ERAS

Question 1

What is the complication rate in GI cancer surgeries?

Answer 1

21-45% (highest in esophagus); 1-4% death (highest in liver)

Question 2

What 5 aspects do patients consider important in post-operative recovery?

Answer 2

o	Returning to habits and routine
o	Regaining independence
o	Overcoming mental strains
o	Resolution of symptoms (pain, N/V)
o	Enjoying life

Question 3

What percentage of patients are not back to their baseline grip strength 6 months post- abdominal surgery?

Answer 3

52%

Question 4

What percentage of patients are not back to their baseline timed walk 6 months post- abdominal surgery?

Answer 4

39%

Question 5

What percentage of patients are not back to their baseline ADL and IADLs 6 months post- abdominal surgery?

Answer 5

9% and 19%, respectively

Question 6

Name 5 risk factors for poor recovery

Answer 6

o	Serious complications
o	Physical status at baseline
o	Cognitive impairment
o	Depression
o	High creatinine

Question 7

What is the effect of ERAS implementation on post-op complications, LOS and hospital readmissions?

Answer 7

Implementation of Enhanced Recovery Programs reduces postoperative complications, reduces length of stay, with no increase in hospital readmissions

Question 8

What is Enhanced Recovery After Surgery (ERAS) ?

Answer 8

The implementation of patient-focused, standardized, evidence-based, interdisciplinary perioperative guidelines

Question 9

Name 2 ways to improve value of care.

Answer 9

o Improve outcomes without raising costs

o Lower costs without compromising outcomes

Question 10

Name 4 pre-op aspects of ERAS

Answer 10

• Patient activation
• Optimization/prehab
• Reduced fasting
• CHO loading

Question 11

Name 5 intra-op aspects of ERAS

Answer 11

• MIS
• Fluid balance
• SSI prevention bundle
• Regional anesthesia nerve blocks
• PONV anaphylaxis

Question 12

Name 4 post-op aspects of ERAS

Answer 12

• Multimodal, opioid-sparing analgesia
• Immediate nutrition and mobilization
• Minimize tubes and drains
• Daily care maps discharge criteria

Question 13

Explain the implementation process in a hospital

Answer 13

Pathway creation (lit review, material) (6 mo) –> Hospital committee reviews and approval (10 mo) –> Personnel Training (1 mo) –> Audit and Revision (3 mo)

Question 14

How did ERAS impact LOS in esophagectomy patients?

Answer 14

Then: 0% home by POD 7 (esophagectomy); now: 60% home by POD 7

Question 15

What is patient activation?

Answer 15

The knowledge, skills, confidence and motivation to participate in one’s own healthcare

Question 16

Which proportion of patients have low PA?

Answer 16

23% (about 1/4)

Question 17

What is low PA associated with in terms of complications, LOS, hospital visits and ED visits?

Answer 17

• Associated with inc complications (OR 1.63) and inc (LOS 1.2 days), inc hospital visits (OR 3.15). inc ED visits (OR 1.64)
• No difference in readmissions (OR 1.06)

Question 18

How are clinical outcomes affected by ERAS as opposed to conventional care?

Answer 18

Total hospitalization, median [IQR]: 7[5-9] vs 4[3-7] d*
60-d readmissions: 11 vs 13% (no difference)
60-d complications: 43 vs 40% (no difference)
Complication severity index, mean (SD): 10.7(17) vs 10.2(14)

Question 19

How are postdischarge outcomes affected by ERAS as opposed to conventional care?

Answer 19

Lost days from work: 35(20) vs 26(18)*
Caregiver lost days from work: 5(12) vs 1.3(2.6)*
Postoperative CLSC visits: 3.7(9) vs 1.4 (4.6)*
No difference in Quality-of-Life (SF-6D)

Question 20

How much money is saved by patients with ERAS?

Answer 20

• Institutional costs: 1,150$ less with ERP; not significant but likely d/t reduced LOS
• Health care system cost saving: 1602 less with ERP; not significant
o Includes physician remuneration, outpatient visits…
• Society cost saving (everything together)
o Time off work, caregiver time off work…
o ~ 3000$ saved per patient!