P067: CREATING AN ENHANCED RECOVERY AFTER CARDIAC SURGERY MULTIDISCIPLINARY TEAM PROCESS: IS IT A VALUE ADD IN THE COMMUNITY HOSPITAL SETTING (CHS)?
George Semien, MD; Robert Brooker, MD; Giselle Helo, MD; Amy Pulido, MD; Adam Blomberg, MD; Joshua Bloomstone, MD; Envision Physician Services
Introduction: The concept of ERAS was first described in 1997(1).Most evidence supporting ERAS is based on studies for colorectal surgery. Additionally most published data on ERAS pathways has been increasingly adopted in other surgical procedures.There is however a paucity of data on the use of ERAS in cardiac surgery. Fleming et.al (2016) demonstrated through a pilot study that ERACS is feasible and has the potential for reduced postoperative morbidity after cardiac surgery.(2)“A recently published trial examined 226 patients undergoing elective valvular cardiac surgery that were prospectively randomized to either an ERAS pathway of care or routine care (control group).They demonstrated that patients managed within their ERAS protocol had a reduced length of ICU and hospital stay, fewer complications, and with lower cost.”(3,4).This paper serves to describe a guideline implementation for an ERAS pathway for cardiac surgery in the (CHS) based on current supporting evidence and describe outcome improvement/value add, if any. Using the process below, we implemented an ERACS pathway in a 224 bed CHS with a cardiac program.
Background: We are in the midst of a revolution in healthcare. Market forces, which include the patient and the payer, (patient, government, insurers, employers) have positioned the provider to deliver care that is superior in quality, satisfaction, and affordabilty. (3) Heart disease continues to lead the top 10 causes of death in the US. (4) The top 10 causes of mortality also represent most of the 80% of expenditures of disease burden in health care. The time is now to focus on an enhanced recovery pathway for cardiac surgery with the goals of improved quality (reduction in morbidity and mortality), cost reduction, and re-appropriation of resources with the overarching goal of optimized valued care. The compounded gains achieved per case would logically be forecasted to grow over time with implementation.
Methods: Recognize that implementing a care pathway is a challenging and rewarding process that requires supportive evidence, resource and change management, and most importantly: the team of critical stakeholders. Below is a list of suggested key components for implementing such a care pathway. 1.Create an ERACS team consisting of key stakeholders in the cardiac surgery process including surgeons, intensivists, administration, nursing, pharmacy, nutritionists, perfusion and anesthesia staff. 2.Create a documentation process to identify and follow the care of patients entered into the ERACS pathway 3.Enlist allied health and hospital quality administrative staff to collect and track data related to care and effectiveness of the ERACS process 4.Create a periodic meeting of the key stakeholders to reassess the program and make adjustments as needed.
Results: Comparing 76 CABG patients in Q1,2,3 2018 vs same quarters 2017.(NS) There was a reduction in mortality post ERACS based on STS data.
Conclusion: Implementation of an ERACS pathway in the CHS has potentially magnified gains as these patients require less narcotic, blood products, ICU LOS, and mortality. Aside the value gain in survival - in an era where profit margins are slim these gains allow reallocation of precious resources critically needed in CHS.