And so our first award goes to Kristen Kupik et al. for their abstract nursing efforts in spine and peripheral nerve, enhanced recovery after surgery, pathway implementation and outcomes. Author block, Mara Capelloni, Emily Missimer, Diana Gardner, Benjamin Hertig, Rachel Pessoa, Albert Abo, Ali Ozturk, William Welch, and Zarina Ali. Hi, thank you so much for this opportunity to speak. My name is Kristen Kupik. I'm a nurse practitioner with the Department of Neurosurgery at Pennsylvania Hospital. And we'll be talking about nursing efforts in spine and peripheral nerve, enhanced recovery after surgery, pathway implementation, and outcomes. Got it. So enhanced recovery after surgery is a multimodal perioperative pathway designed to achieve early recovery for patients undergoing major surgery. ERAS represents a shift in perioperative care and reexamines traditional practices, replacing them with evidence-based practice. It is a comprehensive in scope and covers all areas of the patient's journey through the surgical process. The four main principles of ERAS are that the patient is a partner and active participant in their care, that the patient is in the best possible health before surgery, that we use evidence-based management to minimize the surgical and anesthetic harm, and that we provide the best possible rehabilitation to enable patients to return to their prior level of functioning as soon as possible after surgery. These principles can only be achieved by using a multidisciplinary team that's involved in the patient's entire surgical journey. So our Penn Neurosurgery ERAS protocol spans the pre-, peri-, and post-operative phases of care. The pre-op time period starts from the first visit in the office and goes up until one week prior to surgery. During this time, the goal is to optimize the patient's medical status and get them as prepared for surgery as we can. We do that by identifying comorbidities and surgical risk factors with a big focus on optimizing their nutrition, diabetes management, smoking cessation, chronic opioid use, and sleep apnea. And then we identify potential issues and refer to specialists as needed to optimize their total health before surgery. In addition, we really focus on surgical education to make sure that the patient is well-prepared and understands the surgical process, what the hospital course is like, and what their post-operative recovery is like. And this is the time point from that first appointment that we start talking about discharge planning so that the patients know that they may need help at home and they'll need to find family or friends to ensure that they have a safe discharge home. The post-operative phase starts from the time of discharge. And what we hope for is that we are able to ensure a safe discharge to either home or to another level of care and to prevent readmissions. So we do that with close clinical team communication between our advanced practice providers and nurses in the office, calling the patients within 48 hours of discharge to check in and address any questions. We have very close wound management to make sure they're following up with their incision care and if there are any questions about their incision, addressing those issues early. And we work very closely with our home health care agencies and our post-acute settings to ensure that we're all on the same page with managing the patient in the post-operative setting. The perioperative phase is the phase that starts one week before surgery through the hospital course. And this is where we're really able to make the greatest impact because we have control over the situation. So our goal during the perioperative period is to maintain patients' prior level of functioning after surgery and through the hospital course. The big factors that cause a prolonged length of stay in the hospital are IV analgesia, gut dysmotility, and immobility due to prolonged bed rest. So we really focus on limiting narcotics and increasing mobility to keep patients at their prior level of function. So early mobility is a really big part in the perioperative pathway. And we want patients to be in a situation as close to their home setting as possible even though they're in the hospital. So we've tried to eliminate Foley catheter use unless the patient is on bed rest. That encourages them to be up and mobilizing to the bathroom. They're out of bed within six hours of surgery once they arrive to the floor. We want everyone eating their meals in a chair instead of in bed. And we have an inpatient walking program that starts on day one after surgery where patients are encouraged to mobilize three to five times a day as tolerated. So prior to the implementation of our ERAS pathway, our traditional standard of care did include a mobility protocol. However, there was a lot of variability in when patients were getting out of bed. There were many times that they weren't mobilizing until the day after surgery. We also did not have a protocol for Foley catheter removal. And it was very dependent on the surgeon, what time the case came out of the OR, whether or not they would have a Foley. Both of these factors led to a lot of discrepancies in post-operative care among the nurses. The patients were hearing different things about what their care would be like. And it really caused discrepancies in what the patients were expecting after surgery. Once we created this ERAS pathway, we were able to create a standardized mobility protocol that the patients heard about in the office. So when they got to the hospital, they knew that they were getting up and they knew exactly what their plan was. We had Foley catheters removed in the operating room at the end of the case. And these two changes really made a big difference in the consistency of the post-operative management that our patients received. And then both the patients and the nurses' expectations were aligned and really improved their post-operative course. So in order to roll out this change in practice, we needed to provide a lot of education to many different disciplines. So our advanced practice team led the educational efforts for our nursing, patient care techs, physical therapists, and social work to let them know about the change in practice so that everyone was telling patients the same information. Our surgeons provided education for the OR staff about Foley catheter removal to make sure that they were the champions to remove Foley's at the end of the case. We had frequent reassessment of the protocol, re-education as needed, and modification of our protocol throughout the process. So our pilot neurosurgery ERAS study, we had prospective enrollment of 201 patients from April to June of 2017. We compared that to a historical cohort at our hospital of 74 patients, and also compared it to a control cohort at one of our sister hospitals with the same patient population. And we found that ERAS does improve post-operative mobility and we more than doubled the number of patients who were mobilizing on the day of surgery. And by post-op day one, almost over 80% of our patients were up and ambulating compared to only 45% of them before we implemented this protocol. In addition to mobility, we were able to significantly reduce our Foley catheter use with only 20% of our ERAS patients having catheters after surgery as opposed to 47% of the control group. And the great thing about that is that we also saw no increase in the need for straight catheterization with early Foley removal. So in conclusion, we were able to effectively implement an ERAS pathway by engaging all staff in the launch of the protocol. And by engaging all staff at every level in all disciplines, we were really able to create a noticeable culture shift among our inpatient team. Education by the multidisciplinary team was integral to keeping everyone engaged and focused on the protocol. And we were able to address two really huge nursing initiatives by increasing our ambulation after surgery and really drastically decreasing Foley use. We continue to monitor protocol compliance very closely to make sure that everyone is still on board with the protocol and that we don't need to do extra education. So it's been a really positive experience. And a huge thank you to our whole neurosurgery team, Dr. Ali, who's here, for supporting our ERAS protocol, all of our nurses and staff. Thank you. Thank you. Nice presentation. Any questions? Yes. How are you monitoring ambulation? So, like what is ambulation or how are we tracking it? How do you track it? Is it through ethics? Is there a process that the nurses are following? So that's a great question. So what we had found initially is that we weren't capturing who was ambulating and it was being documented in multiple different ways in Epic. And so we met with our nurse managers and clinical nurse educators and developed one place that everyone is tracking mobility so that we can run reports to pull who's mobilized.

Kristen Kupik

nurse practitioner

Department of Neurosurgery

Enhanced Recovery After Surgery

ERAS pathway