Enhanced recovery

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					Enhanced Recovery Partnership Programme




                                                       Enhanced recovery

                                                             Nigel Acheson

                                                 Consultant Gynaecological Oncologist
                                                    Royal Devon and Exeter Hospital
                                                                   and
                                          National Advisor and joint Clinical Lead(Gynaecology)
                                               Enhanced Recovery Partnership Programme


                                                                          You're better, sooner!
                                          Enhanced recovery
Enhanced Recovery Partnership Programme




                                          • Is a novel approach to elective surgery, ensuring that
                                            patients are in the optimal condition for treatment, have
                                            different care during their operation, and experience
                                            optimal post-operative rehabilitation

                                          • Patients on enhanced recovery pathways recover more
                                            quickly following surgery

                                          • Enhanced Recovery Programmes (ERPs) are often
                                            referred to as Rapid, Accelerated Recovery or Fast Track
                                            surgery

                                          • They should involve the whole health community
                                                                                 You're better, sooner!
                                                                                                          2
                                          Programme
                                          Workstreams
Enhanced Recovery Partnership Programme



                                                    To promote the commissioning and delivery of the enhanced recovery model
                                                     of care across local health communities in colorectal, urology, gynaecology
                                                                                     and MSK

                                              SHA/ NHS                                                                           DH/ Policy
                                               Focus                                                                              Focus


                                                       Spread & Adoption                                   Policy Integration
                                          • To continue to build the capability of ER
                                            amongst providers via 10 SHAs                     • To raise awareness and understanding of
                                                                                                ER amongst commissioners, primary care,
                                          • To raise awareness and understanding of ER          social care – making links with other key
                                            amongst commissioners and primary care so           levers e.g. NQB, PbR, QIPP so the benefits
                                            ER can be commissioned as a model of best           of ER are realised for it to be commissioned
                                            practice care from April 2011                       as a model of best practice care
                                          • Share the learning from the pilot health
                                            community sites to support SHAs taking ER
                                            forwards post March 2011

                                                                          Communications & Engagement
                                                                        Incl. Information, Tools & Evidence
                                            • To raise awareness and understanding of ER across LHCs supported by information, tools, evidence,
                                              and informed by local/ national events/ workshops        You're better, sooner!
                                                                                                                                               3
                                          Government Vision
Enhanced Recovery Partnership Programme




                                                              The core principles of
                                                              enhanced recovery are
                                                              aligned to the Health
                                                              White Paper:
                                                               Patients at the centre
                                                                of the NHS
                                                               Emphasis on clinical
                                                                outcomes
                                                               Empowering health
                                                                professionals
                                                                           12th July 2010

                                                                      You're better, sooner!
     Enhanced Recovery Partnership Programme

                                               Hysterectomy




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                                          Policy Integration

                                          Influential Levers
Enhanced Recovery Partnership Programme




                                                          CQUIN
                                          Goal
                                          To improve the quality of pre, intra and post operative care for patients undergoing major
                                          elective surgery by implementing the enhanced recovery model of care

                                          What does good look like against the indicators
                                          • Implementation of ER - All patients should benefit from the enhanced recovery model
                                            of care and clinical teams should have approximately 80% of the relevant enhanced
                                            recovery elements embedded in the patient pathway. However, the pathway should be
                                            locally determined.

                                          • Delivering an average length of stay - without adverse impact on readmission and
                                            postoperative complication rates. Identifying the appropriate length of stay for each
                                            procedure for the majority (80%) of patients.

                                          • Delivering an improved patient experience – patients are empowered and able to
                                            contribute to the management of their care and be involved in the process for
                                            continuous quality improvement.                      You're better, sooner!
                                          Policy Integration

                                          Influential Levers
Enhanced Recovery Partnership Programme




                                                         CQUIN

                                          • The Government is committed to the continuous improvement of the quality of
                                            services to patients and plan to produce a set of exemplar CQUIN goals that
                                            local commissioners and providers can draw on when agreeing local CQUIN
                                            schemes.
                                          • The exemplar goals could later be considered as national goals (either
                                            mandatory or as part of a national „pick-list‟) as the 2011/12 Operating
                                            Framework is developed. However there are no specific plans around this.

                                          • It is anticipated that many exemplar goals will link in some way to the Outcomes
                                            Framework as the health White paper states ‘the CQUIN framework will be
                                            important for the implementation of NICE quality standards and improving patient
                                            experience and patient-reported outcomes’.

                                                                                              You're better, sooner!
                                          Policy Integration

                                          Influential Levers
Enhanced Recovery Partnership Programme




                                             NHS/ Commissioning
                                             Outcomes Framework

                                          • This will replace the current performance regime with a focus on improving health
                                            outcomes.
                                          • 'NHS' Outcomes Framework sets the direction for the NHS - i.e. the overarching
                                            indicator based on the following five domains:

                                             1.   Preventing people from dying prematurely
                                             2.   Enhancing the quality of life for people with long-term conditions
                                             3.   Helping people to recover from episodes of ill health or following injury
                                             4.   Ensuring people have a positive experience of care
                                             5.   Treating and caring for people in a safe environment and protecting
                                                  them from avoidable harm

                                                                                              You're better, sooner!
                                          Policy Integration

                                          Influential Levers
Enhanced Recovery Partnership Programme




                                              NHS/ Commissioning
                                            Outcomes Framework cont.

                                          • 'Commissioning' Outcomes Framework lists the specific indicators (improvement
                                            areas) that will be used to measure the progress of GP Consortia against the
                                            overarching indicator.

                                          • In setting the Commissioning Outcomes Framework the NHS CB will take into
                                            account NICE quality standards

                                          • The NHS CB will use the Commissioning Outcomes Framework to assess the
                                            level of quality payments to Consortia and they will decide which indicators will
                                            be linked to payments

                                          • Quality payments will reward a consortium's financial performance and their
                                            performance on health outcomes
                                                                                                You're better, sooner!
                                          Policy Integration

                                          Influential Levers
Enhanced Recovery Partnership Programme




                                                QIPP

                                          Enhanced recovery delivers on every aspect
                                          of QIPP - supporting the NHS to identify
                                          efficiencies whilst driving up quality.
                                           • Improved quality of patient care
                                           • Improved quality of working life
                                           • Innovative pre-, peri- and post-operative
                                             techniques are recognised to make a real
                                             difference to patient experience
                                           • Shorter length of stay increases
                                             productivity
                                           • Making sure the patient is in optimal health
                                             condition before surgery minimises risk
                                             (works towards prevention) of readmission
                                             and re-operation

                                                                                            You're better, sooner!
                                          Example of enhanced recovery
                                          elements
Enhanced Recovery Partnership Programme




                                                                          • Optimising pre operative                                        • Planned mobilisation
                                          Referral from                     haemoglobin levels               • Admission on day             • Rapid hydration &
                                                                          • Managing pre existing co         • Optimised Fluid
                                          Primary Care                                                         Hydration
                                                                                                                                              nourishment
                                                                            morbidities e.g. diabetes                                       • Appropriate IV therapy
                                                                                                             •CHO Loading                   •No wound drains
                                                                            Pre-                             • Reduced starvation           •No NG (bowel
                                                                                                             • No / reduced oral bowel
                                                                          Operative                            preparation ( bowel           surgery)
                                                                                                               surgery)                     • Catheters removed early
                                                                                                                                            • Regular oral analgesia
                                                                                                                                            • Paracetamol and NSAIDS
                                                                                               Admission                                    • Avoidance of systemic
                                                                                                                                              opiate-based analgesia
                                          • Optimised health / medical
                                                                                                                                              where possible or
                                            condition
                                                                                                                                              administered topically
                                          • Informed decision making                                                 Intra-
                                                                                 • Minimally invasive surgery
                                          • Pre operative health & risk
                                                                                 • Use of transverse incisions      Operative
                                            assessment
                                                                                   (abdominal)
                                          • PT information and
                                                                                 • No NG tube (bowel surgery)
                                            expectation managed
                                                                                 • Use of regional / LA with                              Post-
                                          • DX planning (EDD)
                                                                                   sedation
                                          • Pre-operative therapy                                                                        Operative
                                                                                 • Epidural management (inc
                                            instruction as appropriate
                                                                                   thoracic)
                                                                                 •Optimised fluid
                                                                                  management                        • DX when criteria met
                                                                                                                    • Therapy support (stoma, physio)
                                                                                  Individualised goal                   You're better, sooner!
                                                                                                                                           Follow
                                                                                                                    • 24hr telephone follow up
                                                                                  directed fluid therapy                                                           Up   11
                                          Modulation of post-operative insulin resistance
                                          by pre-operative carbohydrate loading.
Enhanced Recovery Partnership Programme




                                          Proc Nutr Soc. 2002 Aug;61(3):329-36.

                                          Ljungqvist O, Nygren J, Thorell A.

                                          KarolinskaInstitutet at Centre of Gastrointestinal Disease, Ersta Hospital and
                                          Dept of Surgery, Huddinge University Hospital, Stockholm, Sweden.

                                          •Small meta-analysis
                                          •IV and oral carbohydrate pre-operatively
                                          •Reduced length of stay in elective surgical patients with pre-op carbohydrate
                                          loading
                                          •Reduced thirst hunger and anxiety.
                                          •Overnight fasting not good for patients



                                                                                         You're better, sooner!
                                           Cochrane review (updated 2010)
Enhanced Recovery Partnership Programme



                                          Preoperative fasting for adults to prevent
                                          perioperative complications
                                          Authors' conclusions: There was no evidence to suggest a shortened
                                          fluid fast results in an increased risk of aspiration, regurgitation or
                                          related morbidity compared with the standard 'nil by mouth from
                                          midnight' fasting policy.

                                          Permitting patients to drink water preoperatively resulted in
                                          significantly lower gastric volumes. Clinicians should be encouraged to
                                          appraise this evidence for themselves and when necessary adjust any
                                          remaining standard fasting policies (nil-by-mouth from midnight) for
                                          patients that are not considered 'at-risk' during anaesthesia.

                                          Editorial group: Cochrane Wounds Group.Publication status and date:
                                          Edited (no change to conclusions), published in Issue 5, 2010.Review
                                          content assessed as up-to-date: 14 August 2003.

                                                                                       You're better, sooner!
                                          Pre-operative oral carbohydrate loading in colorectal
                                          surgery: a randomized controlled trial.
Enhanced Recovery Partnership Programme




                                          Noblett SE, Watson DS, Huong H, Davison B, Hainsworth PJ, Horgan AF.

                                          Department of Colorectal Surgery, Freeman Hospital, High Heaton, Newcastle-
                                          upon-Tyne, UK.

                                          Colorectal Dis. 2006 Sep;8(7):563-9.

                                          36 patients open colonic resection
                                          3 groups – starved, water, CHO drink

                                          CONCLUSION:pre-operative administration of oral
                                          carbohydrate leads to a significantly reduced
                                          postoperative hospital stay, and a trend towards
                                          earlier return of gut function when compared with
                                          fasting or supplementary water. You're better, sooner!
                                          Goal Directed Fluid Management
Enhanced Recovery Partnership Programme




                                                            You're better, sooner!
     Enhanced Recovery Partnership Programme

                                           Hypovolaemia




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                                          Hypovolaemia +200ml Colloid
Enhanced Recovery Partnership Programme




                                                          You're better, sooner!
                                          RCTs in Major Surgery
Enhanced Recovery Partnership Programme




                                             Reduction in complications




                                                                   You're better, sooner!
     Enhanced Recovery Partnership Programme

                                           NTAC Website




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                                                    Rectus sheath block
Enhanced Recovery Partnership Programme




                                          •   Use in adults using modern long acting local anaesthetics first
                                              described in 1988

                                          •   Aims to block ventral rami
                                              of the T6–T12 intercostal
                                              nerves

                                          •    Local anaesthetic injected into
                                              potential space between rectus
                                              muscle and posterior aspect of sheath




                                                                                      You're better, sooner!
                                          Operative Gynaecology (in 2
                                          Volumes) Peham H v and Amreich J
Enhanced Recovery Partnership Programme




                                          Published in 1934, Vienna

                                          First 163 pages describe general principles including:

                                          • Preparation of the patient for operation – this includes:

                                          • Optimisation of patients with respiratory or cardiovascular problems

                                          • Recognition of VTE risk

                                          • Importance of avoiding cold, and warming of patients post op



                                                                                          You're better, sooner!
                                          Operative Gynaecology (in 2
                                          Volumes) Peham H and Amreich J
Enhanced Recovery Partnership Programme




                                          Postoperative treatment

                                          Feeding
                                          • Day 1 Black unsweetened Russian tea
                                          • Day 2 – black coffee, soup and tea with milk
                                          • Day 3 – (if bowels open) soup, veal, rice, stewed fruit and a farinaceous* food, crackers

                                          Mobilising
                                          •   “We have been very cautious about allowing our
                                              patients out of bed at an early date, although this
                                              method has unquestionable advantages…..Although the
                                              question of hospital space has made it necessary to give up the earlier-advocated three
                                              weeks of bed rest after a laparotomy, still we see to it, as a matter of principle, that the
                                              patient does not leave the bed before the ninth day”

                                          *Farinaceous – rich in starch




                                                                                                       You're better, sooner!
                                          Dogma (this is the way we
                                          always do it)
Enhanced Recovery Partnership Programme




                                          Obstetrics and Gynaecology
                                           Two distinct disciplines (often) practised by the
                                           same doctors, but with different established
                                           practice in each area
                                           Acceptance of “the way it is”, and difficulties
                                           changing such established practice
                                           1997
                                           Working in large DGH with Gynae Cancer Centre
                                           Patients admitted on the day before surgery……..

                                                                          You're better, sooner!
                                            (Very small indeed) Patient
                                           focused Observational study
Enhanced Recovery Partnership Programme




                                          Obstetrics (commenced 1997)
                                          4 caesarean sections:
                                          Same day admission
                                          Spinal anaesthetic
                                          Early feeding in recovery (tea and toast)
                                          Immediate cessation of IV fluids (cannula removed)
                                          Mobilisation as soon as block wears off (in order to facilitate):
                                          Removal of catheter
                                          Self administered analgesia (Diclofenac and Paracetamol)
                                          (Self) discharge when criteria met

                                                                                   You're better, sooner!
                                          (With “competent adult present”)
                                          How will we know when patients are
                                          ready for discharge?
Enhanced Recovery Partnership Programme




                                          Mobility returned to preoperative level

                                          Tolerating oral food and fluids

                                          Pain controlled with oral analgesia

                                          (Willing/able to go home)


                                                                            You're better, sooner!
                                          Enhanced recovery is all about
                                          helping patients through:
Enhanced Recovery Partnership Programme




                                             => better preparation for surgery

                                             => improving perioperative management to
                                                 reduce surgical “stress” response

                                             => postoperative care in partnership with
                                                patients to enable more rapid return to
                                                normal activities


                                                                           You're better, sooner!
                                          Enhanced recovery in
                                          gynaecology
Enhanced Recovery Partnership Programme




                                          • Enhanced recovery techniques in patients
                                            undergoing open surgery

                                          • Increased use of minimal access surgical
                                            techniques

                                          • Increased patient involvement in care, together
                                            with explanation and expectation of enhanced
                                            recovery through to discharge and return to
                                            normal activity                You're better, sooner!
                                          The research evidence
Enhanced Recovery Partnership Programme




                                           Current practice based on work in colorectal surgery:

                                          “Enhanced recovery after surgery: A consensus review of clinical
                                                  care for patients undergoing colonic resection”
                                                            Fearon KCH, Ljungqvist O, Von Meyenfeldt M et al
                                                                          Clinical Nutrition 2005; 24: 466-477

                                           Some well established practice
                                           eg preoperative assessment, thromboprophylaxis, antibiotics
                                           perioperative warming
                                           Some innovations
                                           eg preoperative carbohydrate loading, early mobilisation from day of
                                           surgery
                                                                                      You're better, sooner!
                                          Research evidence in
                                          gynaecology
Enhanced Recovery Partnership Programme




                                                     Improving patient care with shorter admissions
                                                                                 Schmid KJ, Tewari R, Nordin AJ
                                                  Journal of Obstetrics and Gynaecology Aug 2009; 29(6): 526-528

                                          NB Not performed as Enhanced Recovery

                                          BUT

                                          Move to same day admission
                                          Home with laxatives before bowels open
                                          Reduction in length of stay led to expectation of early discharge
                                          Involvement of patients in preparing for early discharge

                                                                                         You're better, sooner!
                                          Research evidence in
                                          gynaecology cont’d
Enhanced Recovery Partnership Programme




                                           Improving quality by introducing enhanced recovery after
                                           surgery in a gynaecology department: consequences for ward
                                           nursing practice
                                                                        Sjetne IS, Krogstad U, Odegard S et al
                                                                       Qual Saf Health Care 2009; 18: 236-240

                                           “The experiences we made indicate that the expected gains of
                                           implementing ERAS are achieved without compromising the workload
                                           or work environment of ward nursing staff”

                                           One nurse commented “ In spite of my scepticism, it is turning out very
                                           well!”


                                                                                       You're better, sooner!
                                          Critical success factors and
                                          barriers
Enhanced Recovery Partnership Programme




                                          • Leadership and clinical engagement – 5-prong
                                            approach – surgeon, anaesthetist, nursing/AHP,
                                            executive/management and primary care
                                          • Engagement/communication with patients and
                                            staff
                                          • Capability and education
                                          • Information
                                          • Culture
                                          • Process
                                          • Finance
                                                                         You're better, sooner!
                                          Critical aspect of our
                                          programme
Enhanced Recovery Partnership Programme




                                           Michelle Perry, Matron for Preassessment
                                           Gail Webb, Clinical Nurse Specialist,
                                           Gynaecological Oncology
                                           Teaching/information design/data collection/encouragement and
                                           support to patients and staff

                                           Without these individuals, we would have not been able to introduce
                                           or sustain the programme

                                           {There are risks because these individuals are incredibly valuable
                                           assets within organisations, and programmes may be at risk if such
                                           key individuals do not have support and back up}
                                                                                     You're better, sooner!
                                          Key aspects of our
                                          programme
Enhanced Recovery Partnership Programme




                                          Pre-assessment clinic already in place with excellent
                                            leadership
                                            We do not have CPEX, but we have ready access to
                                            anaesthetic team, and other disciplines if required

                                            Antibiotic and thromboprophylaxis prescribed, and bowel
                                            prep never routinely prescribed

                                            Consent and patient information available in this clinic
                                            Specific information for ERAS developed to accompany
                                            this, including inpatient diary and clinical notes
                                                                                You're better, sooner!
                                          Key aspects of our
                                          programme cont’d
Enhanced Recovery Partnership Programme




                                          Intra-operative
                                             Strong teams who work together regularly
                                             Medical teams who work collaboratively with other
                                             specialties eg colorectal surgery

                                          Small tests of change:
                                            Introduction of rectus sheath catheters
                                            No routine NG tubes
                                            No routine drains

                                          Development of minimal access techniques (dual surgeon
                                            operating)                        You're better, sooner!
                                          Post operative care
Enhanced Recovery Partnership Programme




                                            For us, the key phase of the programme (a weak
                                            area in published studies)

                                            Planning –
                                          • education and engagement of ward staff in
                                            programme
                                          • education of patients – from OPD, reinforced at
                                            pre-assessment, and supported with written
                                            information and patient diary
                                          • daily ward round by Consultant to assess
                                                                           You're better,
                                            progress, with monitoring at each nursing sooner!
                                          Sample comments
Enhanced Recovery Partnership Programme




                                           The positive:

                                           “I think that by doing the diary I felt empowered to aid in
                                           my recovery”

                                           “I very much liked the two follow up phone calls…This was
                                           very reassuring…”

                                           “This is my 16th visit to theatre. The nutritional drink was of
                                           great benefit…..(I always wake up starving)

                                           The negative:                          You're better, sooner!
                                                 Snapshot of change in practice in
                                                 Gynaecological Oncology at RD&E
                                                          2006 vs 2010
Enhanced Recovery Partnership Programme




                                          2006                          2010
                                          End of April –Mid-August      End of April – Mid-August
                                          105 patients                  124 patients entered
                                          TAH/open BSO        49(47%)   TAH/open BSO        31(25%)
                                          Laparotomy          48(46%)   Laparotomy          50(40%)
                                          Vaginal hyst        6(5.5%)   LAVH/vaginal hyst 22(18%)
                                          Laparoscopic BSO 2(1.9%)      Laparoscopic BSO 21(17%)


                                          Open                   93%    Open                   65%
                                          Laparoscopic/vaginal   7%     Laparoscopic/vaginal   35%
                                                                               You're better, sooner!
                                          FailedLap (All)   Diabetes (All)   ChronIHD (All)   Endo (All)   ChronicLowerResp (All)     Read? (All)   Exclude? (blank)    Cons (All)
Enhanced Recovery Partnership Programme



                                                                  Hysterectomies by average LoS - 1011 enhanced recovery patients
                                                                                       against 0809 patients

                                           7


                                           6


                                           5

                                                                                                                                                                                     Data
                                           4
                                                                                                                                                                                      Average of LoS total
                                                                                                                                                                                      Average of LOS PreOp
                                           3
                                                                                                                                                                                      Average of LOS PostOp

                                           2


                                           1


                                           0
                                                      08/09
                                                      0809                   10/11
                                                                             1011                  08/09
                                                                                                   0809                  10/11
                                                                                                                        1011                   08/09
                                                                                                                                                0809                   10/11
                                                                                                                                                                        1011
                                                            Not Lap                                          Lap                                 Not Lap
                                                            Open                                           LAVH/TLH                     Vaginal Hysterectomy
                                                            Abd_hys                                                                 Vag_hys
                                                        Hysterectomy
                                                                                                Hysterectomy   LAP     FinYear


                                                                                                                                              You're better, sooner!
                                          What we have achieved
Enhanced Recovery Partnership Programme




                                          • Ritualistic nursing practises challenged & changed.
                                          • Introduction of ER to Torbay patients being Pre-assessed
                                            in Torbay with surgery at RD&E.
                                          • Reduction in length of stay & timely discharges.
                                          • Same day admissions
                                          • Positive feedback from patients
                                          • Regular stock ordering of ER drinks & bags.
                                          • Different ways of thinking.
                                          • Patients taking active responsibility for getting themselves
                                            to hospital on time and for their discharge.

                                                                                  You're better, sooner!
                                          Difficulties
Enhanced Recovery Partnership Programme




                                          • Collecting/processing data
                                          • Achieving patient F/U calls on time.
                                          • Patients mobilising as per ER but then missing
                                            for ward round.
                                          • Maintaining enthusiasm with ward staff – mixed
                                            ER/Non ER causes confusion especially with
                                            Bank staff.
                                          • Getting patient diaries returned.


                                                                          You're better, sooner!

				
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