MEDICALREFORMANDFUTUREOFSURGICALRECOVERY(ENHANCEDRECOVERYAFTERSURGERY)醫(yī)改及手術恢復的未來(增強術后康復JeffreyHuang,AssociateProfessorofUniversityofCentralFloridaCollegeofMedicine,Orlando,FLInternationalGynecologicERASGuidelineworkinggroupDirectorofresearch,DepartmentofAnesthesiology,ArnoldPalmerMedicalCenter,Associatedirectorofresearch,DepartmentofOB/GYN,ArnoldPalmerMedicalCenter,HealthcareinHealthcare:17%ofthegrossnational49.9million--ThenumberofAmericansin2010.That's16.3%ofthetotalpopulation.ThequalityofcareisonaverageinferiortothatofcountriesthatspendmuchHealthcarein醫(yī)療：國民生產年沒有保險的人TheUShealthcaresystemseemsheadedforbecauseofitseverincreasingand 向因為其不斷增Healthcare AffordableCareAct支付得起的醫(yī)療法)seekstoreducehealthcarecostsisbyencouragingdoctors,hospitalsandotherhealthcareproviderstoformnetworkstocoordinatecouldkeepcosts What'sanAccountableCareOrganizations(ACOs)(問責醫(yī)療機構)aregroupsofdoctors,hospitalsandotherhealthcareproviders,whocometogethervoluntarilytogivecoordinatedhighqualitycaretotheirMedicarepatients. accountabletothepatientsandthethird-partypayerforthequality,safety,andefficiencyofthehealthcareprovided ACOandMedicalACOsarecomprisedofmany“medicalhomes”醫(yī)療之家)MedicalHomesareattheheartof醫(yī)療之家醫(yī)療診所MedicalHomeamodelofprimarycarethatisaccessible,andfocusedonqualityandsafety.CoreFeaturesoftheMedicalPatient-centered( 為中心Comprehensivecare(全方位Coordinatedcare協(xié)調服務Superbaccesstocare便利就診Asystems-basedapproachtoqualityandsafety(基于 Patient-centered(以 Providingcarethatisrespectfulofandresponsivetoindividualpatientpreferences,needs,andvalues,andensuringthatpatientvaluesguideallclinicaldecisions eachpatient’sphysicalandmentalhealthcareneeds,includingpreventionandwellness(健康),acutecare,andchronic coordinatescareacrossallelementsofthebroaderhealthcaresystemincludingspecialtycare,hospitals,homehealthcare(家庭健康護理andcommunityservicesandsupports協(xié)調服務更廣泛的衛(wèi)生系統(tǒng)的所有要Superbaccesstocare便利就診shorterwaitingtimesforurgentneeds迫更短的等待時間迫切需enhanced 提高 的時around-the-clockephoneorelectronicaccess(電子)toamemberofthecare整 或電Asystems-basedapproachtoqualityandsafety(基于 usingevidence-based(基于 andclinicaldecision-support(決策支持)toolstoguideshareddecisionmaking(共同決策)withpatientsandfamilies,engaginginperformancemeasurementandimprovement(績效評估和改進)measuringandrespondingtopatientexperiencesandpatientsatisfaction( es結果Evidenceshowsthatpatient-centeredcarenotonlyimprovesclinical es(醫(yī)療結果qualityoflife(生活質量andpatientsatisfaction,butalsoisassociatedwithadecreaseininappropriatehealthcareutilizationintheprimarycaresetting有表明，以為中心的護理不僅提高了醫(yī)療結果，生活質量和的滿意度，而且還JAmBoardFamMed2011,24(3):229-Whatabout Surgicalcareaccountsforapproxima 65%ofallhospitalexpenses外科護理占所有醫(yī)院費用約abetterpatientexperience更好的患者體驗betterhealthcare(更好的醫(yī) alowercost較低的成本Theimmediatechallengetoimprovingthequalityofsurgicalcareisnotdiscoveringnewknowledge,butratherhowtointegratewhatwealreadyknewintopractice (UrbachDR,BaxterNN,BMJWhatisenhancedgetbettersooneraftersurgery更快更好21thcenturysurgicalDevelopedbyKehletinDenmarkincolonicGraduallyhasgainedworld-wideTheERASisnowwidelyusedwithinhospitalsforpatientshavingcertainoperations(Colorectal,Urology,Orthro,Gyn,Vascular)逐漸贏得了世界廣泛接KeyTheunderlyingprincipleistominimizethestressresponsesonthebodyduringEssential(基本要點ThepatientisinthebestpossibleconditionforsurgeryThepatienthasthebestpossiblemanagementduringandafterhis/herThepatientexperiencesthebestpost-operativerehabilitationThebenefitsofenhancedEnhancedrecoverySignificantlypatientexperience,increasing es醫(yī)療成果multi-disciplinaryteamworking多學科團significantreductioninlengthofstay(reducedcost)reducedriskofhospitalacquiredinfections(reducedcost)Averagesaving10%peroverallcost-savingofroughly$6900perpatient(CanUrolAssocJ.20115(5):Program FollowteamleaderFollowHowdoestheprogrampatientpatientinthebestpossibleconditionforThebestThebestInsurgeon’soffice外科醫(yī)生Managingthepatients’expectations Decision-making(決策PatientNonsurgicalSurgeonsandtheirofficeDecision-making(決策helpsthepatienttobefullyinformedaboutthepotentialbenefits,risks,alternativesandrecoverypathsoftreatmentoptions decidetheformoftreatmenttheywishtoundertake,beitsurgeryormoreconservativemeasures.improveexperienceandsatisfactionthroughmorerealisticexpectationsandalsotoensuredecisionsmatchindividualvaluesandpreferences.Decision-Avarietyofdecisionaidscanbeusedasappropriateforthepatient,forexample,writtenmaterials,verbal,DVDs.PAT(住院前測試playsanextremelyimportantroleinhowpatientwillunderstand,considerand yparticipateintheenhancedrecoverypathwayPATisrequiredforsafetyreasonstoensuretherisksofundergoinganesthesiaarePATensuresthatpatientisintheoptimum(最佳)conditionforsurgery.(HTN,DM,Asthma,Anemia,Stable,regularfollowupbyPCPorspecialties Nostable,followProceed,acquirelastvisitnoteandtestresultsstop,reevaluateandconsultwithPCPorspecialtiesforoptimizationHealthypatient:ifnotexerciseregularly,instructthemtowalk1 adaytilldayofsurgerySmoking:encouragepatienttostopsmoking,minimal24hrbeforeAlcohol:stopWatchpreopsurgeryandanesthesiaNPO禁食NPO禁食0-2hrsNothing(nochipsofice,nomints,nogum,nosipsofwater)2hrsClearliquids,coffeewithoutcreamorsugar,juiceswithoutpulp6hrsMilk,fullliquids,lightmeal,low/non-fatmeal,lowvolume8hrsHeavyAskpatientwhethertheywatchPreopmedsincludingneurontin300mgandcelebrex400mgNomechanicalbowelAvoidanceofDrainsandNGTpost-Deepveinthrombosisprophylaxis stockings(深靜脈血栓形成的預防：氣動機械Antibioticprophylaxis:AsingledoseofLocalanestheticsinjectionintheincisionAnesthesiaFluidGoalistokeepfluidadministrationtoaminimum,withanemphasisoncolloidsIntraoperativeopiatesatclinician’s 10mgpre-incisionand10mgatthehalftimeofsurgeryKetorolac酮咯酸15mgIVatendofIVTylenol對乙酰氨基酚)1000mgPulmonaryrecruitment(forlaparscopyAntiemetics(2-3agents)atAvoidanceofopiatesandtheuseofTyenolandnonsteroidalanti-inflammatorydrugs(NSAIDS)Pain PainOralOxycodone5–10mgorallyevery4hasneededforpainrated4orgreaterorgreaterthanpatientstatedcomfortgoal(5mgforpainrated4–6or10mgforpainrated7–10);forpatientswhoreceivedintrathecalgesia,start24hafterintrathecaldosegivenScheduledacetaminophen*(對乙酰氨基酚Acetaminophen1,000mgorallyevery6hforpatientswithnoormildhepaticdisease;acetaminophen1,000mgorallytwicedailyforpatientswithmoderatehepaticdisease; umacetaminophenshouldnotexceed4,000mg/24hfromallsourcesScheduledNSAIDs類固醇消炎藥Ketorolac酮咯酸)15mgIVevery6hforfourdoses(startnosoonerthan6hafterlastintraoperativedose);then,ibuprofen(布洛芬)800mgorallyevery6hstart6hafterlastketorolacdoseadministered)PainBreakthroughpain(paingreaterthan7morethan1hafterreceivingoxycodone)Hydromorphone(氫 酮)0.4mgIVonceifpatientdidnotreceiveintrathecalmedications;mayrepeatonceafter20miniffirstdoseIVpatient-controlledHydromorphonepatient-controlledgesiastartedonlyifcontinuedpaindespite2dosesofIVhydromorphoneFLOOR 護士oralnutritionalsupplementsfromthedayofsurgeryuntilnormalfoodintakeisPatientsshouldbehelpedtositoutinachairontheeveningofsurgery.Itis mendedthatpatientsisoutofbedfor2hoursonthedayofsurgeryand6hoursthereafter.Dischargecriteria(出院標準Thepatientshouldbeabletotoleratedietandoralfluids,tohavepainadequa ycontrolledonoralhavebowelsfunctioningorflatusbeconfidentandagreetogoFollowup追隨(1)afollow-upphonecallafterdischargefromthehospitaltoansweranyquestionsfromthepatientorfamilyortodeterminethatthepatientisrecoveringappropria (2)aphonecalltoaddresspatientsatisfactionissues;or(3)aphonecalltoprovideadditionaleducationorguidancetothepatientonaparticulartopicrelatedtotheirhospitalstayAudit:DataCollection審計:數據收LengthofhospitalPatientcontinuousauditcycleshouldensuredetectionofanyinstitutionalproblemsassociatedwithERASimplementationcontinuouslyup-to-dateandevidencedbasedERASpractice.From:AdherencetotheEnhancedRecoveryAfterSurgeryProtocolandesAfterColorectalCancerDa