ERAS Compliance at Brigham and Women’s Hospital
The following is a transcription of an interview with Kevin Elias, MD, FCAOG, President – ERAS® Society USA Chapter and Director of the Gynecologic Oncology Laboratory at Brigham and Women’s Hospital. During the discussion, Dr. Elias represented his presentation titled “Compliance with ERAS – How we do it” and provided additional insights during a Q&A discussion. A recording of the presentation is available to Watch Here.
This is Dr. Porter Jones. I'm the VP of Clinical Transformation at Avant-garde and privileged to have Dr. Kevin Elias with us today, to represent what he had presented at the ERAS 2022 Conference, in regards to ERAS reporting and the collection of data. As a brief overview, Dr. Kevin Elias is an Assistant Professor of Obstetrics Gynecology and Reproductive Biology at Harvard Medical School. In addition, he holds numerous positions at Brigham and Women's Hospital and finally has just assumed the role of President of the ERAS US Society. Kevin, it's a pleasure to have you. We really appreciate your support, your insights, and also your ability to help guide the ERAS society and help get this information out to hospitals on how to better report, how to better collect and your leadership is much appreciated. And I'll turn the time over to you.
Dr. Kevin Elias: Well thank you Porter. I'm happy to be here and to be able to share these slides with folks who are interested in this topic. I'll be talking about compliance with Enhanced Recovery After Surgery and how we do it currently at Brigham and Women's Hospital. I don't have any specific disclosures related to the content other than the fact that we'll be discussing some software.
ERAS Compliance - Guiding Principles
When we talk about Enhanced Recovery After Surgery and auditing, there are several guiding principles. The first is the fact that audit has several functions. We want to look at compliance. We want to look at adherence, and we want to look at benchmarking compared to our peers. When we are looking at auditing, a compliance must be assured and not assumed. We know very well that if you ask people whether or not they're compliant with ERAS, they will often say they're compliant. But if you actually audit the data, you'll find that compliance typically falls well below perceived compliance. And that really excellence is a habit, and that we see auditing as an ongoing task. It's not a one-time or intermittent thing, but really a continuous activity.
ERAS Compliance – Prioritizing What to Measure
One question is always, what should we be measuring? And so, we want to make sure that we're prioritizing elements that reflect the ERAS practices. So, we always ask when we pick an element to audit, are we measuring this because it's easy to measure or because it actually drives better outcomes? Oftentimes there are things that might be very easy data points, but if they don't actually lead to better outcomes, they’re not that important to measure. We also want to be judicious not to over-measure. Audit fatigue is a real problem. We don't want to measure hundreds of elements. We want to measure enough to get to the data points that we need. And I personally believe that optimal metrics should have a binary variable. We don't want a lot of subjectivity in determining whether or not something is compliant. It’s much easier when we're looking at compliance as far as a percentage of compliance. And it really should be a YES or NO answer from those questions.
ERAS – Four Elements of Compliance Data
When we're engaging with our compliance data, there's really four elements that we look at. We want the data to be relevant to clinical management. The definition should be clear. So there's not a lot of ambiguity in assessing compliance. We should be able to get that data back to frontline providers in a timely manner. And we want this data to live in a database that can be queried, not some sort of spreadsheet that is limited to say an individual project manager’s hard drive.
ERAS – Checking the Box vs Meeting the Goal
When we talk about what is compliant with one of our ERAS protocol metrics, we do want to differentiate giving lip service or just checking a box versus really meeting the intent. So I give some examples here. We talk about patient education being one of our metrics. Well, you could write a note that says that you educated the patient, or you could have a checkbox that says education was given.
That's not quite as much of a step as actually having someone attend an ERAS class or attend an ERAS webinar. Another metric you could document the hemoglobin if you don't do anything about it, that's not really as good of an audit as documenting that for patients who have been shown that they are iron deficient, you've made a referral for IV iron. And then similarly with smoking cessation, recording that someone is a smoker does not meet the metric of assessing for smoking status, referring smokers to smoking cessation, that actually meets the metric.
ERAS – Do We Need Full Compliance?
Oftentimes folks ask whether or not we need full compliance. The ERAS society recommends 18 metrics. And then oftentimes people will audit several dozen variables beyond that. There was a group that looked at this question, do we really need full compliance with the protocol or is good, good enough? They found that it was good enough if you moved from less than 70% compliance to greater than 90% compliance. There's a progressive gain as far as recovery and in moving from 70% to greater than 90% compliance, patients are mobilizing better, they are less likely to use opioids, they are tolerating diet sooner. They also go home faster. Even if it's incremental, there is additional benefit as you move into that ultra-high compliance.
ERAS - The Hard Elements Make the Biggest Difference
We also know that what we call the hard elements actually make the biggest difference. So, the passive elements are things that don't require the patient to participate. Such as; did the patient get their heparin shot? Did you give the antibiotic prophylaxis? People are usually very good about those and they're very easy to audit because they abstract fairly readily from the medical record. The active elements, the early mobilization, the patient-taking carbohydrate loading, the advancing diet after surgery. It turns out in this study, looking at the colorectal literature, the hard elements actually have the biggest bang for the buck. You get a pretty linear improvement. We look at the passive elements, but the ones that are actually statistically significant in preventing major complications, are the harder data points to abstract.
ERAS - Tools for Assessing Compliance and Visualizing Data
How do we actually assess compliance? Well, there are several different tools for assessing compliance and visualizing data. The ERAS society has worked Encare to develop what's called the ERAS Interactive Audit System. And we’ve used the system for several years in our group. It works very well for top level display of compliance and looking at major complications and procedure types. And you can drill down to an extent, looking at different groups. So, you can split it by type of complication or type of procedure and see compliance across them. A lot of groups also use the Redcap database and we've used Redcap as well at our institution. Primarily because the ERAS Interactive Audit System has a fairly limited number of service lines that are covered. So, for identifying procedure types that are not within the system, and also expanding and meeting the need to scale up more readily, we found that Redcap worked very well. So, here's a view, looking at our major data points, looking at a month by month basis. For my service, the Human Oncology service, this kind of heat map approach is a very easy way to display the data so that everyone can see where we're doing well, where the trends have gone, and where we can continue to make some improvement. We can also use that same sort of database to look at outcomes by service line. So here we're looking at Pre-Op Carbohydrate Loading and we present this data at our Surgical Quality Committee. So, every month we meet with the ERAS champions from across the different service lines. And this allows us to see which service lines are doing well, which ones may have fallen off, exchange best practices, get people along the same page.
ERAS – Wo Do We Get The Data?
So how do we actually get the data? That's one of the most common questions. And as we developed more and more ERAS protocols, there's more data to wrangle. We've tended to collect more than 70 variables and how do you display and visualize this? It can be quite tricky, particularly when you want to get that data back in a manner that can be used to spot problems quickly and get it back to the front line.
Before COVID, we were using seven FTEs to manually abstract this data, and we were abstracting every single patient who was on the Enhanced Recovery Protocol. This amounted to several hundred cases a month approaching up to a thousand cases. But more recently we partnered with Avant-Garde to pull that data directly from our EPIC EHR which has really helped in summarizing and visualizing that data and reducing our reliance on FTEs. So, this is an example of what we were doing manually Pre-COVID. We put together compliance scorecards broken down by surgeon, showing trends over time, and we would issue quarterly report cards where we could pull up an individual surgeon and show how that individual was compliant with specific metrics related to our service.
ERAS - Physician-Level Scorecards and Comparisons with Avant-garde Health
Now with Avant-garde, we get a very similar type of presentation. On the left we're showing an example for bariatric surgery data where we can break it down by individual surgeon. We can show compliance and we can show trends over time across the group or by individual surgeon. And we also have the ability to filter it by different DRGs and procedure types and date ranges. This has been very helpful for understanding some of our most important metrics. In the example, we're showing the Pre-Op compliance metrics but similarly we could generate the data for overall compliance Intra-Op metrics or Post-Op metrics. The Avant-garde system is also very helpful for benchmarking among providers in the institution. So, one of the things that ERAS does really well is it minimizes variation within the group. When we'd have less variation in patient management, we see less variation in patient outcome. So here we have both the ability to see individual level provider metrics, and also benchmarking with the best performer within the group. Which is something that we were not previously able to do. And this is a nice report to be able to get back to individual providers.
ERAS – The Weekly Huddle
The last thing that I'll say about ERAS auditing is that meeting often is probably the most important thing. I meet with our frontline nurses on a weekly basis. We review every Enhanced Recovery case in the previous week, and we look at outcomes relevant to Post-Operative care. As examples, we focus on pain and nausea management, how compliant patients were with ambulation and diet, etc. We go over individual complications and troubleshoot those. And I think most importantly, we recognize good work. So, we actually will call out nurses who do a great job at localizing patients early or documenting really well. We give feedback to the anesthesia team about patients who did particularly well after surgery pain-wise, or patients who had a hard time and figure out how we can do better the next time. It's a very simple thing. It takes us about 15 to 20 minutes, and we meet every Thursday morning and enables rapid problem-solving. We can see when trends are suggesting that we might be getting off-track. It makes a tremendous difference.
ERAS Compliance – Conclusions
Just to conclude I think of compliance is a habit. But you have to keep at it. So, unless you're auditing frequently, the service lines will get complacent and your outcomes will get stale and eventually fall off. We know how to measure compliance and outcomes, but it requires auditing more the more active elements, the ones that are harder to achieve and sometimes harder to measure, but they do make the biggest difference.
And finally, I think it's important to give feedback frequently to the entire care team, the surgical team, the anesthesia team, the nursing team because we know that as we drive those metrics up from good to better to best to perfect, patients will continue to do better. And we should always strive to do better every day. So, thank you very much. And again, real pleasure to be here chatting with the Avant-garde team.
What have been some of the major themes in your ERAS journey?
Dr. Porter Jones: Thank you, Dr. Elias. This is great. Very informative. You’ve done a lot of great work and it's great that you're able to now share that experience with other institutions on the step-by-step processes that you went through. I am curious, once you hit your stride, what were the major high-level themes that you saw? Really looking at patient care, some of the outcomes, whether it be with the clinical staff and how they were looking at the way they provided care, and then all the way down to the patient treatment.
Dr. Kevin Elias: Well, one of the things we looked at was developing ERAS flow sheets for nursing documentation. That was one of the most important steps that we took because we were finding actually that without a standardized documentation workflow, we were creating a lot of inconsistent documentation. Some of it was duplicative - the nurses felt like they were documenting in three different places about patient mobility and diet. And also, sometimes it was very detailed and sometimes it was generalized. Well, what does that mean? It doesn't really help us at all. So being able to have ERAS flow sheets within Epic that we could then pull data from so that now the fields are standardized made a tremendous difference. That heled us give feedback to the nurses and get them more involved and also improve the quality of the data.
I think one of the other things that we saw as we really hit our stride was that we could really start to break it down by which patients were doing well and which were doing poorly. That could be based on the anesthesiologist, based on the level of ERAS education that patients were getting, etc.. One of the things that we saw as we started auditing was that we needed to update our language materials for patients. Because we saw that we had a disparity in non-English speaking patients, not receiving the same level of ERAS education, which spilled over into their outcomes. So just by translating some of our basic materials into the most common languages at our hospital, we were able to mitigate those issues. But we wouldn't have known that if we weren't auditing that data in real-time. Because that doesn't come out in just your regular length of stay data.
Does ERAS serve as your platform for standardization?
Dr. Porter Jones: It seems like the real power is not only just what you are collecting and some of the individual steps you're doing, but it seems to spread throughout the entire care process, as you had mentioned just allows for some innovation, look at things in a different manner. But having ERAS is that platform to do so?
Dr. Kevin Elias: Exactly. I think ERAS is a great way to try to keep everybody up to the same quality of care and like everything else that we do, we want to be consistent. And so, what we're looking for is that consistency across all patients all populations. By keeping patients on the ERAS pathway, we’re able to take care ensure outcomes more effectively now and we avoid a lot of the arbitrary variation in care, which can steer people towards less-than-optimal outcomes.
How do you use benchmarking to improve ERAS compliance?
Dr. Porter Jones: Yeah, thank you. I am curious in regards to benchmarking, that seems relatively new. How do you see that playing a role, the importance of it in how you move forward? You can always benchmark internally but tell me how you see that.
Dr. Kevin Elias: The benchmarking is important, I think both internally and externally. Benchmarking we think of as being different from just compliance. Compliance tells you how you're doing. Benchmarking gives you a sense of what's the best that you could be doing? And I think we're all a little bit competitive and certainly it helps with motivating the care teams to benchmark. But also, it helps foster a lot of innovation because when you start asking, “why is this team at another institution getting their patients out in three days and it's taking us four days”, you really start to look at your practice and reevaluate it. We had something very similar happen to us. We used a lot of epidurals in our practice. We just had a length of stay that was four days and we thought that was pretty good. We started working with teams that were using different types of blocks and infiltrations and we saw that they were doing much better. So, we transitioned from epidurals to more local blocks. We were able to get our length stay down to two and a half to three days. Again, without benchmarking you would think that what you're doing is good enough, but it is really important to know that you can do better.
How do you do physician-to-physician benchmarking?
Dr. Porter Jones: Can you expand a little bit on how you've been able to silo physician by physician, so you're able to give reports showing how they compare one to another. How have you rolled that out? And then how has the clinical staff responded to seeing their individual metrics, compliance, etc. by name?
Dr. Kevin Elias: I think it's helpful that we share data on a quarterly basis because it gives enough of a sample size. If we do it too frequently at the individual surgeon level, they’ll say, they had an individual case that was an outlier. But if you look at quarterly, those tend to average out and you can really see, are you practicing in a way that is generally consistent with the rest of the group or are there things that you are not doing that everyone else is doing and are there outcomes better than yours. So, we want to see people who are outliers in both directions. People who have exceptionally good outcomes and people whose outcomes maybe could be better. And then that also gives us an excuse to reevaluate practice. If someone is not doing a metric that we thought was really important, but their outcomes are just as good, we have to reconsider whether that's something we really want to be spending a lot of time auditing or emphasizing.
How have some of the tools helped you evolve your ERAS program?
Dr. Porter Jones: Data is always an issue. It requires people involved or requires statistical analysis. Could you walk through a little bit, focusing on the second half of your journey, specifically using platforms like Encare and Avant-garde and how they helped to push your ERAS program forward?
Dr. Kevin Elias: Once you have your compliance metrics, then you can correlate your metrics with outcomes, right? So, we found essentially a direct linear relationship between compliance and complications. The more compliant we were, complications gradually declined. And we're not talking about necessarily major complications. Some of those people focus on the reoperations or the major surgical site infections. We're talking about a lot of the grade two complications; the patients needing rescue antiemetics and patients needing rescued bolus of IV pain meds on the floor. Patients with urinary tract infections. These are not necessarily things that are going to be producing a huge amount of morbidity, but they do impact both the length of stay and the quality of the experience for the patient. I think has been very powerful for us. The other thing that we can start to do and particularly with the Avant-garde system is we can correlate a lot of these compliance metrics with cost data. So, you can show not only that better compliance results in better outcomes for patients, but that it's also more cost effective care. And you can see what drives cost. And you can see compliance and cost moving in the same direction.
How have some of the tools helped you evolve your ERAS program?
Dr. Porter Jones: Can you expand on that subject - compliance and cost? It's interesting. Sometimes they can be in tandem, sometimes they can be counter. I'd love to hear your view of being able to put those together and what that means for you as a department and as a physician.
Dr. Kevin Elias: We know that from several studies around the world that ERAS compliance does save quite a bit of cost for the hospital. Depending on the research you read, the estimate is somewhere between 4x and 8x return on investment. For us, it really helps with being able to go back to our hospital administrators and say, look, we want to make some investment in our ERAS program to show where those cost savings are coming in. Sometimes it's pharmacy costs - if you're giving fewer doses of rescue medications, that's less money you're spending in the pharmacy on medications. Sometimes it's labor costs. Fewer patients on the floor means less time devoted to the labor salaries for nursing. Those again, are costs that you only really see when you are auditing the full pathway. Because if you're limiting things just so what happens in the operating room, those costs don't vary a lot. It's actually the floor care, maybe from the recovery area onto the floor where there are a lot of modifiable costs for individuals.
Where will ERAS be in five years?
Dr. Porter Jones: Final question, Dr. Elias, where do you hope to see ERAS in five years?
Dr. Kevin Elias: Well, we'd like to think that ERAS is becoming the standard of care. And so I think that's one thing that we're really trying to roll out. Rather than always having to flag that patients are an Enhanced Recovery patient or not Enhanced Recovery patient, we want it to really be the default. That most patients are managed according to enhanced recovery principles.
We’d also like to see ERAS being implemented around the country. Not just at academic centers, but also really out in community centers. ERAS should be seen as an improved way of generally providing patient care.
Dr. Porter Jones: That's wonderful. We really appreciate your time. This has been great. Very informative. Thank you very much.
Dr. Kevin Elias: Appreciate It. My pleasure. Really good meeting with you.
Dr. Porter Jones: Thank you.
A recording of the presentation is available to Watch Here.
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