Edwards Enhanced Surgical Recovery

ESR = 4 phases to implement the enhanced surgical recovery

WHY an ESR program

“No monitoring device no matter how accurate or insightful will

improve outcome unless its is coupled to a treatment which

itself improves outcome”

Michael Pinsky

ESR Program

Phase 1 Phase 2 Phase 3 Phase 4

Select Surgical

Procedures

Build core team Train and develop

competencies

Analyze morbidity rates

and / or length of

hospital stay

Assess current

morbidity rate and / or

length of hospital stay

Choose PGDT treatment

protocol

Establish PGDT as a

new SOP and add to

checklist

Measure clinical and

economic outcome

benefit

Estimate the potential

clinical and economic

benefits of PGDT

Choose a hemodynamic

monitoring platform

Quantify and track

compliance

Publish your results both

internally and / or

externally

Assess Align Apply Measure

3

Owner and tools Steps

Clinical champion Review applicable procedure list

Consider extending PGDT to other medium or high risk

procedures

Review where other institutions have applied PGDT

ASSESS

Patient risk assessment can be based on ASA score,

PPOSUM score, or other surgical score tools.

ASSESS

High Risk

Patients who are “expected” to develop significant complications

At Risk

Patients who “could” develop complications

Of note

Consider applying PGDT for ASA risk score of 2b

+ 1 comorbidity or higher

Applicable Procedures List Sample Procedure Lists

ASSESS

Tools

Owner and tools Steps

Clinical champion

and/or quality person

Identify a reliable data source for hospital metrics

Understand the available data reporting capabilities

ASSESS

Specifying the types of complications to measure before and after

PGDT implementation can help to ensure a direct comparison.

ASSESS

Key metrics

Morbidity

Length of stay

Variable cost per case

Other metrics to consider tracking

Mortality

30-day readmission rate

Patient satisfaction score

Return on investment

ASSESS

Consider if the hospital tracks and can report on the following measures:

Post-Op Mechanical Ventilation > 24h Renal failure requiring dialysis

Hypotension requiring pharmacological treatment Upper gastro-intestinal bleed

Cardiac arrhythmia requiring pharmacological treatment Anastomotic leak (GI surgery)

Wound infection Paralytic ileus

Abdominal infection (GI surgery) Length of stay

Urinary tract infection ICU Admission

Bacterial pneumonia Duration of ICU stay (if ICU admission)

Deep Vein Thrombosis (DVT) Post-operative mechanical ventilation

Pulmonary embolism Lactate at end of surgery or at ICU admission

Pulmonary edema Maximum ICU lactate

Myocardial infarction Re-intervention

Cardiac arrest (exclusive of fatal outcome) Maximum ICU Sequential Organ Failure Assessment (SOFA) score

(or any other organ failure score)

Postoperative delirium Cumulative ICU Therapeutic Intervention Scoring System (TISS)

score (or any other resource utilization score)

Stroke

Hospital Data Form

ASSESS

Tools

Owner and tools Steps

Clinical champion

and/or quality person

Inputs hospital data into Benefit Estimator to calculate

potential improvement in clinical and economic outcomes

based on results from published literature

ASSESS

PGDT Benefits Estimator Business Case Template

ASSESS

Tools

PGDT Literature

ESR Program

Phase 1 Phase 2 Phase 3 Phase 4)

Select Surgical

Procedures

Build core team Train and develop

competencies

Analyze morbidity rates

and / or length of

hospital stay

Assess current morbidity

rate and / or length of

hospital stay

Choose PGDT

treatment protocol

Establish PGDT as a

new SOP and add to

checklist

Measure clinical and

economic outcome

benefit

Estimate the potential

clinical and economic

benefits of PGDT

Choose a

hemodynamic

monitoring platform

Quantify and track

compliance

Publish your results both

internally and / or

externally

Assess Align Apply Measure

16

Owner and tools Steps

Clinical champion Builds a cross-functional, action-oriented team

Team members should be chosen on their abilities to

support the projects needs

Complete the Project Charter helping to define the

program goals

ALIGN

Hemodynamic Optimization through

Perioperative Goal-Directed Therapy

Why and How?

Dr X

Hospital Y

Owner and tools Steps

Clinical champion or

clinical leads

Review protocol summaries which have demonstrated

benefit

Discussion amongst the core team to decide

Possibility to compare with other institutions

ALIGN

ALIGN

Protocol workflow

ALIGN

Owner and tools Steps

Clinical champion

and/or clinical lead

Base monitoring platform designation on patient risk profile

A-line based monitoring can be utilized when arterial line

placement is necessary

Non-invasive monitoring can be used when no arterial line

is needed

Make sure you are aligned

ESR Program

Phase 1 Phase 2 Phase 3 Phase 4

Select Surgical

Procedures

Build core team Train and develop

competencies

Analyze morbidity rates

and / or length of

hospital stay

Assess current morbidity

rate and / or length of

hospital stay

Choose PGDT treatment

protocol

Establish PGDT as a

new SOP and add to

checklist

Measure clinical and

economic outcome

benefit

Estimate the potential

clinical and economic

benefits of PGDT

Choose a hemodynamic

monitoring platform

Quantify and track

compliance

Publish your results both

internally and / or

externally

Assess Align Apply Measure

APPLY

Owner and tools Steps

Clinical champion or

clinical leads

Initial Team Meeting – reveal ‘The Plan’

Training – protocol / compliance / device

Reconnaissance visit to the OR

END OF SURGERY

VASOPRESSORS / INOTROPS RECORDED

ON FORM

ADDITIONAL FLUIDS RECORDED

ALL EVENTS RECORDED DOWNLOAD EV1000 DATA

TO USB STICK

BEFORE INDUCTION

PATIENT DATA ENTERED IN EV1000

USB STICK INSERTED INTO EV1000

ZERO FLOTRAC / MONITOR

CROSS CHECK DATE/TIME ON EV1000

BEFORE PATIENT ARRIVES

ADDITIONAL INFUSION PUMP

FLOTRAC TRANSDUCER

ADD PARAMETERS TO ANESTHETIC

RECORD

EV1000 STAND / DATA BOX / CABLES

50ML LEURLOCK SYRINGE

APPLY

Compliance depends on:

1. Understand the ‘how’ of

compliance

2. Follow the protocol

completely

3. Record ‘what they did’

accurately

APPLY

PHASE 1 only begins when first ABG taken and first skin incision

PHASE 1 - Climbing phase

• EV1000 data entered

• CHECK EV1000 DATE / TIME CORRECTED – USE EV1000 TIME THROUGHOUT OPTIMISATION

• FLOTRAC sensor zero / level

• Insert EV1000 memory stick

• Baseline SV / SBP / DBP / MAP values and time recorded

• CLIMBING:

– 1st COLLOID BOLUS (ALWAYS 250 ml x Tetraspan)

– Increase in SV > 10%

• YES – 2nd COLLOID BOLUS

• NO – MONITOR SV (NOTE THIS AS TRIGGER VALUE ON FORM)

– Increase < 10%

• YES – MONITOR SV

• NO – go back to a)

APPLYCompliance SOP Example

PHASE 2 - Cruising phase

• Monitor SV

• If SV < TRIGGER

– 1st COLLOID BOLUS (ALWAYS 250 ml x Tetraspan)

– Increase in SV > 10%

• YES – 2nd COLLOID BOLUS

• NO – MONITOR SV

– Increase < 10%

• YES – MONITOR SV

• NO – go back to a)

APPLYCompliance SOP Example

Intervention AnalysisEV1000

Intervention AnalysisEV1000

Intervention AnalysisTrack % Change

Apply successful recipe!

ESR Program

Phase 1 Phase 2 Phase 3 Phase 4

Select Surgical

Procedures

Build core team Train and develop

competencies

Analyze morbidity

rates and / or length of

hospital stay

Assess current morbidity

rate and / or length of

hospital stay

Choose PGDT treatment

protocol

Establish PGDT as a

new SOP and add to

checklist

Measure clinical and

economic outcome

benefit

Estimate the potential

clinical and economic

benefits of PGDT

Choose a hemodynamic

monitoring platform

Quantify and track

compliance

Publish results

internally and / or

externally

Assess Align Apply Measure

Measuring results…

ESR Program Status

ASSESS ALIGN APPLY MEASURE

Number of

Hospitals84 56 40 6

Countries

Main surgery type COLON

Driven by Anaesthetist (primarely) & Surgeon

Number of patients 100

Protocol used SVV

Results / experience so far Very positive feedback from both anesthetist

and surgeon

Next steps Measure complication rate after one year with

protocol

Some examplesGermany: Eberswalde

Some examplesItaly: Ospedale Molinette, Torino

Main surgery type UPPER GI (Pancreatectomy-Gastrectomy)

Driven by 2 Anesthetists + OR nurses + surgical team

Protocol used Kuper (NICE)

Results / experience so

far

- Changes behavior in fluid mangement

- Less or more fluids but in different timing

- Patient’s outcome seems better

Next steps - Goal :100 patients and check (B/A)

-Extend to different patient population (Kidney)

-Peer to Peer education

Main surgery type VASCULAR (AAA; ThAAA; Leriche; P-

POSSUM>5% ; ASA IV)

Driven by Surgeon + chief of Anaesthesia + 3

anaestetists

Protocol used PUVAS protocol (Pomeranian University

VAScular)

Technology Used Non Invasive- Avoiding Arterial line

Results / experience so far - Reduction in complication ratio, cost of

treatment and LOS

Next steps - Goal :240 patients and check (B/A)

- Publish on complications & costs

Some examplesPoland: Szczecin

ESR Program Key Learnings

Right patient population

Motivatedchampion /

team

Keep it simpleStart small

(1 procedure)

ASK for support

Others may have done it before !

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precautions and adverse events.

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