Canadians recovering from surgery are leaving hospitals sooner with improved outcomes thanks to a growing push to implement Enhanced Recovery After Surgery (ERAS) – evidence-based protocols that require compliance by both clinicians and patients.
Provincial results are so encouraging, proponents are now pushing for a national network so that tools and best practices for implementing ERAS can be more widely disseminated.
“We have to change the culture,” says Dr. Claude Laflamme, Medical Director of Quality and Patient Safety in the Department of Anesthesia at Toronto’s Sunnybrook Health Sciences Centre. “People think if I have an operation tomorrow I cannot eat or drink after midnight because that’s what we’ve been saying for years. But the guidelines have changed,” he says.
The movement is based on ideas initially put forth in the 1990s and in its simplest form aims to change tradition to best practice. Though it started with a set of guidelines directed at colorectal surgery, it is now being applied across several disciplines, thanks in part to the work of the international ERAS Society and its many national arms, including Canada.
As Chair of the Canadian Anesthesiologists’ Society (CAS) Patient Safety Committee, Dr. Laflamme is currently working with key clinical leaders and associations to enhance the adoption of ERAS across Canada and build on early successes in Quebec, Ontario, B.C. and Alberta.
“Basically what we’re creating at the Canadian Patient Safety Institute (CPSI) is a network for dissemination of knowledge and implementation tools. As well, we’re working to find an audit system that will allow us to measure the impact of ERAS,” he explains. “We call it ERAS for all Canadians.”
In simple terms, ERAS introduces new ways of managing care before, during and after surgery that have been shown to help patients heal and get back to normal everyday functions as soon as possible. Following ERAS protocols also helps to standardize processes related to surgical care so that everyone is working from the same information, from surgeons, nurses and anesthesiologists to dietitians, administrators and patients themselves.
Implementing ERAS requires significant cultural change because many of the protocols – also referred to as guidelines, pathways or care processes – turn convention on its head.
For example, instead of fasting, patients are allowed to drink up to two hours before their procedure and in some cases, special carbohydrate-loaded liquids are prescribed; they are also encouraged to get up and walk, and return to solid foods sooner. The number and complexity of protocols per surgery depends on the procedure and can include everything from fluid and pain management to whether or not to use a Foley catheter. Patient education is always the starting point.
“The ultimate goal is to speed up patient recovery by minimizing complications. By doing these steps you lower the risk of complication for your patients and then they can heal faster,” sums up Angie Chan, former Project Manager, Surgical Improvement, for B.C.’s Specialist Services Committee (SSC).
From November 2014 to January 2016, 11 surgical sites across B.C. worked together as the B.C. Enhanced Recovery Collaborative to implement ERAS evidence-based pathways. Their approach focused on quality improvement and involved careful monitoring of every elective colorectal surgery to measure compliance with 22 protocols, from pre-admission counselling to post-op care.
According to the final report, from January to December 2015 the complication rate fell from 32 per cent to 22 per cent and hospital length of stay fell from seven days to five. Since then, the number of B.C. hospitals participating in ERAS has grown to 22 and pathways are being applied to additional areas, such as breast reconstruction, urology and vascular surgeries.
Data collection and auditing is vital to an ERAS implementation, explains Chan. The majority of larger sites in B.C. use the National Surgical Quality Improvement Program (NSQIP) software from the American College of Surgeons to collect process and outcome data, while smaller sites rely on Microsoft Excel spreadsheets.
When the colorectal ERAS pilot ended and SSC provided a bridge fund to support ongoing implementation efforts, 20 of the 22 sites asked for data support. “Data is an important engagement tool, especially when we see results,” she said.
Vancouver General Hospital was one of the first in B.C. to introduce ERAS as a quality improvement project and now monitors as many as 50 process-measures for colorectal, radical cystectomy, gynecology/oncology and major hepatobiliary oncology surgeries.
In addition to using NSQIP, it developed its own database and document management system to facilitate data collection, adding an extra level of detail in many cases in order to gather a more robust set of data.
Whereas the standard data definition related to giving solid food to a patient simply measures whether or not it was given, for example, Vancouver General records whether or not the food was consumed. Similarly, when looking at “goal-directed fluid therapy” as an ERAS step, the hospital records which monitor was used and the exact amount of fluid delivered.
“Some of the definitions around these things have been a little bit loose, not only within NSQIP but even within the ERAS Society,” says Vancouver General Anesthesiologist Dr. Kelly Mayson, noting that the overall goal is to make information much clearer. “If you’re trying to move change along, and you want to see if there’s increased compliance or if certain patients are doing better than others, then you need to know exactly what combination of drugs and fluids they actually got.”
For the moment, data collection remains a manual process at Vancouver General, relying on nurses or administrators to pull data from patient charts and enter it into the ERAS database manually. Patients have a checklist at bedside to track their post-op activity and that information is updated to the patient chart by nurses. If any variances from what is directed in the protocol are detected, they are investigated immediately. Reports are also generated to keep clinicians informed about outcomes as well as compliance.
“On a monthly basis we can go back to the surgeons and say out of all the process measures we have, here’s where we’re at with compliance,” says Andrea Bisaillon, Operations Director at Vancouver General Hospital. “The data is the proof in the pudding around whether you’re actually doing it or not.”
“You can’t do the quality improvement without the data,” notes Chan. “If you don’t know how your changes are materializing, it’s impossible to identify the areas where you need to improve.”
Since implementing ERAS for colorectal surgeries, Vancouver General Hospital has reduced length of stay by two days and reduced most complications by 15.5 per cent. “In a 28-month period, that’s about 57 cases that didn’t end up with pneumonia, a urinary tract infection or surgical site infection. Those are big opportunities and changes,” says Bisaillon.
Alberta Health Services (AHS) is reporting similar success from its ERAS strategy. From August 2013 to May 2014, six sites implemented ERAS for colorectal surgery. Not only did patients report that they felt better sooner, but the average length of stay in hospital was also decreased by more than three days and the province calculated that for every dollar invested in ERAS implementation, approximately three dollars were saved.
“ERAS is an opportunity to transform surgical care,” says Tracy Wasylak, Senior Program Officer, Strategic Clinical Networks, at AHS. “Our vision is to be able to offer ERAS protocols and principles to anybody who’s having surgery.”
AHS is currently implementing ERAS for colorectal surgery at three additional sites, bringing the total to nine. It has also received a Partnership for Research and Innovation in Health Systems (PRIHS) research grant from Alberta Innovates to investigate the benefit of implementing more than one set of protocols simultaneously. Right now, the province is working to introduce ERAS pathways for gynecology/oncology, major head and neck, breast reconstruction and pancreatic cystectomy surgeries at the province’s two major tertiary academic teaching centres.
Alberta is the first Canadian province to use the ERAS Interactive Audit System (EIAS), a web-based interactive software tool to facilitate implementation and monitor compliance with evidence-based protocols. EIAS was developed by Encare AB of Stockholm, Sweden, a company established in 2009 to facilitate implementation of ERAS protocols on a global basis.
“We want clinicians to get meaningful real-time data to drive their practice because that’s what we believe helps with compliance,” says Wasylak, noting that AHS compares EIAS data to its discharge abstract database to get a clearer picture of outcomes. When clinicians open the EIAS dashboard, they see information recorded for each component of an ERAS protocol, such as when patients were admitted, what surgery they had, what was done pre-operatively, how much fluid they were given in the operating room, how many opioids they received or when they walked.
“The golden rule is we should be doing the same thing 80 percent of the time and allowing for variation where it makes sense,” she says.
Alberta is also working to develop a patient smartphone app to replace the log book currently used to record patient post-op steps and experiences, and is taking a lead position to develop new ERAS protocols, including the guidelines for Gynecologic/Oncology Surgery which were led by Dr. Gregg Nelson, Chair of the Provincial Gynecologic Oncology Tumour Team. This past January, Dr. Nelson was appointed Secretary of the international ERAS Society’s Executive Committee.
“Canada is a leader in moving this model forward,” says Joshua Liu, CEO of Toronto-based SeamlessMD, a company designing software that enables hospitals to launch, optimize and expand integrated care pathways for surgery, including ERAS. “We’re one of the partners of healthcare organizations who are writing this new narrative around, ‘How do you take what we’ve done manually for 20 years and make it digital and more efficient,’” says Liu.
The Seamless MD cloud-based solution is a good fit for ERAS, he adds, because it can be used as a platform to improve patient adherence to protocols and automate data collection. Hospitals can choose from the company’s existing ERAS templates or design their own pathways.
“We guide the patient on their smartphone, tablet or desktop computer through the entire pathway so they get reminders about what they do and when, they can track their progress, record their symptoms and issues, and get feedback along the way,” explains Liu. The software engages patients from pre-operative preparation through their hospital stay to their at-home recovery, allowing them to check off milestones as they complete them.
In 2015, SeamlessMD partnered with McGill University Health Centre to study SeamlessMD’s effectiveness as a patient app to improve adherence and data collection for patient-focused ERAS protocols. The app was given to 45 patients undergoing colorectal surgery and 89 per cent said it helped them to achieve their daily recovery goals.
An added advantage is the SeamlessMD will alert clinicians if a patient falls off track. “Let’s say the patient is now going home a day earlier than they used to. As long as they’re checking in with our solution and recording their progress, the team knows whether things are going well or not,” says Liu. “I think what you’re going to see within the next five years is people won’t be calling it ERAS anymore because it’s going to become standard care paths. It’s just going to be what you do.”
In January 2017, the AHS’s Surgery Strategic Clinical Network hosted a symposium to facilitate local, national and international ERAS best practices. Information sharing was key as participants also examined ways to further enhance ERAS adoption across Canada, including the development of a pan-Canadian network.
“Every centre is agreeable we should all share,” says Dr. Laflamme. “Right now we are talking about enhancing recovery, but we want this to be the standard of care.”