1 00:00:00,000 --> 00:00:02,445 Thank you for tuning in to the Becker's Healthcare Podcast. 2 00:00:03,075 --> 00:00:06,805 We'd like to thank the sponsor of this episode, Edwards Life Sciences. 3 00:00:07,915 --> 00:00:10,365 This is Laura Dedo with the Becker's Healthcare Podcast. 4 00:00:10,945 --> 00:00:13,245 I'm thrilled today to be joined by Dr. Daniel Engelman, 5 00:00:13,245 --> 00:00:16,405 president of the ERA ERAS Cardiac Society and Medical Director of Cardiac 6 00:00:16,925 --> 00:00:20,685 surgical Critical Care in patient services and professor of surgery at the 7 00:00:20,685 --> 00:00:23,365 University of Massachusetts, Chan Medical School, Baystate, 8 00:00:23,625 --> 00:00:24,725 and Dr. Michael Grant, 9 00:00:25,075 --> 00:00:28,685 vice president of the era R Eras Cardiac Society and Associate Professor of 10 00:00:28,685 --> 00:00:32,685 Anesthesiology and Critical Care Medicine at Johns Hopkins Medicine. Dr. 11 00:00:32,685 --> 00:00:35,365 Engleman. Dr. Grant, thank you so much for joining us on the podcast today. 12 00:00:36,545 --> 00:00:38,215 Thank you for inviting us to join you. 13 00:00:39,285 --> 00:00:41,455 Fantastic. Well, I'm excited for our discussion. 14 00:00:41,575 --> 00:00:44,375 I know there's gonna be a lot of important information we go over, 15 00:00:44,515 --> 00:00:46,575 but before we dive into the broader discussion, 16 00:00:46,615 --> 00:00:50,295 I would love to hear from you both a little bit more about your backgrounds and 17 00:00:50,295 --> 00:00:53,775 really how your careers have evolved up until this point. So, Dr. Engleman, 18 00:00:53,775 --> 00:00:54,608 can we start with you? 19 00:00:55,755 --> 00:00:59,165 Sure. Well, I am a cardiac surgeon. I trained in cardiac surgery. 20 00:00:59,445 --> 00:01:03,605 I spent most of my time in the operating room in the first 17 years of my 21 00:01:03,605 --> 00:01:07,285 career. And my father, however, 22 00:01:07,585 --> 00:01:12,085 was an academic cardiac surgeon and he was publishing on fast track recovery 23 00:01:12,085 --> 00:01:13,205 following cardiac surgery. 24 00:01:13,945 --> 00:01:18,805 And he did a lot of publications talking about the speed at which you could 25 00:01:18,805 --> 00:01:23,365 get patients healed and back home to their baseline state using a combination of 26 00:01:23,365 --> 00:01:27,205 medications and protocols. And that intrigued me, but I started thinking, well, 27 00:01:27,205 --> 00:01:31,085 it's not all about the speed. Perhaps we need to just tighten up our protocols. 28 00:01:31,585 --> 00:01:35,045 And that's when I kind of stumbled across enhanced recovery after surgery. 29 00:01:35,905 --> 00:01:38,485 And ever since 2017, 30 00:01:39,205 --> 00:01:43,325 I worked with a group of multidisciplinary experts to start the International 31 00:01:43,645 --> 00:01:47,325 Enhanced Recovery after Surgery Cardiac Society in which we standardized 32 00:01:47,565 --> 00:01:50,525 evidence-based best practice. Uh, Mike, your thoughts? 33 00:01:51,475 --> 00:01:55,325 Yeah, so, um, you know, I was lucky enough that Dan reached out to me, um, 34 00:01:55,325 --> 00:01:58,325 shortly after he realized the society. Um, 35 00:01:58,505 --> 00:02:02,845 and at the time my particular interest was both in kind of the area of systems 36 00:02:03,245 --> 00:02:03,945 engineering, you know, 37 00:02:03,945 --> 00:02:08,165 how you think about constructing smart systems around patient care, um, 38 00:02:08,165 --> 00:02:10,405 but also patient safety and quality. Uh, 39 00:02:10,405 --> 00:02:14,165 and so it ended up being a really nice marriage of being able to kind of bring 40 00:02:14,175 --> 00:02:18,365 those, that background plus my clinical background in anesthesia. Again, 41 00:02:18,735 --> 00:02:23,125 kinda a nice synergy with the surgical side. So I brought that background, uh, 42 00:02:23,185 --> 00:02:25,725 to the board as well. And you know, we've created a, a, 43 00:02:25,925 --> 00:02:28,005 a board of other executive, uh, 44 00:02:28,005 --> 00:02:31,565 members that are from a host of different disciplines, and I'm sure we'll, 45 00:02:31,565 --> 00:02:35,005 we'll dive into that as well. Um, and so the last couple of years we've, um, 46 00:02:35,005 --> 00:02:38,125 been working in collaboration to see the society moving forward. 47 00:02:38,865 --> 00:02:40,485 That's amazing to hear. And you know, 48 00:02:40,485 --> 00:02:44,925 really an outstanding society and organization to support some important work to 49 00:02:44,925 --> 00:02:45,758 be done. Now, 50 00:02:45,885 --> 00:02:50,005 I was wondering if you could tell us a little bit about the quality improvement 51 00:02:50,005 --> 00:02:52,765 programs that you have at both your organizations. 52 00:02:53,145 --> 00:02:56,485 How do you optimize patient care? And Dr. Engleman, can we start with you? 53 00:02:57,295 --> 00:03:02,245 Sure. So historically cardiac surgeons felt that if you did a good operation, 54 00:03:02,905 --> 00:03:06,845 the patients would do well, that all the magic happened in the operating room. 55 00:03:07,345 --> 00:03:09,685 But it turns out that isn't really true. 56 00:03:10,395 --> 00:03:15,085 That maybe up to 75% of the preventable morbidity and mortality that 57 00:03:15,105 --> 00:03:19,765 occurs following cardiac surgery actually occurred outside of the operating 58 00:03:19,765 --> 00:03:24,365 room, either from a patient that wasn't preoperatively optimized or 59 00:03:24,505 --> 00:03:29,325 postoperatively could have been treated in a different way in the intensive care 60 00:03:29,435 --> 00:03:33,285 unit or, uh, on the telemetry floor or even after discharge. 61 00:03:33,285 --> 00:03:37,525 So there's a lot of important work that needed to be done outside of the 62 00:03:37,525 --> 00:03:38,845 operating room. Uh, 63 00:03:38,865 --> 00:03:42,245 and that's where we started getting into dividing it into phases of care where 64 00:03:42,245 --> 00:03:46,325 we divided up into preoperative optimizing patients intraoperatively, 65 00:03:46,435 --> 00:03:50,125 what could we do, working with our anesthesia colleagues and our, our, um, 66 00:03:50,125 --> 00:03:52,445 perfusionist colleagues, and then postoperatively, 67 00:03:52,445 --> 00:03:55,765 which is where I would say most of our work has occurred. 68 00:03:55,905 --> 00:03:58,965 And we could delve into each of those areas separately. Uh, Mike? 69 00:04:00,315 --> 00:04:03,405 Yeah, I mean, you know, one of the things I think that's worth mentioning is, 70 00:04:03,545 --> 00:04:06,605 you know, we have a lot of literature. 71 00:04:06,795 --> 00:04:09,605 It's been published over the course of decades and decades, um, 72 00:04:09,705 --> 00:04:14,325 and in some ways that literature has provided us the keys to kind of how to 73 00:04:14,325 --> 00:04:15,158 manage patients, 74 00:04:15,745 --> 00:04:20,205 but actually kind of unfurling that literature and understanding where all those 75 00:04:20,275 --> 00:04:24,325 data should be incorporated into your clinical care has been a challenge. Um, 76 00:04:24,355 --> 00:04:28,685 they actually say that oftentimes the translation of primary literature to the 77 00:04:28,685 --> 00:04:33,165 bedside can take as much as, um, 15 to 20 years to actually realize. 78 00:04:33,305 --> 00:04:36,885 And so a big part of the effort that I think we've been excited about is 79 00:04:36,965 --> 00:04:41,525 establishing best practice around the care of the cardiac surgical patient by 80 00:04:41,525 --> 00:04:44,645 using largely literature that we already have at our disposal, 81 00:04:44,705 --> 00:04:48,805 but also helping to generate new literature and do it at a pace that allows us 82 00:04:48,805 --> 00:04:50,165 to bring it to the bedside more quickly. 83 00:04:50,385 --> 00:04:55,125 And so that's a lot of this is us standardizing best practice and then applying 84 00:04:55,185 --> 00:04:59,085 it, um, in implementation science format to help the clinician. 85 00:05:00,955 --> 00:05:03,615 So if we want to delve into maybe some pre-op elements, 86 00:05:03,675 --> 00:05:06,095 is that what you're thinking we should start, perhaps? 87 00:05:06,285 --> 00:05:07,855 Yeah, I mean, absolutely. 88 00:05:07,895 --> 00:05:10,935 I think that would be fantastic and just really helpful to look at all those 89 00:05:10,935 --> 00:05:12,655 different areas you mentioned, um, and, 90 00:05:12,655 --> 00:05:16,495 and dive one bit deeper to think through what's gonna be very critical in those 91 00:05:16,495 --> 00:05:20,055 spaces as well as the best opportunities to grow and develop and, 92 00:05:20,055 --> 00:05:20,888 and get better. 93 00:05:21,585 --> 00:05:21,935 Sure. 94 00:05:21,935 --> 00:05:25,715 So patients who are non-emergent where you have a little bit of time to work up, 95 00:05:25,715 --> 00:05:30,155 these patients probably can be optimized in about five different domains. 96 00:05:30,535 --> 00:05:32,915 Now, every hospital isn't going to do every domain, 97 00:05:33,135 --> 00:05:35,395 but at least it's worth thinking about these domains. 98 00:05:35,575 --> 00:05:37,435 And the domains would include, uh, 99 00:05:37,505 --> 00:05:41,795 alcohol and cigarette cessation in those patients that have a little bit of 100 00:05:41,795 --> 00:05:42,435 time. 101 00:05:42,435 --> 00:05:45,275 Patients do better if they stop smoking and drinking before a cardiac surgery, 102 00:05:46,175 --> 00:05:49,235 uh, anemia optimization. So those patients that are anemic, 103 00:05:49,655 --> 00:05:54,395 you can either replete them through iron through, uh, epogen, 104 00:05:54,855 --> 00:05:58,365 uh, through all types of different, um, means in which you can, uh, 105 00:05:58,465 --> 00:06:02,405 get their anemia under control to prevent the blood transfusion postoperatively. 106 00:06:03,285 --> 00:06:04,245 Patients who are frail, 107 00:06:04,385 --> 00:06:09,135 you can work on their strength and exercise them based on their 108 00:06:09,535 --> 00:06:11,975 critical anatomy or whether they need valve surgery. 109 00:06:12,035 --> 00:06:16,375 But there is a way to get patients better prepared, uh, physically, uh, 110 00:06:16,435 --> 00:06:18,335 before their surgery. Uh, 111 00:06:18,335 --> 00:06:22,295 there's an entire bundle surrounding SSI prevention, surgical site, 112 00:06:22,295 --> 00:06:24,295 infection prevention, nutrition, 113 00:06:24,295 --> 00:06:28,415 malnourished patients can be optimized preoperatively, um, 114 00:06:28,645 --> 00:06:32,055 education surrounding opioid use. What am I missing there, Mike? 115 00:06:32,845 --> 00:06:35,815 Yeah, I mean, I think those are the, those are the big ticket items, you know, 116 00:06:35,815 --> 00:06:37,255 these individual pillars. You know, 117 00:06:37,255 --> 00:06:40,215 one of the pieces that you allude to Dan that I think is really appropriate is, 118 00:06:40,475 --> 00:06:43,255 um, we have often, especially in the United States, 119 00:06:43,255 --> 00:06:46,855 thought that time to surgery was the real key. You identify an issue, 120 00:06:46,915 --> 00:06:49,455 get 'em into the operating room. The moment you're in the operating room, 121 00:06:49,455 --> 00:06:52,415 you can actually get to the heart of why those patients, um, 122 00:06:52,415 --> 00:06:54,655 were infirm to begin with. Well, you know, 123 00:06:54,655 --> 00:06:56,695 it turns out that there's actually this, I think, 124 00:06:56,725 --> 00:06:59,655 appropriate period of time where you may choose to, you know, 125 00:06:59,655 --> 00:07:03,815 paradoxically delay that surgical encounter in order to optimize patients. 126 00:07:03,815 --> 00:07:05,295 And that's a real paradigm shift, 127 00:07:05,355 --> 00:07:09,375 but that's kind of a hallmark of what that preoperative optimization period 128 00:07:09,375 --> 00:07:10,208 would require. 129 00:07:10,975 --> 00:07:15,675 And we call it prehabilitation instead of standard rehab, it's rehab. 130 00:07:15,695 --> 00:07:16,595 That's the pneumonic. 131 00:07:18,475 --> 00:07:18,755 Absolutely. 132 00:07:18,755 --> 00:07:22,675 That's fascinating and just so helpful to understand and consider for those who 133 00:07:22,975 --> 00:07:26,635 do have time and are able to go through those processes and really optimize 134 00:07:26,635 --> 00:07:28,515 themselves for the surgical procedures. 135 00:07:28,975 --> 00:07:32,995 So then what happens for those patients once they're ready for surgery and, 136 00:07:32,995 --> 00:07:35,475 and then the recovery, um, time periods, you know, 137 00:07:35,625 --> 00:07:39,075 what strategies have most successful for improving patient care in the or? 138 00:07:39,075 --> 00:07:39,955 And then the ICU. 139 00:07:40,765 --> 00:07:42,055 Mike, you wanna take a stab at this? 140 00:07:42,055 --> 00:07:45,695 Yeah, so, so you know, the operating room, um, there are obviously some, 141 00:07:45,765 --> 00:07:47,775 some large bucket items. So, you know, 142 00:07:47,775 --> 00:07:51,095 we think an awful lot about how you manage hemodynamics. Well, 143 00:07:51,235 --> 00:07:54,655 the way that you think about vasopressors and fluid administration, 144 00:07:55,065 --> 00:07:59,375 there is a entire period of time where you're on a cardiopulmonary bypass 145 00:07:59,485 --> 00:08:04,295 machine and there are strategies to optimize organ perfusion while you're on 146 00:08:04,295 --> 00:08:05,215 that machine. Um, 147 00:08:05,515 --> 00:08:09,255 things that we probably don't use as ubiquitously as we should. Again, 148 00:08:09,255 --> 00:08:13,135 that's a big set of best practices around perfusion based care. Um, 149 00:08:13,315 --> 00:08:17,055 we have to think about obviously how we administer opioids, 150 00:08:17,055 --> 00:08:19,175 how we administer pain medications in general, 151 00:08:19,425 --> 00:08:24,295 using balanced anesthetics that compliment your, um, pain management techniques, 152 00:08:25,035 --> 00:08:27,575 how we ventilate patients. Um, so, you know, 153 00:08:27,575 --> 00:08:31,135 obviously in the operating room there are strategies to reduce some of the risk 154 00:08:31,275 --> 00:08:34,775 to lung injury that are associated with positive pressure ventilation. 155 00:08:35,075 --> 00:08:37,215 And the list can kind of go on and on and on. 156 00:08:37,565 --> 00:08:41,855 What we really try to avoid is diving into some of the more technical aspects of 157 00:08:41,855 --> 00:08:42,695 the surgery itself, 158 00:08:42,695 --> 00:08:47,215 because there are entire societies devoted to how to do a specific 159 00:08:47,685 --> 00:08:48,518 kind of surgery. 160 00:08:49,045 --> 00:08:53,295 This is more about how do we optimize the care that's surrounding that surgical 161 00:08:53,365 --> 00:08:54,415 encounter, um, 162 00:08:54,415 --> 00:08:58,005 and using best practices in the operating room to facilitate that surgery. 163 00:08:59,175 --> 00:09:01,825 That really is helpful to know and, and definitely I, 164 00:09:01,905 --> 00:09:05,265 I love that kind of mindset of continuing to try to get better use best 165 00:09:05,585 --> 00:09:08,505 practices and, and really those the technical aspects of, 166 00:09:08,505 --> 00:09:12,905 of surgery getting better. Um, and then too, you know, from your perspective, 167 00:09:13,055 --> 00:09:14,625 when you're looking at all of these things, 168 00:09:14,765 --> 00:09:18,185 how do you best share best practices between colleagues? Um, 169 00:09:18,185 --> 00:09:20,625 whether it's within the organization or, or just broadly, 170 00:09:20,975 --> 00:09:24,065 what have you seen worked really well once you kind of gather the data and, 171 00:09:24,085 --> 00:09:26,385 and see that there's a change that made a big difference? 172 00:09:27,695 --> 00:09:31,905 Well, I think your, your classic mechanism in academics has been publication. 173 00:09:32,445 --> 00:09:32,845 Um, 174 00:09:32,845 --> 00:09:36,585 and one of the advantages of that is that that's something that gets around to 175 00:09:36,585 --> 00:09:38,785 kind of at the society level. And, you know, 176 00:09:38,785 --> 00:09:43,025 people who are really into the academic side of this have exposures to that 177 00:09:43,385 --> 00:09:44,055 literature. 178 00:09:44,055 --> 00:09:47,185 What we have found is that those aren't always the people who are making the 179 00:09:47,345 --> 00:09:51,145 decisions, and that's not how you get it out to all of the masses. 180 00:09:51,445 --> 00:09:56,185 And so we spend a lot of time, um, doing things like being able to create, um, 181 00:09:56,555 --> 00:10:01,185 ready-made turnkey order sets that can translate some of those, um, 182 00:10:01,185 --> 00:10:05,265 elements of literature to kind of a bundled application to take to the bedside. 183 00:10:05,805 --> 00:10:08,585 Uh, we think a lot about how we can, um, lecture, 184 00:10:09,195 --> 00:10:13,785 especially on a societal level or in some of the kinda local hospitals to be 185 00:10:13,785 --> 00:10:16,305 able to, um, you know, disseminate that information. 186 00:10:16,705 --> 00:10:18,465 A lot of this is word of mouth and networking, 187 00:10:18,525 --> 00:10:21,785 so you get to know your colleagues very well in these various areas and that 188 00:10:21,785 --> 00:10:24,185 helps with some, um, dissemination. Um, 189 00:10:24,205 --> 00:10:27,425 and so there it's a multi-pronged approach that really requires a, 190 00:10:27,545 --> 00:10:29,505 a lot of different avenues to get the word out. 191 00:10:31,135 --> 00:10:32,075 Yes, we, um, 192 00:10:32,285 --> 00:10:36,155 wrote initial guidelines in 2019 that were published in JAMA Surgery, 193 00:10:36,415 --> 00:10:37,875 and now we are, um, 194 00:10:38,395 --> 00:10:42,035 updating those which will be published in the Annals of Thoracic Surgery as an 195 00:10:42,035 --> 00:10:46,155 expert consensus document. And that should come out in January. But, uh, 196 00:10:46,175 --> 00:10:50,995 as Mike alluded to, just publishing generalized guidelines of, 197 00:10:51,185 --> 00:10:54,035 well, it's important to prevent acute kidney injury, 198 00:10:54,345 --> 00:10:58,155 doesn't exactly tell the bedside practitioners, how do I do that? 199 00:10:58,425 --> 00:11:01,635 Just tell me some of the metrics you're gonna use and physically, 200 00:11:01,635 --> 00:11:02,875 what do I do for my patient? 201 00:11:03,175 --> 00:11:08,115 And that's why we think that these turnkey order sets that we're 202 00:11:08,115 --> 00:11:12,075 now publishing, which translate not just our expert consensus work, 203 00:11:12,095 --> 00:11:16,075 but the world's expert consensus work into an actionable bedside document is 204 00:11:16,075 --> 00:11:19,235 very useful. So we have written one on acute kidney injury. 205 00:11:19,575 --> 00:11:21,835 We have one coming out now on patient blood management, 206 00:11:21,895 --> 00:11:25,475 how to decide when to transfuse patients and prevent them from getting 207 00:11:25,475 --> 00:11:27,035 transfused unnecessarily. 208 00:11:27,565 --> 00:11:30,515 We're going to be publishing them soon on surgical site infection, 209 00:11:31,175 --> 00:11:35,195 on atrial fibrillation prevention and treatment, uh, 210 00:11:35,195 --> 00:11:40,075 which medications you should hold prior to surgery to prevent untoward uh, 211 00:11:40,075 --> 00:11:43,355 effects of these medications, which should be held pre-op. 212 00:11:43,865 --> 00:11:44,155 Well, 213 00:11:44,155 --> 00:11:48,275 that absolutely sounds like they would be extremely beneficial tools to have and 214 00:11:48,275 --> 00:11:51,955 really be able to implement for organizations. And, you know, I'm wondering, um, 215 00:11:51,955 --> 00:11:56,085 especially for those that maybe have not had much experience with the enhanced 216 00:11:56,365 --> 00:12:00,125 surgical recovery programs, what has been your experience implementing them? 217 00:12:00,505 --> 00:12:02,125 How do you really do that, um, 218 00:12:02,225 --> 00:12:06,645 on the people level to make sure that all the clinicians and care providers are 219 00:12:06,645 --> 00:12:10,005 on the same page and understanding the information, the data, 220 00:12:10,105 --> 00:12:12,565 and the different things that you're trying to do, 221 00:12:13,025 --> 00:12:14,885 as well as what have the results been? 222 00:12:15,685 --> 00:12:18,345 So, yeah, so I mean, the bundle of postoperative things, 223 00:12:18,345 --> 00:12:22,225 which is very extensive, would include things like, um, reducing opioids, 224 00:12:22,335 --> 00:12:26,105 getting patients mobilized earlier, paying attention to their nutritional needs, 225 00:12:26,765 --> 00:12:30,425 uh, getting them, uh, off the ventilator as soon as possible. 226 00:12:31,365 --> 00:12:35,945 All of these elements we like to think of as aggregations of 227 00:12:36,265 --> 00:12:36,885 marginal gains, 228 00:12:36,885 --> 00:12:41,505 little tiny improvements in each of these different areas come together and 229 00:12:41,505 --> 00:12:46,105 reduce length of stay, get patients home instead of to rehab hospitals, 230 00:12:46,105 --> 00:12:51,065 which is where they want to be, uh, get them to be less likely to be readmitted, 231 00:12:51,155 --> 00:12:54,905 which is, uh, very costly and also very unfortunate to the patients. 232 00:12:55,255 --> 00:12:57,465 It's improves patient satisfaction. 233 00:12:57,845 --> 00:13:00,705 The education that's associated with all of these things, uh, 234 00:13:01,145 --> 00:13:04,825 absolutely resonates with our patients and with hospital administration because 235 00:13:04,845 --> 00:13:09,425 it lowers healthcare costs by reducing hospital stays and 236 00:13:09,425 --> 00:13:13,225 postoperative complications, which increases patient value, 237 00:13:13,595 --> 00:13:16,705 which we think is, uh, absolutely essential. Uh, 238 00:13:16,805 --> 00:13:19,145 and besides it's just the best thing to do for patients. 239 00:13:19,805 --> 00:13:21,915 Right? Yeah, I mean, I think to feed off that a little bit, you know, 240 00:13:22,125 --> 00:13:25,435 every single thing that we've mentioned is not, 241 00:13:25,905 --> 00:13:27,515 it's not controlled by an individual, 242 00:13:27,665 --> 00:13:31,395 it's controlled by a whole team of individuals and they're from a variety of 243 00:13:31,395 --> 00:13:35,115 different backgrounds. And so anytime you try to do something of this scale, 244 00:13:35,315 --> 00:13:37,355 I mean, we're talking about individual phases of care, 245 00:13:37,645 --> 00:13:41,395 we're talking about multi-pronged approaches to each of those individual facets 246 00:13:41,655 --> 00:13:45,995 that's gonna require you to have a team of individuals that are responsible for 247 00:13:45,995 --> 00:13:48,315 those care elements. And so I think a, again, 248 00:13:48,395 --> 00:13:51,675 a hallmark of kind of the enhanced recovery concept is that you have to develop 249 00:13:51,995 --> 00:13:56,595 a multidisciplinary, um, executive team. You know, you have to have, uh, 250 00:13:56,595 --> 00:13:58,515 members from all different disciplines, 251 00:13:58,515 --> 00:14:02,395 whether it's anesthesia and surgery and nursing and your perfusionists, but, um, 252 00:14:02,735 --> 00:14:06,875 uh, a host of other, um, areas of expertise, things like pharmacists, um, 253 00:14:06,875 --> 00:14:09,475 you're a respiratory therapist, your physical therapists, 254 00:14:09,765 --> 00:14:13,595 these are vital aspects of the care elements that you're trying to employ. 255 00:14:13,655 --> 00:14:16,355 And I'll be honest with you, as a, you know, 256 00:14:16,385 --> 00:14:20,075 routine anesthesiologist in the operating room, I'm just simply not, um, 257 00:14:20,265 --> 00:14:23,915 experienced or expertise enough in those various areas. 258 00:14:24,375 --> 00:14:27,355 We never hope to try to take all of that on as an individual. 259 00:14:27,455 --> 00:14:29,595 And that has really been what, um, 260 00:14:29,595 --> 00:14:34,155 kind of surgery has been asking of surgeons for decades. Um, 261 00:14:34,175 --> 00:14:35,515 and that's not really fair to the surgeon. 262 00:14:35,695 --> 00:14:38,115 So what enhanced recovery really does is it says, listen, 263 00:14:38,215 --> 00:14:41,915 I'm not asking one individual to be an expert in all of these areas. 264 00:14:42,515 --> 00:14:46,635 I want this team of experts to come together and coalesce around a single 265 00:14:46,825 --> 00:14:50,675 unified, um, we'll call it a care package that goes to the patient. 266 00:14:52,525 --> 00:14:53,125 I love that. It, 267 00:14:53,125 --> 00:14:56,005 it seems like that would paint a really clear picture of what you're trying to 268 00:14:56,005 --> 00:14:58,965 do and what you're looking for and be an exciting thing for them to work on 269 00:14:59,165 --> 00:15:01,165 together to really have a better, uh, 270 00:15:01,165 --> 00:15:04,525 grasp of what patients are needing and how to coordinate their care in a really, 271 00:15:04,625 --> 00:15:05,925 um, effective way. 272 00:15:06,475 --> 00:15:07,205 Yeah, and you know, 273 00:15:07,205 --> 00:15:11,365 the other piece to mention here is that enhanced recovery also shifts some of 274 00:15:11,385 --> 00:15:15,765 the priority away from how you want to do the job 275 00:15:16,425 --> 00:15:21,405 around the patient to actually having the patient be involved as a 276 00:15:21,405 --> 00:15:23,765 kind of driver in their own care. Um, 277 00:15:23,865 --> 00:15:27,005 so one of the pieces that Dan alluded to initially was this idea of patient 278 00:15:27,035 --> 00:15:31,405 education and patient engagement. Enhanced recovery asks the patient, 279 00:15:31,595 --> 00:15:36,445 what do you want your life to look like after this surgical encounter 280 00:15:36,545 --> 00:15:39,285 and how will this surgical encounter get you there? 281 00:15:39,745 --> 00:15:42,885 So you're engaging that patient to give them a more formal education base. 282 00:15:42,945 --> 00:15:46,925 You're gonna give them expectations around things like how yet surgical 283 00:15:46,925 --> 00:15:48,045 encounter's gonna look. 284 00:15:48,235 --> 00:15:51,285 It's a roadmap of sorts of what surgery is gonna entail for them. 285 00:15:51,665 --> 00:15:56,245 And then it asks us to follow that patient from the decision to make, uh, uh, 286 00:15:56,305 --> 00:15:56,545 to, 287 00:15:56,545 --> 00:16:00,285 to actually engage in the surgical encounter all the way through full recovery 288 00:16:00,285 --> 00:16:04,005 at the end. And that may be days after surgery, it may be weeks after surgery, 289 00:16:04,545 --> 00:16:06,525 it may be quite a long time after surgery. 290 00:16:06,665 --> 00:16:09,925 And the idea behind all of this is the patient remains the focus, 291 00:16:10,025 --> 00:16:13,045 the very center and the driving force behind that care plan. 292 00:16:14,155 --> 00:16:16,545 Laura, one thing I'd like to point out is, you know, it seems like a lot, 293 00:16:16,625 --> 00:16:16,865 I mean, 294 00:16:16,865 --> 00:16:21,305 we've talked about all these different elements and it may be overwhelming for a 295 00:16:21,745 --> 00:16:25,705 hospital or a practitioner to, to delve into this. 296 00:16:25,925 --> 00:16:27,625 And if you want to get started, 297 00:16:27,725 --> 00:16:29,505 the first thing you need to do is look at your metrics, 298 00:16:29,655 --> 00:16:32,505 pull up the SDS database on your particular program, 299 00:16:32,565 --> 00:16:37,385 and look for areas of low hanging fruit areas in which you are not performing 300 00:16:37,525 --> 00:16:41,425 as well as you think you can. And just work on that one, delve into that one, 301 00:16:41,455 --> 00:16:44,785 work on early extubation, early mobility, um, 302 00:16:45,915 --> 00:16:50,225 blood utilization, acute kidney injury, one area, and get a small win. 303 00:16:50,525 --> 00:16:53,945 Get everybody behind it, get a small win, and it will feed on itself. 304 00:16:54,365 --> 00:16:55,345 And next thing you know, 305 00:16:55,345 --> 00:16:59,185 they'll be wanting to pull in a couple more areas for improvement and track it. 306 00:16:59,485 --> 00:17:02,745 See, hey, look, now we're getting our patients off the ventilator, uh, 307 00:17:02,765 --> 00:17:04,505 in six hours. It used to take eight hours. 308 00:17:04,515 --> 00:17:07,265 We're getting all of our patients out of bed the morning after surgery. 309 00:17:07,325 --> 00:17:08,345 It used to take two days. 310 00:17:08,775 --> 00:17:12,705 This will empower the team and you can celebrate the wins and the patients will 311 00:17:12,705 --> 00:17:13,538 appreciate it. 312 00:17:14,755 --> 00:17:17,955 I love that, that that's really great advice. And you know, I'm wondering too, 313 00:17:18,095 --> 00:17:19,355 um, as we wrap up here, 314 00:17:19,815 --> 00:17:22,755 is there any other advice that you have for clinical leaders to make sure 315 00:17:22,755 --> 00:17:24,195 they're making the most of UAS? 316 00:17:24,625 --> 00:17:26,795 Yeah, I mean, I think, I think there's, uh, 317 00:17:26,815 --> 00:17:31,275 an incredible opportunity for you to look at your deficiency and to begin to 318 00:17:31,275 --> 00:17:32,115 track it immediately. 319 00:17:32,415 --> 00:17:36,275 So if you get the sense that you're really suffering from this, we'll call it, 320 00:17:36,285 --> 00:17:39,355 we'll, we'll call it one item that you really need to, you know, 321 00:17:39,735 --> 00:17:42,555 get a big victory on to kind of sell it to your administration. 322 00:17:42,555 --> 00:17:45,115 Let's say surgical site infection rates, for example. 323 00:17:45,815 --> 00:17:48,955 Use that as the mechanism by which you're gonna start thinking about program 324 00:17:49,125 --> 00:17:51,645 elements. But you have to audit that, okay, 325 00:17:51,645 --> 00:17:56,565 so not only are you gonna audit the degree of surgical site infection over time, 326 00:17:56,585 --> 00:17:59,885 but you're gonna look at the individual elements that you think inform that and 327 00:17:59,885 --> 00:18:02,725 predict that. And these are process care elements. 328 00:18:02,745 --> 00:18:05,205 So am I doing things like surgical scrubs? 329 00:18:05,305 --> 00:18:08,605 Am I giving antibiotics appropriately ahead of time, et cetera, et cetera. 330 00:18:08,865 --> 00:18:11,805 And you're gonna track not only kind of your adherence to those individual 331 00:18:11,805 --> 00:18:14,285 elements, but then the overall outcomes as well. 332 00:18:14,705 --> 00:18:19,085 And that that auditing then feeds back to your individual team members. 333 00:18:19,625 --> 00:18:22,925 If you don't have that kind of closed cycle communication around those elements, 334 00:18:23,225 --> 00:18:25,565 you're, you're gonna be doing things well intendedly, 335 00:18:25,665 --> 00:18:27,765 but maybe a little haphazardly. Um, 336 00:18:27,825 --> 00:18:29,445 and you certainly won't see the needle moving. 337 00:18:29,545 --> 00:18:33,885 So I think my biggest take home for this would be identify the measure you are 338 00:18:33,885 --> 00:18:36,645 trying to improve upon and actually measure it. Which, 339 00:18:36,645 --> 00:18:39,125 which sounds a little perfunctory, but it's incredibly necessary. 340 00:18:40,255 --> 00:18:43,845 Thank you, Dr. Grant, that that's really great advice and certainly, um, 341 00:18:44,235 --> 00:18:47,845 very helpful for our audience to think about as they're looking at what can be 342 00:18:47,845 --> 00:18:51,685 really beneficial for them as they're using ERA AS in the future. Dr. Engleman, 343 00:18:51,685 --> 00:18:52,805 do you have anything else to add? 344 00:18:53,745 --> 00:18:56,905 I do. So if any programs or practitioners want more information, 345 00:18:56,925 --> 00:19:01,145 if they actually want to get these order sets or even programmatic guidance of 346 00:19:01,145 --> 00:19:05,865 how to start an era AS program and how to look at bundles of care and example 347 00:19:05,885 --> 00:19:08,745 orders and example checklists and PowerPoints, 348 00:19:08,815 --> 00:19:13,345 it's all available on our website, which is e eras cardiac.org, 349 00:19:13,445 --> 00:19:18,385 one word Eres, C-A-R-D-I-A-C, eres cardiac.org. 350 00:19:18,805 --> 00:19:22,865 And for a small annual fee of $50 or something, 351 00:19:22,935 --> 00:19:25,785 they could have unlimited access for that year to all these materials. 352 00:19:25,785 --> 00:19:27,625 They can ask us questions, engage with us. 353 00:19:27,885 --> 00:19:30,065 We have a monthly practitioner meetings, 354 00:19:30,065 --> 00:19:34,105 which are live Zoom events where we get an expert at one of these domains to 355 00:19:34,105 --> 00:19:36,185 speak and then open the floor for questions. 356 00:19:36,185 --> 00:19:39,225 So there's lots and lots of interaction and room to improve. 357 00:19:39,465 --> 00:19:42,585 'cause we wanna learn from practitioners, we don't know what's right, 358 00:19:42,845 --> 00:19:46,785 we just know we need to standardize evidence-based best practice for our 359 00:19:46,985 --> 00:19:47,818 patients. 360 00:19:48,395 --> 00:19:51,005 Fantastic. I love it, Dr. Uncommon. Dr. Graham, 361 00:19:51,005 --> 00:19:52,245 thank you so much for being here today. 362 00:19:52,245 --> 00:19:54,845 This has been such a fun and interesting conversation and I look forward to 363 00:19:54,845 --> 00:19:56,725 connecting with you both again soon. Thanks. 364 00:19:56,725 --> 00:19:57,525 For much for having us. 365 00:19:57,525 --> 00:19:58,358 Thank the. 366 00:20:00,705 --> 00:20:03,965 It is so important for leaders at the top of organizations to keep learning, 367 00:20:04,115 --> 00:20:04,875 stay sharp, 368 00:20:04,875 --> 00:20:08,685 grow their networks to help our audience better do this in a more simplified, 369 00:20:08,685 --> 00:20:13,365 personalized, and meaningful way. Becker's Healthcare has launched my BHC, 370 00:20:13,755 --> 00:20:16,845 it's your trusted Becker's healthcare experience and more with content, 371 00:20:16,875 --> 00:20:19,125 connections, events and learning opportunities. 372 00:20:19,875 --> 00:20:21,685 Join the community free of charge at 373 00:20:22,425 --> 00:20:26,685 www.my.beckerhospitalreview.com and we'll see you there.