Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Vijaya Gottumukkala
M.B;B.S, M.D (Anes), F.R.C.A
Professor
Deputy Chairman & Clinical Director
Director, Cancer Anesthesia Fellowship Program
Department of Anesthesiology & Perioperative Medicine
The University of Texas MD Anderson Cancer Center
Houston- Texas
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
DISCLAIMER
• Not a psychiatrist
• Not a psychologist
• Not a marriage counsellor
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
www.lattitudesafety.co.uk
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Catherinescareercorner.com
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Common
Goals
Radharenu.hubpages.com
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Dept. of Anesthesiology & PeriOp Med
The mission of the Department of Anesthesiology &
PeriOperative Medicine at The University of Texas
MD Anderson Cancer Center is to provide patient
centered, team based, high value care aimed at
improving oncologic outcomes by enhancing
functional recovery and reducing symptom burden
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Mission statement for MDA ESRP initiative
Develop procedure specific- patient centered
perioperative care pathways to minimize symptom
burden, enhance functional recovery, improve
outcomes and enable delivery of safe, effective, and
value-based cancer care to an increasing number of
patients.
Our strategic focus areas
Our culture, values, innovation, education, quality and safety are integrated through the focus areas
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Environment
Radharenu.hubpages.com
Enhanced Surgical Recovery Program
The MDACC Initiative
Team
Title
Anesthesiology Lead
Surgery Lead
Co-Lead
ERLS
Enhanced RecoveryLiver Surgery
Vijaya Gottumukkala
Thomas Aloia
Keyuri Popat
ERTS
Enhanced RecoveryThoracic Surgery
Gabriel Mena
David Rice
Reza Mehran
ERGS
Enhanced RecoveryGynecologic Surgery
Javier Lasala
Pedro Ramirez
Alpa Nick/Larissa
Meyer
ECORS
Enhanced RecoveryColo-rectal Surgery
Bryce Speer
Miguel Rodriguel-Bigas
Brian Bednarski/Craig
Messick
ERBS
(OSJ)
Enhanced RecoveryBladder Surgery
Juan Cata
Jay Shah
Gabriel Mena
ERSS
Enhanced RecoverySpine Surgery
Keyuri Popat
Claudio Tatsui/
Lawrence Rhines
Justin Bird/Roxana
Grasu
ERHS
Enhanced RecoveryHIPEC Surgery
Pascal Owusu-Agyemang
Keith Fournier
Andrea Hayes-Jordan
ERPls
Enhanced RecoveryPlastic &
Reconstructive
Surgery
Bryce Speer/Gabriel Mena
Jessie Selber
Patrick Garvey
PROJECT CONSULTANT: JOHN CALHOUN, ICCI
MDA ESRP- Beginnings 2012
Enhanced Recovery In Liver Surgery
Program developed in ERILS
Expanded to surgical practice at MDA
MDACC ESRP Teams – 2012 to 2016
H&N
Surgery
HIPEC
Surgery
Breast
Surgery
Liver
Surgery
Anesthesia
Bladder
Surgery
Surgery
Colorectal
Surgery
Neuro
Surgery
Nursing
Spine
Surgery
GYN
Surgery
Thoracic
Surgery
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Training
Radharenu.hubpages.com
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Fearon KCH, et al. Clinical Nutrition 2005; 24: 466-477
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
ESRP
•
•
•
•
Not a technique
Philosophy of care
Perioperative continuum
Multidisciplinary
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
MDACC Enhanced Recovery Pathway
• Patient and care-giver education
and engagement
• Procedure specific opioid sparing
analgesia strategies
• Minimize oxygen debt (fluids
therapy-hemodynamic
optimization-blood management)
• Early ambulation, return of GI
function and enteral nutrition
• Early diagnosis and rapid
response to manage postop
complications
FUNCTIONAL AND DISABILITY FREE
SURVIVAL
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
faithatthebeach.com
PATIENT EDUCATION, ENGAGEMENT AND EMPOWERMENT
Enhanced Recovery Pathway
Intraoperative Opioid Sparing Strategies
Dexmedetomidine
Wound Infiltration
X
TAP Block
Ketamine Or N2O
XX
Lidocaine infusion
PVB
PIC Block
x
Epidural
IV Acetaminophen
MDACC Enhanced Recovery Pathway
Preoperative Maneuvers
• Clear liquids up to 2 hours prior to reporting for surgery
• Preventive analgesia
Tramadol ER
Oral Acetaminophen
X
Pregabalin/Gabapentin
X
Celecoxib
Image modified from aafp.org
ANESTHESIOLOGY 2015; 123:307-19
Anesthesiology 2015; 123:00-85
MAINTAINING TISSUE PERFUSION
AVOIDING OXYGEN DEBT
AVOIDING DEEP ANESTHESIA
PERIOPERATIVE CARE OF THE CANCER PATIENT
IMPROVING ONCOLOGICAL OUTCOMES-OUR VISION AT MDACC
Immediate Postoperative care: PACU and POD 0
Rapid Emergence from Anesthesia
Dynamic Pain Control
Opioid Sparing Strategies
PERIOPERATIVE CARE OF THE CANCER PATIENT
IMPROVING ONCOLOGICAL OUTCOMES-OUR VISION AT MDACC
Postoperative Care In The Hospital
“ Get Back on Track “
Dynamic Pain Control
Ambulation
Opioids: Good, Bad and The Ugly
Pulmonary Rehab
Optimal Fluid Therapy
Balanced Enteral Diet
PERIOPERATIVE CARE OF THE CANCER PATIENT
IMPROVING ONCOLOGICAL OUTCOMES-OUR VISION AT MDACC
Postoperative Complications are
expensive
Need Rapid Diagnosis, Response And
Rescue
PERIOPERATIVE CARE OF THE CANCER PATIENT
IMPROVING ONCOLOGICAL OUTCOMES-OUR VISION AT MDACC
Discharge Planning and Post discharge Care
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Challenges
Radharenu.hubpages.com
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Typical Barriers to change
• Lack of evidence
• Poor understanding of change
• Funding issues
• Lack of focus
• Poor leadership
• Successes not recognized
• Lack of interest
• Progress not measured
• Complexity
• Politics
• Numerous parallel initiatives
• Organizational culture
• Absence of motivators
• Tradition
• Tradition/Resistance to change
• Duplication of effort
• Inability to integrate across
• Undeveloped strategy
• Lack of project management
• Poor execution
John D. Calhoun of MD Anderson Cancer Center
Institute for Cancer Care innovation
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
People don't resist
change. They resist
being changed
-Peter Senge
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Resistance to change
•
•
•
•
•
•
•
Lack of trust
Threat to individualism, personal value or role
Paranoia of interference
Change not necessary or possible
Change is expensive
Fear of failure
Comfort in status-quo
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
www.managementstudyguide.com
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Include in the team
Communicate
often
Communicate
often
Skeptics
Adapters
Keep them
engaged and
Keep them engaged
involved
Enthusiasts
Pragmatists
[email protected]
Adapted from ianjseath.wordpress.com
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
planzsolutions.com
Understanding Process- Measuring
Outcomes
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
windsonline.com
Stoplight Status Chart – All Teams
Project Phases
Team
Define Implement Measure Analyze Optimize
General Status
ERLS
Holding to single surgeon until epidural
study complete. RCT in planning stages
ERTS
Initial data with PICB published. RCT in
planning stages
Continuing good progress with patients on
pathway (over 550). MIS project to start
soon
RCT to start soon
ERGYN
ERCS
ERHS
ERSS
ERBS
Neuro
PRS
Breast
4/1/15
6/1/15
N/A
Continuing to see initial patients with
primary focus on anesthetic technique
Outstanding results. Evaluating cost of care
In progress
In progress
In progress
Our strategic focus areas
Our culture, values, innovation, education, quality and safety are integrated through the focus areas
MDACC Enhanced Surgical Recovery Measures of
Performance
Patient Reported Outcomes
Frequency/Definition
Procedure specific perioperative symptom
burden: MDASI (MDA Symptom Inventory)
(symptom burden and functional interference)
(validated 13 core items, plus 6 procedure
specific module items) Pre-op; Daily until
discharge; Weekly for up to 3 months
postop
Return to baseline functional status
Days from surgery to return to baseline
functional status
Clinical Outcomes
Frequency/Definition
Post operative complications
Count, frequency, grade
Medical readiness for discharge (MRD) and
Return to Intended oncological therapy
(RIOT)
Days from surgery to MRD and RIOT
All Readmissions
30, 60 and 90 Day
Business Outcomes
Frequency/Definition
Length of hospital stay
Days from surgery to discharge
Episode or total TDABC cost for patient
Total true MDACC costs / total patient costs
Modified from John Calhoun- ICCI, MDACC
7.1d
5.1d
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
CHANGE IS
HARD AT THE BEGINNING
MESSY IN THE MIDDLE
GORGEOUS AT THE END
Marlosneoldeous.com
Leadership matters
• Leading from the top (authority)
- Priority to strategy, then Interactions, then execution
• Leading from the middle (influence)
- Priority to interactions, then strategy, then execution
• Leading from the line (action)
- Priority to execution, then interactions, then strategy.
At MDACC we are working from the middle and the line
John D. Calhoun of MD Anderson Cancer Center
Institute for Cancer Care innovation
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Dare2compete.com
ESRP Implementation at MDACC
Collaboration as cornerstone of the program
PERIOPERATIVE CARE OF THE CANCER PATIENT
IMPROVING ONCOLOGICAL OUTCOMES-OUR VISION AT MDACC
Setting up an Enhanced Recovery Program
Elements, Buy-in, Hurdles, and Conflict Resolution
Thanks you for your attention
[email protected]