 34

Baseline2014 Improvement2015 Improvement2016

VariableDirectCost

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Immunonutrition within enhanced recovery after surgery (eras): an unresolved matter

Authors: Ruchir Gupta, MD1, Anthony Senagore, MD, MS, MBA2

1Stony Brook School of Medicine 2University of Texas Medical Branch Although there is clear evidence that sarcopenia, malnutrition, and a high arginase activity state in isolation or in combination contribute to adverse surgical outcomes, the precise combination of nutrients remains unclear. A further challenge of the extant literature is that the majority of assessed studies had small sample size (<100) and no current study has used current markers of these nutritionally impaired states. A second area of concern is the wide mix of surgical pathology and procedures with distinct risks and associated comordibities grouped into these large metaanalyses. The assumption that the nutritional needs and catabolic state are the same for these very different clinical scenarios is a major gap in current knowledge. Finally, most of the recommended nutritional formulas contain arginine, omega-3 fatty acids, carbohydrate/protein ratios, and glutamine all of which have been associated with neutral to negative outcomes in large randomized trials in critically ill patients. Thus, the issue of how best to implement immunonutrition within an ERAS framework remains unresolved. Future research into this area should look to group patients based on preoperative risk adjustment using both image guided assessment of sarcopenia and biomarker assessment of the nutritional and inflammatory state of populations of patients. Likely candidates are CT measured sarcopenia scores, ultrasound assessment of rectus femoris, nutritional metabolic scores, systemic methylarginines, ornifine:citrulline ratio, and proline:citrulline ratio across the perioperative period in patients undergoing colorectal surgery within an ERP program with a robust historical data set of specific outcomes. References 1. Braga M, Wischmeyer PE, Drover J, Heyland DK. Clinical evidence for pharmaconutrition in major elective surgery. JPEN J Parenter Enteral Nutr. 2013 Sep;37(5 Suppl):66S-72S 2. Hegazi RA, Hustead DS, Evans DC Preoperative standard oral nutrition supplements vs immunonutrition: results of a systematic review and meta-analysis. J Am Coll Surg. 2014 Nov;219(5):1078-87 3. Moya P, Soriano-Irigaray L, Ramirez JM, Garcea A, Blasco O, Blanco FJ, Brugiotti C, Miranda E, Arroyo A. Perioperative Standard Oral Nutrition Supplements Versus Immunonutrition in Patients Undergoing Colorectal Resection in an Enhanced Recovery (ERAS) Protocol: A Multicenter Randomized Clinical Trial (SONVI Study). Medicine (Baltimore). 2016 May;95(21): 4. . Martin JM1, Stapleton RD. Omega-3 fatty acids in critical illness. Nutr Rev. 2010 Sep;68(9):531-41 5 Andrews PJ, Avenell A, Noble DW, Campbell MK, Croal BL, Simpson WG, Vale LD, Battison CG, Jenkinson DJ, Cook JA; Scottish Intensive

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care Glutamine or seleNium Evaluative Trial Trials Group. Randomised trial of glutamine, selenium, or both, to supplement parenteral nutrition for critically illpatients.BMJ. 2011 Mar 17;342 6. Heyland D1, Muscedere J, Wischmeyer PE, Cook D, Jones G, Albert M, Elke G, Berger MM, Day AG; Canadian Critical Care Trials Group. A randomized trial of glutamine and antioxidants in critically ill patients. N Engl J Med. 2013 Apr 18;368(16):1489-97 7.Dioguardi FS1. To give or not to give? Lessons from the arginine paradox. J Nutrigenet Nutrigenomics. 2011;4(2):90-8 8. trition and Elective Colorectal Resection Outcomes. Dis Colon Rectum. 2017 Jan;60 9. Vandewoude MF1, Alish CJ, Sauer AC, Hegazi RA. Malnutrition-sarcopenia syndrome: is this the future of nutrition screening and assessment for older adults? J Aging Res. 2012;2012 A. J. Cruz-Jentoft, J. P. Baeyens, J. M. Bauer et al., “Sarcopenia: European consensus on definition and diagnosis,” Age and Ageing, vol. 39, no. 4, pp. 412–423, 2010 10. A. J. Cruz-Jentoft, J. P. Baeyens, J. M. Bauer et al., “Sarcopenia: European consensus on definition and diagnosis,” Age and Ageing, vol. 39, no. 4, pp. 412–423, 2010

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