what the protocols themselves look like and I'll contrast what we had at the University of Virginia and what we're doing at Atrium Health. And then would love any feedback about what you guys are doing or thinking about. Okay. So, okay. These are some self-assessment questions that I threw in here, but I think we've talked about a lot of them, but just things to think about, really, this presentation would be if you knew nothing about enhanced recovery programs, so which of the following is not a key concept? These are just things to think about. You don't have to answer them. Early ambulation, opioid sparing, preoperative fasting, or patient education. Next self-assessment question would be who are three key members of your enhanced recovery team? And don't worry, we'll answer all of these questions. And the last one is which of the following could be considered a major barrier to implementing enhanced recovery protocols? Changing traditional practice, the cost, or that your staff is continuously changing over. For example, you have a new resident on service every month. Okay. So we talked a little bit about, so there's the preop, intraoperative, and postoperative phases. And preoperative, the most important part being the patient teaching, the surgery handbook. I think we talked a lot about that. The other thing is the preoperative hydration that we didn't really get into. So, you know, the goal here, and I think a lot of times, especially for our older patients, you tell them they have to drink a Gatorade, they're like, oh, I hate Gatorade, like the little older women. That's all organic, no artificial options that all of our patients have worked with. We have the same drama, trust me. I have convinced some anesthesiologists that coconut water is actually pretty okay. I have a very high number of all-natural. You definitely need to make sure it's okay with your anesthesiologist first, though. Here's the paper, and I think it does pretty well, too. Because I had a student who was like... Because I won't remember that. It depends on the anesthesiologist. We have no nurses at our hospital, it's all anesthesiologists. And they each have their idea of... They're not supposed to practice as far as how they understand the patient. So, if you have one that might be really progressive, yeah, then you have to put two hours before. They're like, oh, no way, we're not going to put that patient to sleep. We have barriers to implementing the preoperative Gatorade, or whatever that... I'll find it. It's a whole paper on, like, literally someone with their self-controlled lipogastric angina, and it's gone. Gatorade is gone. I think we're going to have to start at the top of the chair. I was just going to say, that's what you need to do. And there's plenty of evidence now out there that it's safe and that people are doing this. And so, I think presenting that head person, in my experience, with the evidence, and then that helps sort of trickle it down to convince everybody else. Especially if then it becomes a protocol. So, the requirements for that drink is it needs to have carbohydrates, electrolytes, and no particulate matter in it. So, you do have some leeway, but I think it's important to pick one, and then maybe have an alternative, so you're telling all of your patients the same thing. And especially because then when our preoperative nurses call the patients the day before and are reviewing things with them, you want to make sure you're all consistent in saying the same thing every time. So, if then all of a sudden you can have this or this to drink, then automatically patients are confused about what the protocol is supposed to be. Clear communication about that. Okay, so what was I going to say here? So, this is a little screenshot of what my packet that I made looks like. So, I don't have the fancy binder, I have a packet. And you can see there's a little excerpt on there that says, remember to bring this with you to every single office visit, to your admission, and all to your follow-up visits. And when you sort of circle that and put a star next to it, and then go through the whole rest of the packet, it works. And when patients have questions, they really do pull out their packet. I think that's kind of the most amazing thing about this. Emphasize, of course, her role in her recovery. So, you do that by setting up expectations. And then also saying your expectations for discharge. So, for us, when we're trying to make sure, you know, as a goal of ERAS at Atrium Health now is to encourage same-day discharge, by setting that on the first page, it says, I'm expected to spend this many nights in the hospital. And I fill it out, how many nights in the hospital they're supposed to stay. I think, you know, again setting that expectation is a major motivator for whether or not they want to or not. Identifying the patients as enhanced recovery patients in the chart. So, that one, the preoperative nurses. So, we have the preoperative nurses call all the patients who are having surgery the following day. I'm sure a lot of places do the same. The evening before, just, you know, confirm the time and go through some preoperative teaching with them. And so, to make sure that those nurses are saying the same thing to our patients that we say to our patients is a huge part of it. Okay, we looked at this before. So, this was the preoperative phase at University of Virginia. So, it says on here gynecology light, because at the same time we started enhanced recovery, our gyne-onc colleagues also did. And they had the ERAS full version of the protocol. And so, the full version of the protocol included a preoperative spinal, because those patients are all having laparotomies. And we didn't want the spinal as part of our protocol. So, I purposely left this here so you can see what the anesthesiologists pull this up. Okay, they know this is a light or a full patient and this is what they can follow. And so again, in the preoperative area, the surgical admission suite, they're allowed to have Gatorade up to two hours before induction. And really that means they've finished it by the time they get to the parking lot in the morning. They had Celebrex, Gabapentin, Acetaminophen, and Escapolamine patch. And the Anoxaparin, plus or minus, based on the, you know, our VTE stratification protocols, most of the time not in our patients. IV is placed, but they're not given any fluids in the pre-op area. So, atrium health, what does that look like? So, again, they had the same thing, 20-ounce Gatorade that they can drink on the way to the hospital. They finished two hours prior to induction. Pretty much everyone got SCDs, again, based on the VTE risk stratifications. Colmium patch, Tylenol, Gabapentin. We chose not to give an NSAID preoperatively because we'll be giving NSAIDs intraoperatively, so there is some leeway. Preoperative warming, the patient, is also an explicit part of the ERAS protocol. It's something we were doing at the University of Virginia already, but a new thing for atrium health, so maintaining a certain body temperature is another thing you might want to think about including in your protocols. And then whether or not to do a tap block is sort of based on attending preference still. We haven't quite figured that out yet, but I think there is room in ERAS protocols to either do a tap block or not. The way we do this now is when we post patients for surgery, when we submit that posting slip, we say they're going to get a tap block or they're not so that then anesthesia knows because our anesthesiologists are doing it in the preoperative area if they know that's happening. So that would be another barrier if you start to say everyone in my ERAS protocol is going to have a tap block and preop you might have to think about your anesthesia resources. And I know our colorectal colleagues who do do tap blocks in all of their laparoscopic surgeries do the tap blocks themselves now intraoperatively to try to overcome that. So it's a transabdominal peritoneal block. So it's a local anesthetic that you're injecting really into the peritoneum under ultrasound guidance. And you do that in the either preoperative area or intraoperatively. It's sort of another way to do that would be to just inject local at your port sites during laparoscopic surgery. There's about a million publications out there in benign GYN surgery trying to compare the two tap block to just port site injections. And for every study you find a difference for you can find a study that shows no difference for. So, open to opinions about that. Did you put in the orders for the psoriasis, pre-dementia, and gabapentin? Yep. That's a good way to do it. Exactly. So when we have our little power plan or whatever you guys call your standardized order sets. And so for the preoperative phase, we put in all those orders. We have the antibiotic ordered, we have the scope patch ordered, and everything you see on here is ordered. Is there a timing for how soon they arrive they should get into primary surgery? There's not. So, you know, they come in two hours before their start time. So they pretty reliably are in the preoperative area two hours before. And sometime in that time frame. So is there a delay, for example, if they get their pills 30 minutes before or an hour before? There's not. They take their pills with the water. So we have actually, we have encountered that if you have a cancellation and the patient moves up, what do you do? Because then they don't have that two hour delay that they had their Gatorade. At University of Virginia that was no problem. At Atrium Health that did delay some cases the first week. And so we had to sort of have a meeting about that and talk about that. I mean, it doesn't happen very often for us, that patients... Yeah. Yeah. Put your FPDs on. So I'll preface this by saying whenever anyone has studied an individual element of the ERAS protocol, they haven't seen a huge significant difference. So if you say, okay, let's just give our patient scabapentin and do nothing else, you don't have the same outcomes as if you are using the whole bundle. So I think it really has something to do with this multimodal regimen as opposed to anything in particular. I don't know if any... Feel free to disagree with that if you... There's this pretty cool panel. Felicia's super excited about it. And they're putting together this amazing guy who is an epidemiologist. He's so smart. He's on first and then I somehow got asked off. And then PT. And he's literally going to go through how gabapentin isn't... It's not one answer, but it can literally all work. He understands all of this. It's interesting. I just reviewed a paper on this and they found no difference. But then again, they did whatever they wanted pre-op. They did whatever they wanted intra-op and whatever they wanted post-op. So yes, I rejected the manuscript because I was like, what? But it literally modulates pain at a nerve level. I don't want to steal his thunder. But it literally does this to the nurse. And it brings down the volume of the nerve that's about to be attacked by others. I'm not... People... I don't... I won't have to talk about it because we understand it better than this house. I understand it. It just turns your brain down to that nomming stimulant that we're about to cause. It's not sick. It's not infected. It's just that the nerve is now like... So it just turns down the volume of how your body is going to appreciate that. That's very helpful. We've had really good luck with that. We've had really good luck with that. It's like $25. She did a really nice paper on that. It's okay. That's one of the nice things about having to work together on here. You sit across from the front of a super, super strong person and they're like, why are you here? I'm a state institution, so they're just like, we don't get that. But they basically told us P.O. works just as well. So when we did it on our ashram in the first place, I would have said the same thing. It's just so great. I'm just thinking from a moving patient's perspective. Again, I think maybe this is the cost. We just had to use P for stuff. We're just using less expensive. For example, Toradol. We did it for only 15, I think, percent of the same day. We found that Toradol made no sense post-op. So again, there's all these things you have to kind of challenge yourself like, oh, it doesn't work when you actually look at it. But for some reason, these three together in a setting, it just lowers the cost. So another part of this is post-op nausea, vomiting, prophylaxis. So that's a big part of this. That's what this fulminum patch is about. And you'll see it's sort of built in throughout as well. Well, so I would say to that, I think the nice thing about at University of Virginia is colorectal surgery had a protocol. And so we could use that protocol to sort of build off of. When I got to Atrium Health, colorectal surgery sort of had a protocol that they were kind of just starting, but not really. And so I really used, what I wanted to use is just, okay, here's the one I used at University of Virginia. It worked great. And there's, well, what about our tap box? Well, we want to use Toradol. Well, there's lots of pushback from lots of different people. So I sort of restarted. And when I made this protocol, there was that whoever your anesthesiologist who's going to be on your team is, whoever that is, if he's the head anesthesiologist or he or she, or just anyone who has some kind of sway among his colleagues. So it has to be an anesthesiologist, someone from pharmacy, a pre-op and a post-op nurse, and a floor nurse. And so we all sat down together and made this protocol together. So you'll see there's lots of things that are different, but the structure is similar. So you have some kind of NSAID. You have some kind of neuromodulator. Some people use Lyrica instead of gabapentin and acetaminophen. Yeah. Go ahead. You go first. But if I could just say something right now. I think because we say, this is so great. You're going to do so great. And then they're like, but I'm not. Oh, but this is so great. And I actually was thinking that last night before I said it. They do really well. I don't know. I think it can teach you. And we brainwashed them from the very beginning that you're going to do so great. Oh, but I'm so sweaty when I have problems. And they're like, no, but you're going to do so great. Because this is going to be so different than anything you've ever had before. But you're right. I have to actually look at that. At Atrium Health, there's one of our providers who does most of the chronic pains. Of course, it's a little bit skewed because it's really just her patient population. Those patients take gabapentin for three days before surgery. They have our intraoperative, they go through the enhanced recovery protocol. Those patients almost all get a tap block. And then she continues gabapentin for five days after surgery. So it's a little bit different. Hi, I'm from Dallas. So those patients would be like laparoscopic surgeries for endo or something like that? Correct. Yep. My question is, I know we try to protocol as much as we can and have it standardized as much as we can, but are there patients for whom little ladies or renal dysfunction or something that you have to check this or have the alternative plan for your patients? So the NSAID, of course. And scopolamine patch in patients older than 65 we're not using. And so we have, I think, maybe it's the next slide. You do your VTE, prophylaxis, whatever way, whatever risk stratification you want to do. Here's our postoperative nausea, vomiting. I think it's the next slide. I'll get to answer your question. But this is what anesthesia was previously using. So I sort of use this to convince them that, look, all of our patients are going to fall into that risk score of three or more and need all of those things. So there is evidence to justify each component of the ERAS protocol is what I was getting to with this. Oh, shoot, I didn't include it. So we do have exclusion criteria for some of those things. And it's part of printed on that protocol. And especially because we're placing those preoperative orders, either the residents or myself or whoever it is, it's not the anesthesiologist or nursing who's just choosing what to be part of that protocol. Once you have that specified, then they just, they'll give whatever is ordered in the preoperative phase. So yes, there are times where you need to modify based on renal function or age or things like that. ... ... ... ... ... ... ... ... ... ... ... I think that's an excellent idea if you have those resources available to you. ... ... ... ... ... ... ... ... Okay, any other comments about the preoperative phase? All right, so now we'll move to intraoperative. So the biggest thing that you'll need anesthesia's assistance with is this goal-directed fluid therapy. So trying to minimize the amount of IV fluids they're getting intraoperatively. And there's a couple different ways to do it. At University of Virginia, they all had these pleth variability index monitors in every single OR. And so that's a constant recording of the patient's maps. And so they fluid resuscitate based on maps. Those little monitors are apparently very expensive. So there are other ways to do that where anesthesia can do it just based on blood pressure, fluid resuscitation by weight. There are ways to get around that. And there's lots of different protocols available out there. So this is the part of the protocol that you really can't do by yourself, I think. But if you have an anesthesiologist on board, which you'll need, they can come up with a protocol that will work for everybody. Encourage vasopressors for hypotension instead of more fluid volume. I think that's the main thing. Just coming up with a standard protocol that your anesthesiologist can get on board with, that's opioid sparing. And for us, and really what's published in the literature is a lot of ketamine and propofol intraoperatively. And then plus or minus on the lidocaine infusion. So there's a couple different ways to include the local anesthetic into your protocol. You can do it with the transabdominal peritoneal block we talked about. You can do it with the lidocaine infusion. Or you can do it just with local injections of or an injection of a local anesthetic at your port sites. So all have been studied. There's ERAS protocols using any variation of those. I found the easiest thing to convince people to start out with at Atrium Health is just make sure everyone's using local anesthetic in your port sites. And you have to use at least this much. So that's an easy way to start your protocol. At UVA, colorectal surgery was already doing the lidocaine infusions. The issue with the lidocaine infusion is if you're going to continue that postoperatively. We had an anesthesia team who followed the patients postoperatively for anyone who had a lidocaine infusion because they're monitoring for lidocaine toxicity. And that's who the nurses page if they're concerned about it. So that gets into another conversation if anyone has had experience with that. That's just a question that I would give. I do a lot of injection of local during my vaginal head. And I already have them jumping, oh that's too much local, oh that's too much local. I got one for you. So, it's definitely a culture change we've had. We negotiate. And we have a huge checklist in our ORs. We have to do inpatient, outpatient. And one of the things we found that was fake is how much local we're using. I pretty much push as far as I can. And I have this great, I have this resource from one of the CRNAs who gave me, it's from the, someone help me take the British Health System. And you've got this great chart I can also provide that as well. But I could of course select 50, and we use lidocaine because of the decreased rate of toxicity. And we can give a lot of I give it plenty. You can give a lot. 50 or 60. I'm going to change the site right now. We use it plain. We just use it plain. We don't use that. Yeah, we just use it plain. I think the point here, what I've learned is that it's important to include a local anesthetic in the protocol. But there's some leeway in terms of how you can do it. And there's not a lot of evidence out there about if one way works better or another. So hopefully there will be one day. But I think the important thing is when starting your protocol, make sure it's in there somewhere. And then how long do you do lidocaine infusion? Just intraoperatively if the patient's going home that same day, or continue it postoperatively if they're not. Tap block if it's an abdominal surgery, or just the local anesthetic if it's a vaginal surgery. Okay, so this is what the laminated protocol looks like in the operating room. So again, no opioids without attending approval. We talked about that. You can see their induction agents there. The dexamethasone is part of that postoperative nausea-vomiting. And then their IV analgesia. Cold directed fluids. I think we sort of talked about that mostly. Questions about that? Okay, this is what the intraoperative protocol at Atrium Health looks like. So again, we have the nausea-vomiting prophylaxis. They standardize the amount of dexamethasone and zofran that patients are giving. They keep the rooms a certain temperature so that the patient is a certain temperature using a fluid warmer, bear hugger. They have very strict protocols for managing hyper and hypoglycemia. And then again, for us, it's either the local injection of anesthetic or the tap block. And if they're getting a tap block, those patients have received the maximum amount of local they can with the tap block. Our patients get an intraoperative NSAID. Ketamine, propofol, and again, limiting narcotics. Okay, so then onto the postoperative phase. So, you know, part of this is pretty, you know, it's easy to say, early ambulation and early feeding, but how to actually implement this has a lot to do with nursing education. So, for us, all of the patients who are spending the night in the hospital get up and they sit at the bedside chair for six hours or three hours, or you know, you choose your time frame. And then they have to walk once with the nurse in the hallways. And that is specified in the order set. And after multiple meetings with nurses on floors and nurse educators, it works. I mean, you just have to present them with evidence for it and tell them why you're doing it and who they need to do that with. Same with the use of the incentive spirometer. And then they're drinking clear fluids and PACU and eating by that evening. Anything you want to add to that? Okay. And then postoperative phase. So, this is what it looks like for the University of Virginia protocol. So, in PACU, they can have opioids as needed. We actually, we don't give any IV opioids at all. So, it would have to be oral. Again, at University of Virginia, if it was a chronic pain patient, we had that acute pain service, which was the anesthesiologist who also managed the lidocaine drips. So, they were there to assist with the need for that, which is nice. I don't have that atrium health. And then, again, you risk stratify for VTE prophylaxis. I think the next... So, clears and out of bed and PACU, no IV opioids. The lidocaine drip, that depends whether or not they're spending the night restricting IV fluids. That's something I didn't mention. And then, I think the important part of this slide here, as you can see, this is what the nurse's checklist looks like. So, in the EMR, the nurse has a checklist of, did I do this? Did I do that? You know, they go through the checklist for all the ERAS elements. They're also weighing the patient every postoperative day. So, if nothing else, the patient has to get out of bed to stand on a scale. And the same discharge criteria as before. Yes, question in the back. They're in the EMR. I think you need to make it as easy to integrate into their workflow as possible. And also, a place where you can easily follow up on it. Everything's all in the same place. That would be, I don't know if anyone's had a different experience with that. But, definitely working with your EMR folks is important for this. Mm-hmm. Yeah, there's definitely a difference between the order set that the nurse is using versus the nursing checklist. Because the nursing checklists are really things that they have to do as part of their flow sheet of documentation. So, that was a learning point for me, is that just because I put it in the order set doesn't mean that, you know, just because I put in, make sure the patient ambulates on post-op day zero, that's different than having it as part of the nurse's checklist of to-do things. So, that's something that, working with nurse management, that's how I learned that. That's awesome, yeah. The gum is a great idea, and so are the cordless STDs. Yeah. Mm-hmm. Yeah, making sure patients are able to get out of bed the same day of surgery took more work than I thought it would. So, like Dr. Turbridge mentioned, we had Bethany at University of Virginia who was sort of our nurse coordinator. So, she would, especially at the beginning, visit every single patient on the floor and make sure that the nurses were helping the patients get out of bed. We don't have that. You just sort of expect, okay, well, you told them that's what they're supposed to do, that's what they're going to do. But it actually, just something as simple as unplugging the STDs or getting them, you know, unplugging the IV pole takes more work than you think. So, that's an excellent idea. I was going to add to this is, I don't know how long we've had this now, but every patient room has like a little braille erase board. I don't know if you all have that. And the nurses, so when I do a post-op, if I have a chance, and the residents all know to do that, we literally make a little checklist. You need to walk three times. You need to eat, sleep, eat, sleep. And then the nurses or the nurses then have a little place to check off. So, it's very old school, but then when I come in the morning, I'm like, oh, look, all the boxes are checked off. Or that afternoon, they've already walked once or twice. And again, again, it gives that patient, that nurse, it's like, you haven't walked me. It's not just because I have to walk. And again, it's a dry erase board with a, it's not fancy technology. And it's very cheap. It's similar, but they've set up the medications that the patients have to receive and then they circle it by starting from pre-printed dry erase boards so that the patients already know what they can do. And so, instead of looking in the electronic records anymore, we can look at the work they're working on. That's nice, yeah. This slide just shows you what the atrium health post-operative phase looks like. So, for patients staying in the hospital, they're getting scheduled Tylenol, scheduled Toradol, and then they can have as-needed Oxycodone 5 mg every four hours, no as-needed IV opioids. Fluids are at 40 cc's an hour and then they're turned off the next morning. Out of bed to the chair the night of surgery and then to walk three times a day each post-operative day. So, not too much different, but just shows you another way to go about it. I think we talked about this, power plans and order sets help standardize all of this. I think that's it for each of the components of the ERS protocol. So, again, the next thing we've alluded to this a lot is, you know, what is your team and how do you even start making these protocols? And it's, I can't say enough how important it is to make sure you have nurses involved, anesthesia involved, pharmacy in order to structure these protocols. Because if you just make them and ask people to abide by them, you'll inevitably find some resistance and lots of different opinions about it. And then in order to implement the actual change, doing this with your medical record, having checklists in the operating rooms, in the pre-operative and post-operative areas, and again, ongoing education. So, meeting with people multiple times to encourage this and to talk about why this is good for our patients. This just shows you the timeline at the University of Virginia of the time between when we very first started it until patients were actually enrolled, just to give you a sense of how long it took us. So you can see we first started the discussions in the summer of 2014 and then it was the summer of 2015 by the time we started enrolling patients. Some important things on here were implementing all of the education for patients and for nurses, making our EMR order sets, and then finally implementing ERF. Were you the first to go live in your institution or did Colorectal go first? Colorectal went first. I think I have a slide about that. This is, Dr. Hedrick said, it's never going to be a perfect time, so just get something out there. Don't wait for forever. I'm going to skip, yeah, here it is. So you can see ours is 2014 to 2015. The colorectal surgery really started in 2013. And you may find that there are divisions in your institution that are already doing this too. Certainly the most data for this is in colorectal surgery. So it may be worth looking into that or asking your colorectal surgery colleagues. I was surprised to see that the orthopedics group at the University of Virginia has a different program. Oh, that is interesting. I think orthopedics is the most recent group at the University of Virginia to start doing it. Okay, and we're going to talk a lot more in the next lecture about overcoming these sort of leadership and institutional barriers, but these are the main things that you guys either identified on the survey or that we've heard before. We've come, just anecdotally, the biggest barriers that we've confronted. I think the biggest things are changing deep-rooted practices, convincing people to change what they've been doing forever and ever. People are worried it may be more expensive. And an academic medical center, trying to standardize something when you have a constantly rotating staff. I think Dr. Turbridge is really going to go over the system's perspective of this in a lot of detail, but I think the take-home point is that you really are involving a multidisciplinary team when you come up with the protocol, and then you're constantly giving them feedback along the way about how things are going. And it's been very successful at University of Virginia. We talked about that and how it's expanding. We have new institutional support, and hopefully I can say the same in a year at Atrium Health. I think that's it. I think we can go ahead to our break. Oh, okay. I think you guys answered this already. Which of the following is not a component to enhanced recovery? Of course it's the preoperative fasting is not a component. Early ambulation, opioid sparing, patient education and expectation management are. Three members of an interdisciplinary ERS team. Oh, I don't have an answer there. I guess you guys have to answer that. Patient. Anesthesia. Nursing. Yeah. Those are the biggest ones, I would say. And then which of the following are barriers or perceived barriers? All of the above, definitely. But hopefully in the next couple hours we can help you address some of those. So let's take a break. There's snacks in the back. They're illegal. So despite me being at this podium, this is supposed to be interactive. So please interrupt me at any point, ask questions, comments. The purpose of this first part of the presentation is that we are going to review just basically the main principles of enhanced recovery protocols. What are some components of the protocol with each phase of perioperative care? And then we'll review our own institutional data from UVA about what we've found. And then the next presentation will really get into the nitty gritty details about each component. So I'll sort of just review them first. So first of all, what is enhanced recovery? So enhanced recovery programs are protocols with evidence-based multimodal interventions designed to standardize perioperative care and really decrease the time required to recover from surgery. And when we asked you guys in that pre-workshop survey what you thought the biggest or most important aspect of ERAS was, you said faster recovery after surgery. And really that is the overarching goal here. This of course contrasts current perioperative practices like fasting or giving a lot of IV fluids and opioids. And we know based on our own experience and the data that those current practices result in longer hospital stays, increased hospital costs, and poor patient experience. So the goal is to improve on all of that. Dr. Kailat really started enhanced recovery in the 1990s in Europe. He was an anesthesiologist. And his goal was to ultimately attenuate your body's surgical stress response by maintaining normal physiology as much as possible in the perioperative period. So every single aspect of enhanced recovery is focused on that goal. And we know based on the literature that enhanced recovery programs have reduced hospital length of stays, especially in R and OBGYN for patients undergoing abdominal hysterectomy and those who have cancer. That's where the bulk of the literature is right now. So I'm gonna briefly go over each of the aspects of ERAS. And then again, the next presentation will sort of get into the details about each of these. So when we think about enhanced recovery, we break it up into preoperative, intraoperative, and postoperative components because it does span the entire perioperative experience. And arguably, this preoperative part might be the most important. So this is really patient education, the patient owning her own care, thorough patient education, not just about what's going to happen during surgery, but that she's part of this enhanced recovery protocol and what that means and why we're doing it. And the second aspect of the preoperative phase is the preoperative hydration or carbohydrate loading, which for us was Gatorade. And that prevents tissue catabolism and dehydration. And again, decreases your body's surgical stress response. And when we ask our patients, it also helps with their anxiety. And intraoperatively, two main goals. One is to have a goal-directed fluid therapy to avoid over-hydration of our patients with IV fluids. And we'll talk about that in a little bit more detail in the next presentation. And then, as everyone probably knows, the multimodal analgesia. So we're avoiding opioid use, maximizing pain control using things other than opioids. And then lastly, in the postoperative phase, so early ambulation and early feeding, taking out catheters and IV lines as soon as possible, and really encouraging patients to get out of bed on really the day of surgery. So now I'll just briefly review some of our own institutional findings when we've looked at our outcomes after we implemented enhanced recovery programs. So this was a presentation that we gave here at Oggs in 2016 and we have finally gotten around to writing the manuscript and publishing for it. So you can look out for that soon, two years later. This was a prospective study. So we looked at patients who were having surgery, pelvic reconstructive surgery, at the University of Virginia, both before and after we implemented our enhanced recovery protocol. Our primary outcome was looking at length of hospital stay. And we looked at also opioid administration, patient pain scores, complications, readmissions, and finally patient satisfaction. So this is our protocol for the preoperative phase at University of Virginia. Again, we'll talk much more about this in the next presentation, but you can see it included patients drinking Gatorade on their way to the hospital or two hours prior to anesthesia induction. Multimodal analgesia in the preoperative area, including an NSAID, acetaminophen, gabapentin, and postoperative nausea, vomiting, prophylaxis with scopolamine patch, plus or minus the anoxaparin. We'll talk about that. And while they had an IV started, they weren't given any fluids in the preoperative area. Yes, SAS is what we, our surgical admission suite. So this is a screenshot of what everyone in the whole hospital can see when they look at ERS protocol. So it's for the nurses, for anesthesia, for us, for everybody. So I didn't edit that sort of purposely so you can see what everybody's looking at. Okay, then intraoperatively, and again, this is hanging in all of the ORs in the University of Virginia. So patients didn't automatically get a spinal unless we requested it for some reason. They were not, there was no intraoperative opioids given without the attending anesthesiologist approval. You can see they used for induction, propofol, ketamine, magnesium, dexamethasone. The dexamethasone is for postoperative nausea, vomiting, prophylaxis, and even patients who would be planned to be discharged home the same day or the following day would have propofol and ketamine. Intraoperatively, a lidocaine infusion and ketamine infusion. Again, no more acetaminophen or ectetorolac because they receive this preoperatively and will receive it postoperatively. This is just an example, and I'll contrast this to the example of what we use at Atrium Health in the next presentation as well. But I would never be able to come up with a dose of ketamine they need for induction. So this is why it's important to have an anesthesiologist on board when you make these protocols. We talked a little bit about the goal-directed fluids, and I'll talk more about that. You know, take-home point here is that none of the anesthesiologists, and at University of Virginia we had residents at Atrium Health, and now we have CRNAs, and so they're not giving any additional opioids outside of this protocol without approval from someone. And then postoperatively, there are opioids ordered as needed, but really the focus is on midazolam or ketamine as needed for rescue once they're in the postoperative recovery area. And then we'll talk about what happens when they get to the floor. Again, lots more detail about that coming. So we looked at patients who were having surgery, pelvic reconstructive surgery, after we implemented ERAS, and then we took patients for about a year prior to the implementation of ERAS as our control group. And again, ERAS for us was a quality improvement initiative which is a nice way to sell it to your institution. And so our historic controls were actually patients who were part of the NISQIP database, so all these patients had the same pelvic reconstructive surgical procedures by CPT code with the same two fellowship-trained urogynecologists that we had at UVA, and that was our control group. And then for patient satisfaction, at the time we did this study, we weren't really looking at patient satisfaction in any way specific to urogynecology, we used the HCAP survey that our hospital sent patients after hospital discharge. There were voluntary surveys that covered a large amount of different fields that some of you might be familiar with. Okay, so here was our data. So you can see really no difference in age. Most patients were Caucasian, average BMI of 28. Most patients had an ASA score of two, which means they had mild systemic disease, but nothing severe. There was a slightly higher incidence of diabetes in our post-ERAS group, which I'm not sure why that is. No difference in blood loss, duration of surgery. Both groups had a combination of vaginal robotic or obliterated procedures, but you can see our robotic reconstructive rates really increased in the post-ERAS group, which I think is just because of timing of when we were collecting this data. And you can see, a lot of this is basically because we set this protocol out. So now, intraoperatively especially, morphine equivalents were significantly reduced because now in order to give an opioid outside of the protocol, they need to ask permission for it. So we significantly decreased intraoperative morphine equivalents and total morphine equivalents without any difference in pain score. And so this is sort of sometimes argument as well, you're not making their pain any better. And the purpose, I mean, really our patient's pain by post-operative day number one, you can see it from one to 10, a pain score of three, our patients didn't have a lot of pain at baseline. So the goal here is to maintain that pain control while also decreasing opioid requirements. And again, patients significantly getting out of bed and ambulating the day of surgery and then at least twice a day after surgery, which is not only a favorable outcome, but also shows us that they're abiding by the protocols that we set forth. No difference in 30-day post-operative complications. And in terms of patient satisfaction, so you can see there's a significant increase in patients who said they would recommend this hospital to others, that their pain was always well controlled, and that they had a good understanding of what happens after discharge when they get home. And when you compare that to other peer institutions, post-ERAS patients ranked the 97th percentile compared to the 42nd percentile prior to ERAS, which is obviously a big difference. In terms of length of stay, so in hours, we didn't see a huge, we saw a significant difference, but maybe not a clinically significant difference of about three hours different. But for our institution, really the important thing here is discharges before noon, which is a big financial incentive for our institution. So that pretty much doubled the amount of patients we're getting out of the hospital before noon. And again, no difference in hospital readmissions. And there was also a cost savings per patient in the pre- versus post-ERAS group. So all of this is nice to be able to take back to your institution. Do you think your cost savings was related to length of stay or? I think probably not, because it was only a three-hour length of stay per patient. I don't think we have a good answer for that. And it's been consistently shown throughout the Enhanced Recovery literature that there is cost savings per patient. And I've never really seen a good explanation for why we think that is. We tried to break it into direct and indirect costs. We saw cost savings in both. So I don't have a good answer for you, but I'd be open to hearing what you all think about that, too. I mean, I can read the picture. They're just using less hospital resources, right? They're less nominated. They're getting less tests. They're getting usually less stuff. They're just spending less money on their care. I can't remember to that. I can't, none of you can figure out how to study that. Our Colorado colleagues also, well, they went from being in a hospital four to 10. So it made a huge impact for them. And they're in Texas on the right-hand way down. So theirs was very easy. But we were already, you know, our services are in some ways not fully, not in a way invasive. And also, you know, in some ways, our study was five out of five. We had two fairly senior surgeons, right? So operating on, you know, so we spent a lot of time. Versus maybe having, you know, one person, one out of fellowships. And we spent 20 years out of fellowships. So it's pretty homogeneous group. So Kathy and I are pretty efficient in the door, right? So all those things. But I think it's just a number of resources we used. You know, we had less low blood pressures. We had less chest pain. We had less, we just had less, less, less, less. So how long was the patient staying typically before? Is that three, three, how long were they staying? Yeah. We said 27.9 post ERS versus 29.9 pre-hour, hours. Yeah, and really at the University of Virginia, a lot of that was because they're coming from six or seven hours away. Is what I think. We were asked that when we gave the couple, why did you keep them overnight? And like, they have to drive by for hours. But it's just not, those are some practices in more rural areas, it's just not. You just can't put people in a car. You know, we're not Chicago, we're not New York. We're not in Dallas. Like I can't put you guys in a car. Yeah. So were there any other incentives to give them up for near the post ERS part? Because it's a pretty dramatic change in pre-noon versus post-noon. They have a three hour difference to the actual length of stay. So were there additional incentives to do this? But ever since there's something to get them up. Oh, we're going there, great. We can go out of order. Yeah. Oh, I'm sorry. No, we were hoping that this is what this would be, not us up there talking the whole time. So, yeah, I mean, I'll be honest with you. We were, there's a lot of incentives. We're a state hospital. We're, as of this year, the third and best hospital in the state. So we run at 95% capacity, all year. So getting someone out, if I could show this, I was gonna get stumped. I was gonna get a court date. So at our institution, this is really important. If I could get, if I could demonstrate as a service, that I could get the majority of my patients up on you. Am I answering the question? But it also required that we spend a lot of time, we have generally one area our patients go to, the short stay unit you've been talking about, this unit of 20 beds, and the whole goal of that unit is to get you out by noon. So it's just a whole, sometimes they end up in a different bed, and then that's when we have compliance issues, right? The protocol. Did that change between the four units? No, they always have a court date. It's just that this time, the nurses have the power to say, you have to get up at six o'clock. You have to have a court of health, so you're going to be in at eight thirty. So it's just they had, and they loved it, because that was the mandate of that unit. But it had always been the mandate, they just didn't have the protocol. And then the patient was there. Before ERS, it was when the patient woke up and felt ready to eat her breakfast tray, and when she felt like walking around, and now it's like, okay, you're gonna eat on post-op day zero, you're gonna get out of bed on post-op day zero, so by the morning, they're ready to go. If somebody operates in multiple institutions, how much of this is the function of adding that one central hospital? No, he means one hospital versus multiple hospitals. Not just one hospital, but one floor, one place, one set of steps. Yeah. A group of people who are included into your goals and maybe share them. You know, I think, at Atrium Health now, we're doing it at two different sites. So I can sort of speak to that, and it's definitely more work, because you have to get buy-in from everyone, and it takes, and at one institution, at one hospital, they go to multiple different floors. So it really did take me going to multiple different meetings and floors and I think, ultimately, a year later, I'm seeing that outcome, but it was definitely a different experience at University of Virginia. So, to your point, it makes it more challenging, but I do think it's still possible, and it's just a matter of, and really what I found is getting your, who's ever, like the nurse coordinator, who's ever higher up involved, because then there's someone who's always there to oversee that, once you're not, and even when your patients aren't. And then have a way to easily identify who your patients are and when they're ERAS, so then they know, okay, who does this apply to if they're seeing patients from lots of different services? So a way to easily mark it in their chart somehow, and then that will sort of trigger, okay, now I know I have this protocol I can pull out, and I can look at it, and I know exactly who I can call if I have a question, things like that. Go ahead. Go ahead. It's really great to hear that. Yeah. Can you all say your names? I feel like a child, I know. I'm Sonali Ramanan. And where are you from? I'm from Northern Kentucky, I'm from Nigeria, I'm sort of a chiropractor, and I do mostly robotic cases, and I would say most of my patients go home before noon the next day, so halfway since I've been developing an ERAS protocol, they're probably, it's amazing that I'm getting this strict for you to be, you know, if I'm not able to get out of office quickly around before noon. Really great, you're doing really well. I don't think that we have, I definitely know we don't have that strict protocol like 830 and you're up, and that's fantastic, but how do I market this to my administration? So I would say the first thing is, you know, there's lots of different goals you can take from this. So when I was trying to sell my new program on this, the first thing was, okay, well, what do you wish was better? What do we think we can improve about the status quo? And so, for example, it could be your patient satisfaction scores. It could be your opioid use. You know, it doesn't have to just be those discharges, and then make that your goal that you will then be able to go back and say, okay, we met this goal. And something like that, you know, it depends who you're trying to sell it to. But patient satisfaction, if nothing else, is usually something that the bigger institution can get on board with. The tricky part, I think, and this is kind of why I like doing this course, is I feel like we're lucky at Theriotype Medicology in general, because our patients don't have that much pain. They can stop, they can move on, and they're pretty satisfied. So, like, our numbers are not so much that we're gonna change, change a big part of that percentage. But I know, inherently, that's what we need to go to. I just don't know how to show that. So, one thing, I don't know if you all have a chance and we're all super busy, but most medical centers pick certain metrics that they're going towards back in here, whether it's couting, whether it's, you know, everything is targeted, but there's so many, so your institution has something that they are focusing a lot of effort towards. You have a quality officer, you have to talk to, and then figure out, like, there's no way they want you all to be giving your hud. At some point, our hud is a little heavier than our hud. So, the entire institution, so what's all that going on? Well, we all were forced to be here at the entire institution, and it's very interesting, anesthesiologists have learned a lot. Some of the bigger, sort of, people that are having fighting, going to ER, were like, wow, this is cool, maybe we gave too many of our hudders. And I was like, yeah. So, I mean, you'd be surprised. I mean, if you could get, like, how many equivalents you're giving, you're still giving a lot of narcotics. Also, for patient satisfaction, I will say, anecdotally, I would think all of our patients are happy when they come back after surgery. They seem great. But if you've ever objectively looked at your survey evidence, it's not always the case. So, sometimes that's what it takes, is looking at, okay, well, do we have some kind of objective assessment of patient satisfaction at baseline, and then we can use that to improve on it, as opposed to when they come back and hug you and tell you they love you after surgery, because, of course, they do that, but. Somebody, I think you first. I think, also, we need to challenge, I totally agree, we buy in from the institutions, and I think we have them, because of their challenges. I think we have to challenge ourselves to say, now it's time to go to CPAs. Yeah. We can do that, but that's a huge take on our own. Yeah. Especially that for sciatic patients, they really don't need this. Yeah. So, just in follow-up to that, I'm not gonna tell your name, I'm sorry. I'm not gonna tell your name. I'm sorry. I'm not gonna tell your name. I'm sorry. I'm not gonna tell your name. I'm sorry. I'm not gonna tell your name. I'm sorry. I'm not gonna tell your name. I'm sorry. I'm not gonna tell your name. I'm sorry. I'm not gonna tell your name. I'm sorry. I'm not gonna tell your name. I'm sorry. Are you doing it as an outpatient proceeder, because I think that's the other thing, there's leverages. If they're staying 27 hours, they're technically in. And, especially with outpatient, also changes financial benefits as well. I think that really depends on the institution. Because actually, these are not considered additions. These are called 23-hour observations. But they're staying long. I think it's until you reach, like, 30 hours or something at UVA. There's some arbitrary kind of, two midnights, that's what it is. Two midnights, yeah. These are still observation periods. That's what they're considered by our institution. My understanding is, because you're right, I'm about to start my robot in an outpatient surgery center this year. But again, because of course this is my understanding from our biller, is that they don't know any different. So, what we're gonna be doing, this is coming, is we're gonna put them, once again, in the short-stay unit. Because we don't, in that setting, we can't watch you fight the cat. It's not possible. This is still, this is my dominant program. So, we're gonna put them back again in the short-stay unit. This is in protocol, but with the host set, we'll get you out by four o'clock. Versus, watch you over the next weekend. But it still will be way more efficient to do that process when they know. You know, then it will be, at 12 o'clock, you better walk. At two o'clock, you better avoid your child. You know what I mean? It will still, this will still be crucial to them getting home by four o'clock. Is that answering the question? Yeah, and patients, yeah. This happens at 12, this happens at 10, this happens at four. You know what, when we find that the patients don't get on the nurses, they're like, I'm supposed to be walking, here's my notebook. Yeah. This is like, and there's a checklist. Yeah. They get very, like, they get very, like, they become very, you are not gonna get me out of bed. That's a trick question. Do you need me? I've been called in my office that someone is breaking our protocol. Is that true? Is it true? Yeah, it is true. So just, we have to, we have to go where? What is it, I'm sorry? Please, please. We have to go where? So just a quick, you guys get the protocol book full, so in there, you're pre-op, so that the patients come in the hospital knowing what their expectations are. Is that correct? Correct. Oh, there's a very nice notebook. Oh yeah, you know, every single, almost to every 10-minute interval, what happens? Before and during and after. Is that your question? Yeah. Okay. And I can say, now at Atrium Health, we have a lot, a much, much larger proportion of our patients go home, and we're looking at right now, robotic sacral copepaxi with same-day discharge and enhanced recovery protocols. I don't have any data to give you from that yet, but we're doing it, and it's going well. So, maybe next year I'll have some data for that. So, it's feasible. We're getting there. Okay. Are you getting the copepaxi with or without? With and without. Even if they're not a seven-day discharge? Correct. Although, that's definitely one of the outcomes to see. My suspicion is it's the time of day that's gonna determine whether they stay or go. So, we're looking at that too. But I think, you know, a lot of it has to do with patient education and patient motivation, because I see some last cases of the day, when you see them before, you sort of know if she's gonna go home or if she's not, based on your interaction. And I think a lot of it has to do with the counseling that we give them before too. Do you have any questions for me? So, I just wanted to make sure that you got that. That's pretty important. You know, at the end when you said it was just a patient satisfaction. Mm-hmm. And I saw the breakdown, but the biggest breakdown is the understanding of the way that you know. Mm-hmm. Right? So, you've broken that down, so that I understand that you're gonna say it's a whole protocol. Yep. I believe what you're saying is a protocol versus a characteristic of the patient. You have more information on your CVs than you do on your appearance. That's true. Yeah, I mean, that's a great point. If you're just, if this is all just too much for you to take on, if I could get you the data you need to do these things, if you get together with your nursing staff, you probably have to talk to the quality officer that you have to work with to get together a really awesome handbook. It's online. Anybody can take it. And we spent a ton of time on it. But honestly, it cost us $5. And people walk around with it after the first appointment. They walk around, it's great. There's so much ownership. So, I think you're asking me, yes, I think it's probably the most, this part of it is an option for us. The patient goes, then, but we have to do it, yeah. Yeah, I have a question to add to that. This goes into sort of a follow-up to that question. You know, we will counsel the patient, draw their pictures, go through all that with them. The nurse comes in, and it goes through some of the meetings, pre-op meetings, blah, blah, blah. Our hospital has instituted, we call it a surgical home. And for all of the people to enter the practice room, use all of everything we can in pre-op, we've already arched a tunnel. They can do some of the counseling. That's the perfect process. Go through that packet, or do you have your own nurses do it? Do you hand them the packet, and then you go get through all that? You definitely can't just hand them the packet, I've learned. I think it's been, you know, I have two different experiences of this now. I think the most successful is when they, it's our nurses, it's the nurses that they're going to continue to have follow-up with afterwards. It's in their doctor's office. You know, they know Dr. Turbridge is in their office, that they're hearing information, and the nurse is sitting down and doing that pre-operative counseling with them. So it's built into the pre-operative clinic visit that really the bulk of the time they spend there is with the nurse and going through that handbook. And they go through every single page in that handbook. When I started at Atrium Health, and it was sort of, I didn't have that kind of, we couldn't build that time into the pre-op schedule, and so we have a pre-operative clinic, and I made a packet, and I educated everyone on the packet, but that was sort of it. I said, okay, try to go through as much of this as you can in a time period. These are the most important points to get to. And I found patients wouldn't bring the packet to surgery, or they didn't have it, or they didn't remember, they didn't know they're part of the ERS protocol. So it wasn't until we changed that to be that same structure that we now, that we had at UVA, where we do build in time. I think the next step would be, okay, well, can we make a little video presentation that they can watch instead to save time? Whatever resources are available to you. But I think the important part is that every single page of that is really going over with the patient. Don't just hand it to them to read at home. Because I think that emphasizes how important we think it is, and then that communicates it to them. How much time do you think? I can, so we have a paper we're gonna hope to submit by the end of this month that would be just with the patient's obsession. Because something isn't very good at getting at what ERS is good at, and then there's not really ERS patients that, so we had to kind of make, we took it from American College Surgeons, they have this pretty good survey, so we kind of based it off of that. And I just wanted, we call it, we're gonna call it the patient experience of the paper, but they asked, you know, was it the eating, the walking, what was it that you thought was so great, you were so happy with your experience? You know what, what I think is the best in spending time with my one-on-one nurses. I think that's later in this presentation. When I did the surgery. So I'm here to tell you that like, in our experience, so what have we done resource-wise? Obviously I can't get my super high-functioning nurse to do this, so what we've been able to convince our nursing staff, we've almost created almost an accreditation system, it's only a few people who teach this. We've actually had gotten our PPPs and MAs to do this. Because it's a checklist, so they're not really doing T-sheets, which PPPs and MAs aren't technically allowed to do, at least not in the state of Virginia. But they are allowed to go through a checklist. So that's how we've gotten worked around the, and if you see, I would say it takes us 10 minutes. And the way our flow is, they come in, and it depends on how wide the clinic is, but they come in, they go into a room, the folders, they know they're in there teaching, and then I'm just writing my note or whatever the resident's doing, and then I walk in and pre-op. It's actually pretty efficient, to be honest with you. And you know, the patients already know that Bobby, on the MA, said they're not nurses. So what they do know is that someone sat down with them and said, this is important, this is important, so we call it a checklist. So that's how we've gotten around it. But no, that's what they think is the best part of our whole area of experience. The notebooks and the one-on-one nursing teacher. Not talking to me about that. Not the fact that you guys are in here. I'm serious. I think that's, go ahead. Yeah. Hi, this is Leanna. Are there any of yours in relation to your non-specialty areas for the model? Hydro-dispension. Cysto and just Botox. And in fact, we actually, because Kate Bradley is on this here, we actually are doing ERAs in the outpatient surgery center. And it's wildly successful. Because none of those patients care about it. And we're getting to the care lane and we're giving them ERAs. And they go home so fast. So we're actually doing it. So I guess the answer to your question is like 82% of our patients do the one-on-one. Have you, in your, once you're in your micro-ERA, in your outpatient surgery, noticed a difference in the way you all answered? She has a, she has a salon session on that. She has a salon session. Come on, it's just today. I thought you guys could have looked over. But to answer your question, that was disappointing. It's like no difference. 21, 22%. But actually, by the way, much higher in robots. So I don't know if you've had that. So maybe that's one thing you could go about. Like our avoiding the function is much higher in our robots. I don't know if you've all found that or looked at that. I was really shocked. Much more, yeah. I haven't. But the opposite. I feel like more of my robots have the kind of more really tight anterior repair. Yeah. Oh, I don't know how to do that. Someone else? Yeah. Disappointing. It's very disappointing. We have so much to do on avoiding this function. Yeah. I'll just briefly go through. This was a review that we worked on looking at just enhanced recovery outcomes in general and benign GYN surgery. We looked at nine different studies. We excluded gynecological patients, non-adult patients, or patients who were supposed to have just outpatient surgeries. There's a lot of heterogeneity between the studies, but in conclusion, not surprisingly, we found that in the benign gynecologic world, enhanced recovery protocols have overall shown to decrease length of stay even improve pain scores, reduce hospital costs, and not increase perioperative complications. I just wanted to breeze by this because this is the next part that Dr. Sherbridge referenced already. This is when we tried essentially to break down what part of all of this is most important to patients and to their satisfaction. While, of course, it's a non-validated questionnaire, we did at least try to break it up into the different perioperative phases of enhanced recovery and then each part each element of enhanced recovery in each phase. Before surgery, during surgery, and after surgery. Again, these are patients coming to their post-op visits who are filling out this survey or we mailed it to them. 200 patients responded. It was about a 50% response rate. Again, 90% of our patients rated their surgical experience favorably. We're not comparing this to pre-ERS at all. All of these patients have been part of the ERS protocol. Over 90% said that their preoperative teaching was the most important part and that they found that binder to be the most important or effective educational material. Patients who reported that their patient education was important to them were more likely to report a positive perception overall of their surgical experience. I think we pretty much talked about all of that already. That's all I have for the first part of the presentation. In the next portion of this presentation we're going to go into the nitty-gritty details of each element of the protocol unless anybody has any questions or comments before. I don't know about that. Our protocol, I mean, we do things like glucose monitoring and avoiding hypothermia and we have part of that built into the protocol but nothing about the pneumoneperitoneum. That's interesting. I don't know about that. Our protocol I mean, we do things like glucose monitoring and avoiding hypothermia and we have part of that built into the protocol but nothing about the pneumoneperitoneum. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. 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I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know about that. I don't know how that's been funded. I don't have any answer for that. So she is the, as far as the next level up of management at Surgical Services with our institution. But the actual holders are, it's my department. That pays for the five dollar bill. I mean, five dollars. I don't get any issues from my chair about paying for that, at all. And we have them in Spanish, too, though. Because we have a huge, we have a very big Spanish-speaking population. Can I put this on the website? Yeah. I don't know that the Spanish one is. I know where you are. Well, we can also make sure we email it to you guys all, too, before. Yeah. I can say we don't have the binders at Atrium Health yet. Because I haven't been able to convince anyone to pay that five dollars. So I just printed out a bunch of the packets. I did it in color. So there's, you know, it's something they can, you know, remember this is an important piece of paper. So it's a blue piece of paper, a pink piece of paper, whatever you want to choose. And people are still bringing it back with them now and holding onto it and carrying it around now. So I do think it's maybe not so much the physical binder as it is that now we're, like I mentioned before, going over each page and each checklist and every single word in it with them in the preoperative setting. And that's why they're remembering it. So it doesn't have to be a binder. Although, the binders are nice. Yeah. Yeah. Yeah. So you need to have definitely an anesthesia champion who's on your team who helps you build the protocol and then communicate that and educate that to all the other anesthesiologists, CRNAs, residents, whoever it is. They have a little laminated protocol in all of the operating rooms, especially at UVA when more and more divisions were doing ERS. It was sort of easy for them. It was either the same or they could say, okay, this is a GYN ERS patient. Atrium Health, for us, it ends up being just colorectal surgery and us. And so at first I thought one of the challenges I had to overcome is to make sure that the patients are properly identified as being enhanced recovery patients because I'd find they wouldn't be following the protocol because they didn't know that that patient was. So we worked through that. And now it runs very smoothly even when I'm not there. The patient is flagged as ERS in the chart. They pull up the protocol. So the nice thing about this is it is protocol-based. So as soon as they know what to do. It seems like certainly the benefits for this for a hospital system out to the south is to be able to save money. And obviously all this will benefit care across the board. For private practitioners, part of it is because they don't see a financial incentive, but obviously patient improvement and experience is a great part of it. I was wondering, is there any data about litigation? Obviously over time you spend with patients pre-op, you significantly decrease risk of litigation. None of us ever want to hear that word. But that might be a way to sell it to private practitioners that kind of buy into the big center like UVA. Maybe you could see some change. I don't know. It's a really interesting point. It's a really interesting point. Yeah. So I mean, obviously this is where, you know, today when I go through the different stages of change, we're obviously towards bettering our institution. But there's always something coming up. That's one of those things that's not like awesome. Some of it's like, kidney is terrible, we can't use it. Calm down, look at the data. I think kidney is okay. But I will tell you something I haven't been able to look at. I haven't had the time. Is that like my number of new patients and physical lines have gone up. I'm February, March for pre-op. So I don't know how to tell you badly, but like we're overflowing. And it's because everyone's like, they do that fancy thing at UVA. The patient talk, that's really hard to measure. But our marketing people probably know about it, right? I mean, we're on the news. It is very easy to market. And as we talk about that thing, like I'm here to teach you the backbone and how to actually get this done. But like the marketing of this is not very good. I don't see these things. We have an article. It's so innovative. It is. But in some ways, at this point, it doesn't feel innovative. It just feels like the right thing to do. Who's pointing? Is that helpful, Louise? Yeah, I'm not Louise. Yeah. I mean, it's a way to get buy-in in practice. That's what I'm like. There are all kinds of practices. I can come into a hospital and say, mommy, I'm not going to get a buy-in to change anything they can do in the classroom. I need to find a way to get them to buy-in. Right. So again, this is the second half of the workshop. But I can tell you, you'll get too buy-in when the nurses stop getting 30 phone calls a day. We have very few phone calls. Again, I wish I had measured that. I didn't want to do that. Just another question. This will be on the end of the session. I have the same issues that you had, since this is the middle of the semester. We get people coming in. Everybody does. Everybody does. Are you saying you're still trying to send those people? I'm sorry. We are trying to get people. I'm trying to get people from Charlottesville. I'm trying to get people who are at a place called Hamilton, which is a 40-minute drive. Or we're actually getting people from Virginia that are coming there. So people in LaGuardia, South Richmond. And that's a 45-minute drive. I'm trying to get them home. But the people coming from very rural West Virginia or very rural South Richmond. And I think that speaks to the point. At University of Virginia, we started this with just patients we know are spending the night in the hospital. And our goal was not to get them not to spend the night. It was just to try to improve all the other outcomes. Whereas when I tried to implement this at Atrium Health, they were like, well, our goal is to get everybody home the same day. And that's how I had to sell it there, is that we're getting everybody out of the hospital. But that would not have worked. So I definitely think that's important to set your goals first. All right. And I'm glad everyone enjoyed the almonds, too. They're my favorite. All right. Once again, we're going to keep this interactive. Oh, that's loud. Do I need this, Sarah? I'm pretty loud. So I'm going to go ahead and get started. So this next part, Sarah, in a minute is going to give you what I call the one-minute worksheets, which will make sense in a minute. But I'm going to get started. Looks like everyone's back. How many of you are here? The number keeps shifting around. Five, six, seven, eight, nine, ten. I don't know, Sarah, tell me. About 15, 16 people? Yeah. All right. So I'm going to get started. Again, same thing. We'll keep this. So if you have a burning question, please just ask while I'm talking here. I appreciated hearing your comments during the break. I heard a lot of the different frustrations you all are having. So it's a great segue to this next half of the workshop. So leading change, why transformation efforts fail. So when I was talking to Bethany, our ERAS coordinator, I said, well, Bethany, I'm teaching this workshop. And she's like, well, you need to teach leading change. And I was like, Bethany, what the heck is that? So back in January, she would, oop, forgot to. Back in January, she was like, you will be ordering this book. I don't work for Dr. Cotter, Professor Cotter, but I will tell you it's been a very good investment. We'll talk more about this book in a minute. So the agenda today will be to define, have you all understand what transformational leading change is, go through Cotter steps one through four, take a small break, then go through Cotter steps five through eight. After that, we'll actually have you all get together into hopefully four groups, work as a group. And then at the end, you all are going to present what you all found. We'll call it a wrap-up, because I want to hear what that is and how you guys can then make, and then you'll leave with pieces of paper to help you make these changes. So I have no disclosures. So transformational change, as defined, is a shift in an organizational culture resulting from a change in an underlying strategy and process. I know, ugh, business talk, that an organization has used in the past. The better definition for me is this transformational change is designed to be an organization-wide, because this is what I'm hearing from you all, that is enacted over a period of time. In other words, how is this different? This is different than when the hospital is like, there'll be a policy change, right? Like, this goes down now, right? That's very different than what we're proposing you all do. We're proposing that you all kind of get into the different parts of your institution and fundamentally make a change over a period of time versus saying, this will happen today. Very, very different. Much, much harder to do. All right, the rate of change is increasing. What does that mean? So a survey of 300 large companies reported that 82% of them consider transformation as vital, of importance. Delivery of care is no different. What does that mean? What that means is that, for the first time, patients have access to how well we do. Whether all of that is true or not, the number of little stars, they have access to, they can make all these comments, there's changes in how we deliver care, there's change, change, change all the time. And if you're probably gonna survive in your community, you need to change, right? I don't think any of us would agree with that. But the most significant reason that transformation project failure is a lack of adequate attention to the people-related aspects of organizational change, right? So, in other words, you can have, as it says here in the second point, you can have lots of processes, tools, and techniques, but if you don't take the time to talk to the people, it's not gonna work. All right? Common reactions to change. I heard lots of them during the break. Continue to work as if nothing has changed. In other words, the work doesn't change. We're still using paper. Not really. It's all digital. Patients get to us via social network. Everything is changing. Passive-aggressive. I heard that from folks, too, here, from their nursing. For people to come to grips with change as required. And then there's just active resistance. I heard that from some of you all, as well. Passive resistance. And then there's just folks who are determined, I can't remember who told you, who are just determined to do it the way they've always done it. Fortunately, there are those who ever, however, there are people you're gonna hopefully engage who are interested in looking forward, but with caution. And then there are those who are able to identify the benefits of change and ways to implement it. And lastly, there's just some people who are just more open to change. And lastly, engagement is a really important part of this process that I was hearing a lot of you are having trouble engaging people. And again, you're gonna have to find excited, energetic, and enthusiastic people who wanna be agents of change. It's possible. So again, when I was talking to Bethany, I was like, Bethany, how am I gonna do this? And she goes, well, you need to provide a structured framework. Here it is. This is one approach. If you Google leading change, there's many books on this subject. Bethany just felt like this was a 192-page book. I usually don't like reading business books. I've had to read a lot of them recently, and I found this to be one of the most palatable ones I've read in a while. So who is John Cotter? John Cotter is an internationally known and regarded as the foremost speaker of the topics of leadership change. So really what I'm teaching you today is actually leadership. Who knew? He's a premier voice on how the best organizations actually achieve successful transformation. He's a professor of leadership and actually graduated MIT. I think his background is actually in engineering, of all things. So here are the eight steps. Establishing a sense of urgency, creating a vision, communicating the vision, empowering others, planning for and creating short-term wins, consolidating improvements, and institutionalizing new approaches. I will tell you that we are not going to spend a ton of time on seven or eight because that's like if you've had a program in successfully for like us. That's where we are now, and every once in a while, we have to jump back up to step six. But most of you all are in one through six, which is what we're going to work on today. If I can't talk you into reading this book, I'm going to tell you a short story. When I got this book, I finally had time to read it. My husband's family is from the Cape. We go there every summer. It's a week long of important family trip, I call it, with my in-laws. And this year I had this crazy idea that we were going to leave the beach and go to Nantucket. That was not well received. So I was not happy. So I told my husband on the beach, rather upset, that we need to create a sense of urgency about us wanting to do something different, and that he was going to have to build a coalition by which this was going to happen, and the vision of why this would happen, and how he would communicate this vision, and how he was going to empower others for this new vision I had. We got to go to Nantucket. But I will tell you, it was because of this book. I finally had a way to structure my frustration with this situation, and I've also had to recently use it when one of my daughters came with an unexpected grade on her science test. We created, once again, a sense of urgency, created a coalition about how she would not get a D on the science test again. So again, it's also good for your marriage and maybe for parenting. So... I'm not kidding. It's a great little book, and it's got great examples. I probably could just teach a course on leading change at this point, because it's awesome what's in this book. So why is it so hard to change? Well, I'm not going to surprise you by telling you that people just like to be the way they are. We're all creatures of habit, and to change habits, wouldn't it be awesome if it was as simple as this, taking a habit-breaker magical mineral bath salts. But unfortunately, that doesn't exist. So getting to our first step, establishing a sense of urgency. Well, I first defined complacency, which is what you all are describing, which is a state where people fail to react to signs that actions must be taken, telling themselves and each other, everything is fine. So it's okay. I mean, she got readmitted for fluid overload. I mean, you know, this happens. She's 86. Or, you know, once again, we have another UTI. I mean, you know, this happens. We put in catheters. I mean, that just kind of happens. Or, oh, we had another hypotensive event. Oh, but, you know, she just got a lot of morphine. But, you know, that happens. So people get into these habits. This just happens. This is the most business-y slide I'm putting up, I promise. But you can look around for the different sources of complacency. I will be very specific that ours was that we were performing low on certain standards. I was sharing with Scott that part of why we were able to do this at UVA is that in 2013, or 10 or 11 or 12, we ranked rather low. What is that? What is the name? It's called, like, the Beehive, or what's that score called? Whatever. It's a big ranking of the whole institution. And that did not go over well. Leapfrog, sorry. Where'd I come with Beehive? But whatever, Leapfrog. Thank you. Sorry. Sorry. Sorry. Sorry, Leapfrog. I'll have to remember that. So, you know, we just had gotten a brand-new CEO. We had gotten a brand-new Vice Chair of Operations. And they were like, whoa, uh-uh, this ain't happening. Now with the amount of brainpower at this institution, with the amount of resources we have, the amount of volume, we're actually a higher acuity medical center than Duke is, which is hard to believe, but we are. So it's like, uh-uh, this has to stop happening. So basically quality and safety became all we talked about. And not surprisingly, in the last three years, we became the best hospital in Virginia. But it has been a tremendous amount of work and a huge culture shift. Because Rick Shannon kept saying, if you do the safety and you do the quality, the money will come. He was right. He was absolutely right. So it has been our leadership. So it was very easy to then say, hey, let's do ERED. And he said, sure, this is great. This won't cost a lot of money. Let's do it. So I will tell you that. It came in the setting in 2012 and 2013 that this started. But because we were performing low, and we should not have been. False urgency. You probably have seen this, and those of us who have been on labor and delivery, and certainly when I was a faculty member doing labor and delivery, people would look busy. And all of a sudden you're like, so is everyone triaged? And all of a sudden it's like, no. And you're like, what's going on? So people were busy. People were getting tired. But nothing was actually being done. And there's great business examples of this. So again, just because people are doing stuff doesn't mean that people are actually getting stuff done. And people get really burned out and frustrated when they're working a lot. But nothing's really changing, as it turns out. It's really not great for humans. So how do you do this? You've got to aim straight for the heart when you are trying to create this urgency. This is okay. Connect to the deepest values of a staff and leadership. So those of you who are frustrated with your nurses, that's where you've got to go. And you will appeal to them. Create a case for change. Come alive. Come up with an example, whether it's positive or negative. This patient had a really positive experience when they did this. Because remember, the nurses see them, and then they don't see them, right? At our institution, as I just mentioned, our institution was very focused on metrics. So that's what we had to use. We had to decide. Our UTIs had to go down. Our readmissions had to go down. Our discharges had to go improve. Any time you can be imaginative and clear with this sense of urgency. So here it is. The homework begins. I want you all to, you have your one-minute sheet. Your first question is to, again, I don't want you to overthink this. This is classic design thinking. Just, like, throw your first thoughts out. Like, how are you going to make a sense for enhanced recovery protocols at your institution? Did you get that? Sorry, I'm a mom. Stop. Why is it doing that? Oh, wrong button. All right. So I should probably come clean that my husband teaches human-centered design at UVA, which is super cool. I'd love to actually come and teach a workshop on that. It's very cool. So a lot of this will be based on those thoughts of how you just kind of design on the fly, try something. So Brianna's going, yes. And we're very, very behind as physicians on this way of thinking. So maybe that's what we should teach next year, Sarah. But this is this idea that you just jot some ideas down. So if it's kind of uncomfortable for you all, I promise this is a well-known process of just taking a quick minute and writing it down. So here are some of the pitfalls, as you all think about starting this process or continuing in your journey. Is failing to create a sufficiently powerful guiding coalition. And maybe this has already happened to you all. You need to put together a group with enough power to lead change. And I was talking to Scott about maybe some of his champions he could think about. So who is that at your institution? You don't need to write that down, or maybe you want to write it down right now. So no one person, no matter how competent, is capable of single-handedly developing the right vision, communicating it to vast numbers of people, eliminating all obstacles, generating short-term wins, managing dozens of change projects, and anchoring new approaches deep in a culture. Do we all agree? Sarah apparently has tried this. However, I think someone could probably do it, right? She could probably do it, right? I've seen this movie many times. I have two daughters. However, this is probably how you should do it. And these are the four qualities you're looking for. And you're looking for position of power. You need enough key players to be on board so those left out cannot block the process and fight. You might want to include some of the naysayers. I'm just throwing that out there. Just put them right in so you know what may be, and you'll have a better idea of what the naysayers don't want to do. Put them in the group, but they have to be powerful. Expertise. All relevant points of view should be represented so that informed, intelligent decisions can be made. You need a really smart pharmacist, right? You need a really smart nurse manager. Really smart residents. We highly involved our residents in this process, day one. Credibility. The group should be seen and respected by those in the institution. So the group's pronouncements, their ideas, as they're sitting in the elevator talking about this, at the cafeteria, in the parking lot, in the OR, recovering, they should be people that people trust and taken seriously. And leadership. Again, I hope today I convinced you that I'm mostly teaching you leadership today. The group should have enough proven leaders to be able to drive the change process. So these are known people that you all know get stuff done. At our institution, that's who got chosen or was asked to participate, those of us who get stuff done. And it went pretty well. So as you know, Wonder Woman also needed her guiding coalition as well. All right. So here's our next one minute. Who would you include at your institution in the Enhanced Recovery Program Guiding Coalition? And it might be different for everyone here. Okay. Sorry, I'm trying to make it not do that. All right. All right. So that's your coalition you just thought about. All right. I'll be honest with you. This is probably one of the hardest things to do, and I think our medical training doesn't really teach us how to do this very well. We're really good at hearing things and then recognizing patterns and figuring out what's going on and what's not said. But our field doesn't really teach us how to think about developing a vision and strategy. That's not really, right? That's not really our field. That's more of a marketing, journalism kind of thing. So what this is is you want to clarify the direction that you want your department, your division, your hospital to go in. The same vision has to motivate people. I know. Ooh, this is uncomfortable. And it also has to coordinate actions in a common direction. Again, this is a leadership statement. This isn't management. Effective vision includes these qualities. It has to be imaginable, desirable, hopefully to most people, feasible, pretty focused, flexible, and you have to be able to communicate it. I would say that our vision was more in the feasible because colorectal had already done that. We were asked to do it because we were not general surgery, we weren't huge, but we also weren't just colorectal. So we were kind of this medium-sized service. There was also a lot of strong champion leaderships that they thought the institution that we could pull this off. I mean, it was pretty focused, right? We decided to focus on gyn-onc and then benign-gyn. So it was very focused. But again, that was our vision. Pitfalls. Underestimating the power of vision. Again, the book does a really good job explaining this better than I'm going to be able to since I'm not a leadership leading change expert. So in the book, it says, So in other words, what this can mean is that you don't necessarily include all the players in this in the vision. It might mean that potentially it antagonized a group. So this is probably for a physician, I think, one of the hardest exercises for today. I'm not going to keep talking about it, but I will just acknowledge that it is hard. So because of that, I'm giving you two minutes. And again, recognizing that this is like writing poetry or something for us, right? Like, this is hard. I like poetry. I just can't write it. You probably can, Sarah. I like poetry. I just can't write it. You probably can, Sarah. Okay. Okay. Okay. Okay. I can't make that stop. So I was trying this this year, doing these one-minute thoughts, and I find it that our lives are so complex and busy and fulfilling and so forth as physicians that I don't know about you all, but I find it really hard to find a quiet time to just think in a quiet room. So that's why I'm having you all do your homework before you go to your institution. So whether you feel it's a waste of your time, I just figured I find it really hard to find quiet time to just think. And here you are, have this wonderful luxury to think in a quiet room. Sarah, we're doing all right. So it's going to get more design-y here and weird, but we are going to do a warm-up, and there's many different design warm-ups you can do as we move on to this next phase. Any questions about the first four before I move on to them? No, the first three. No, the first three. No, everybody got it? So this next part, we want to have you warm up your design thinking, your whole ideas. And so what I want you all to do is to pair up, and if you're sitting with someone that you've known since forever, you probably should pair up with someone else. Or you can, I guess, pair up with others. But ideally, you would pair up with someone that you haven't worked with before, and now the warm-up is going to be that you all have to come up with your own personal handshake, unique handshake. And you will have, I know, that's right. You're going to have about two minutes to do that. You can stand up. Everybody stand up. Stand up. Please stand up for a minute, and you're going to come with me. And you can do whatever you want with the handshake. Yes, sir. Yes, sir, we can. If there are two people to pair up, can you just pair up? Yes, sir. All right. All right. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Tha good one. None? I only have one. No, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no These are international veterans that we need to honor. We have people coming from big geographies. We have people coming from small villages. Do they come from long distances? Do they come from far away? Right, right, right. Yeah. How many miles? I mean, because Qatar is small. Yeah. That's right. How many miles? Right. Right. All right. All right. How we do this? We have to combine our energy. All right. Who would like to? All right. Let's go in the back of the room. Remind me of your names again. I'm Sarah. Sarah, Sarah, tell me where you're from. I'm sorry. I'm from Georgetown, MedStar. I'll go with you both. Sorry, I've been bouncing back and forth. Sarah. I'm Geneva. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. I'm Katrina. All right. Okay. All right. Tell us your name one more time. Debbie. And you're from? From Atlanta. I'm Dallas. All right. Dallas. Okay. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you for participating. We're very interested in your feedback and we'll follow up with a, hopefully, a survey. Thank you. Thank you. Thank you.

Enhanced Recovery Programs

Evidence-based protocols

Postoperative recovery

Patient education

Goal-directed fluid therapy

Multimodal analgesia

Early ambulation

Clear communication

Opioid administration

Faster recovery

Patient satisfaction

Cost savings

Multidisciplinary team

Ongoing education

ERAS protocol