SuperSHIFTER Dr. Claude Laflamme is the Medical Director of Quality and Patient Safety in the Department of Anesthesia at Sunnybrook Health Sciences Centre. He recently co-led a Canadian initiative aimed to improve safer surgical care across the country. Dr. Laflamme is currently involved in various aspects of quality and patient safety research. One of his interests is to spread best practices aimed at improving surgical outcomes from a multidisciplinary approach.

What is Enhanced Recovery After Surgery?

Enhanced Recovery After Surgery, or the acronym ERAS, is a program highlighting surgical best practices. It consists of evidence-based principles that support better outcomes for surgical patients. Implementing ERAS protocols result in an improved patient experience, reduced length of stay, decreased complication rates, and fewer hospital readmissions.

ERAS is a comprehensive, multidisciplinary approach to the care of the surgical patient. The multi-modal approach to recovery was pioneered in 1995 by Danish surgeon Dr. Henrik Kehlet for colonic resections. The International ERAS® Society, based in Stockholm, Sweden, was officially registered in 2010 and since then, the ERAS principles have expanded around the world. They are now applied to nine different specialties.

Is ERAS new to Canada?

In 2013, I joined the Canadian Patient Safety Institute’s Safe Surgical Care Working Group to help develop the Integrated Patient Safety Action Plan and improve the quality of care in Canada. In looking at best practices in surgical care, it quickly became clear that ERAS was the path that we should take to improve surgical outcomes here in Canada.

When the Safe Surgical Care Working Group met, we talked about how we could scale and spread ERAS in Canada. We invited representatives from McGill University, the University of Toronto, Alberta Health Services, and the British Columbia Patient Safety and Quality Council to join a group of CPSI partners we now call Enhanced Recovery Canada (ERC). Among ERC partners, we now have Health Quality Councils, the Royal College, healthcare providers such as nurses and doctors, and many other professional organizations. Today, Enhanced Recovery Canada is a group of clinical experts and leaders working together to improve surgical outcomes for all Canadians.

In Canada, there are currently a few ERAS Clinical Centres of Excellence: McGill University Health Centre, University of Toronto, Alberta Health Services, and the province of British Columbia. These healthcare organizations have gained significant knowledge and experience to support the implementation of ERAS program in other organizations.

What is the role of Enhanced Recovery Canada?

Enhanced Recovery Canada is a volunteer group of passionate physicians, nurses, and allied healthcare providers. The group first met in January 2017 and agreed to work together to spread ERAS across the country. Together, what they accomplished to date is very impressive. Everyone is very engaged.

The first clinical pathway ERC has addressed is colorectal surgeries. Looking at the international ERAS principles, there are about 20 elements in colorectal. If we multiply this by the number of surgical specialties, it could be overwhelming. However, Enhanced Recovery Canada chose six pillars for colorectal surgeries: patient and family engagement, nutrition, early mobilization, perioperative fluid management, multimodal pain management, and evidence-based surgical best practices. These core principles encompass the most important ERAS actions and are relevant for most surgeries.

We started with colorectal, but want to touch areas such as urology, digestive, pancreatic procedures, as well as gynecology and obstetrics, which are in every operating room in the country. The next phase of the ERC initiative will address other evidence-based practices.

Enhanced Recovery Canada has secured support from industry partners and over $500,000 has been committed over five years to fund this work.

How is ERAS innovative?

ERAS is evidence-based, it improves patient outcomes, and reduces both the length of hospitalization and cost. In addition, the fact that it is truly multidisciplinary shatters conventional siloed practice. It is a comprehensive approach, from the top down, that is multidisciplinary and includes both patients and healthcare providers.

What major learning have you had that you can share about ERC?

Most quality improvement projects are viewed as medical projects and not geared toward changing the culture of safety. They are not comprehensive and the work often vanishes after the project is completed. What we need to do is change care delivery that will create a ripple effect across services and throughout the country. I truly believe ERC can do that.

What future possibilities do you see for ERAS?

Because ERAS is truly multi-disciplinary, there are tremendous possibilities for the future. ERAS was originally developed for surgical procedures, but really it is a foundation that can be replicated for other things. If you want to speed up the process for quality improvement in Canada, ERC is the solution to make a patient safety culture happen.

Collaboration between jurisdictions is also an ERC benefit. A few weeks ago, we had a discussion with the American College of Surgery (ACS), about their national quality surgical improvement program and they are very happy to work with us. In fact, two Canadian physicians are currently working with ACS to develop new material. The United States has protocols in place for colorectal surgeries and for hip and knee replacements; they will work on gynecology procedures next. ERC is convinced that once the multidisciplinary quality improvement structure is in place, it will be easier to spread new practices.

Where can we go to learn more?

For an international perspective, visit www.erassociety.org. There is valuable information on that website.

The Canadian Patient Safety Institute provides the national perspective for Enhanced Recovery Canada. There is a lot of information out there and we have links on the website to McGill University Health Centre, who have excellent documentation on patient engagement, and Enhanced Recovery BC, who have good information to support the implementation of enhanced recovery programs. You can also learn from others and connect with an experienced ERAS coordinator.

Questions about Enhanced Recovery Canada can be directed to: info@cpsi-icsp.ca