Monitoring ERAS Protocols and Optimizing Outcomes

Raoul Concepcion, MD: Sanjay, earlier you mentioned that one of the key things here is obviously revisiting and tracking compliance, tracking adherence, tracking outcomes. At the University of Oklahoma, now that you’re sort of the lead guy on the urology side, how are you planning on tracking your outcomes and efficacy of your program?

Sanjay Patel, MD: For a lot of it, we try to set it up early on so that we can prospectively collect data. We study it, going forward, for many reasons, from a quality standpoint, or even a research standpoint, to study how we’re doing. We set up all of these endpoints at the very beginning. We have someone that comes by. One of our research associates comes and collects the data and works with the administration to abstract the cost of all the various things that we’re doing. It’s hard to meet, but we try to get everyone in the same room, together, every 6 months or so to take a look at it and see if there’s things going on.

We found out that a lot of the TAP [transverse abdominis plane] blocks weren’t happening. The reason was that there wasn’t a coordination with the pain team. It was just a logistics issue. We also found that a lot of the physical therapists that we had on board, we kind of have more control over this at our cancer center, weren’t necessarily translating the information or the plan over to the hospital side. So, we found out things like that. We learned about it. We made the change. I think that you find those things out and you can also look at your endpoints to see if you’re meeting your mark or not. It’s really helpful for us just to look back at it and then tweak little things as you go along.

Raoul Concepcion, MD: Traci, I’m assuming you’re using some robust electronic record and sort of monitoring this from specialty to specialty and program to program at the University of Virginia Health System?

Traci Hedrick, MD, MS, FACS, FACRS: Yes. Going back to Sanjay’s point, when we started in colorectal, it was just myself and my partner. We collaborated with an anesthesiologist, and we chose 6 anesthesiologists that we knew would do the protocol. We started with that. At that point, it was before we were ever using an electronic medical record. We set system-level changes into place. We made sure it was marked on the posting slip. We had a little sign on the patient’s chart so that everybody knew that those patients were enhanced recovery. We had a checklist that we gave the patients. We had a booklet that we gave the patients. And, as we experienced success, then the institution started to take notice and we developed a program with a staff. We, at that point, really incorporated it into our electronic medical record. Now, our checklist is all electronic. The patients are identified on the electronic medical record. We have order sets, so it makes it nearly impossible for the residents, at night, to order opioids without our knowledge. All of these things can help to set you up for success. It’s difficult for patients to fall off of the protocol.

Declan Fleming, MD: We still have the sticker on the door though, just to make sure that everybody walking in and out understands that.

Raoul Concepcion, MD: From an ordering standpoint, is this something that when you’re ordering a low anterior resection, or you’re ordering a Whipple procedure, or a radical cystectomy, we all have standard order sets, is that something that you’re specifically having to mark as an ERAS (enhanced recovery after surgery) protocol?

Declan Fleming, MD: Yes.

Traci Hedrick, MD, MS, FACS, FACRS: It’s just the way we take care of our patients, even our urgent cases. We have 1 order set, the colorectal surgery order set, and it’s enhanced recovery.

Raoul Concepcion, MD: It’s in there.

Traci Hedrick, MD, MS, FACS, FACRS: And then, as we go from service to service, they build off of that order set and our educational materials. But the system changes and our electronic medical record system are all transferrable to each service.

Raoul Concepcion, MD: John, how are you rolling this out at PhyMed, in terms of getting all of your anesthesiologists, again, to think the same way? Has this been problematic?

John Dalton, MD: Well, it’s a challenge. I mentioned it earlier. We’re at several different systems. There’s nothing easy about implementation, but it’s probably easier to get the anesthesia providers on board because we can do it centrally through PhyMed, than it is to implement at each local place. That’s difficult and everyone wants to do the right thing, but it’s different every place you go. We’ve been fortunate, in this position as anesthesia providers, to kind of broker the organizational change at those facilities. There’s been a shift from where we’re trying to implement and no one knows what we’re trying to do, to, now, we have facilities coming and asking us, “Can we do this here?” That’s been a nice shift to see. Leading that organizational change is what we try to do in anesthesia.

Raoul Concepcion, MD: I’m sure that when you make that paradigm shift in a system that’s currently not doing it, you get zero pushback from the surgeons, correct?

John Dalton, MD: Well, that’s a great observation. We’re getting less because they’re starting to come and ask us for it. First, there is that competitive thing. They see what Traci is doing in her facility, or they go to a meeting. They’re saying, “We’ve got to do this,” and they’re coming and asking us for it. “We’ve been trying to do this for a while.” It changes the dynamic.

Raoul Concepcion, MD: I think it’s like anything else. Regardless of what the program is, you’ve got to have a physician leader that takes charge of this and is really pushing for it. They’ve got to push, and, of course, you do get pushback.

Transcript edited for clarity.