Enhanced Recovery

Getting Started

Introductions

Housekeeping

Objectives for the session

This Session

• Practical activities to get you started

• Based on the Implementation Guide

• Access to advice, guidance and support

• Discuss the key elements of your local implementation plan

Overview

This Session:

Principles, elements and benefits of ERP

Drivers for Implementation

Current and future pathway

Action Planning:

Stakeholder Analysis

Testing changes for improvement

Measuring Outcomes

Principles, elements and benefits of Enhanced

Recovery

What is it? Enhanced Recovery is a new way of improving the

experience and well-being of patients who need major surgery

It helps people to recover sooner so that life can return to normal as quickly as possible

It gives people a better overall experience due to higher quality care and services

It lets people choose what’s best for them throughout the course of their treatment with help from their GP and the wider healthcare team (“No decision about me without me.”)

Many people who have experienced Enhanced Recovery say that it makes a hospital stay much less stressful

Your Better Sooner!!!

The Principles of ER

Getting the patient in to the best possible condition for surgery

Ensuring the patient has the best possible management during their operation

Ensuring the patient has the best post-operative rehabilitation

Kehlets theory – 1980s

9

Referral fromPrimary Care

Pre-Operative

Admission

Intra-Operative

Post-Operative

FollowUp

• Optimised health / medical condition

• Informed decision making• Pre operative health & risk

assessment - CPEX• PT information and

expectation managed• DX planning (EDD)

• Minimally invasive surgery

• Use of transverse incisions

• No NG tube (bowel surgery)

• Use of LA with sedation• Epidural management (inc thoracic)

• Optimised fluid management

• Planned mobilisation• Rapid hydration & nourishment

• Appropriate IV therapy• No wound drains• No NG (bowel surgery)• Catheters removed early• Regular oral analgesia• Paracetamol and NSAIDS

• Avoidance of opiate-based analgesia where possible or administered topically

• Optimised Fluid Hydration

• Reduced starvation• No / reduced bowel

preparation ( bowel surgery)

• DX on planned day• Therapy support (stoma, physio)

• 24hr telephone follow up

• Optimising pre operative haemoglobin levels

• Managing pre existing co morbidities e.g. diabetes

• Audit & outcome measures

Example of ER elements

Physical impact

Clinical evidence compelling!

Colorectal Surgery: Length of stayLarge Intestine: Major Procedures

0

2

4

6

8

10

12

14

16

UK Kehlet

Benefits being realised...

Multi-Disciplinary Teams? It give patients a better overall experience through higher

quality care and services

It introduces innovative best practices that empower and motivate staff

It accelerates the clinical decision-making process by empowering MDTs

It doesn’t increase MDT workload

It ensures the most-efficient use of healthcare resources

Best-practice is day surgery or an Enhanced Recovery pathway

What does it mean for providers?

It improves patient safety and involvement and meets Care Quality Commission requirements

It reduces demand on resources such as critical care, surgical beds and patient uptake of procedures

It increases job satisfaction of Multi-disciplinary Teams through better ways of working and improved patient outcomes

It improves the reputation of the healthcare provider

Best-practice is day surgery or an Enhanced Recovery pathway

Process & capacity impact

Commissioners? It enhances the reputation of the healthcare provider

It helps patients recover sooner from surgery

Best-practice is day surgery or an Enhanced Recovery pathway

It improves patient experiences through increased partnership and empowerment (“No decision about me without me.”)

It motivates medical teams through best practice, empowerment and innovation

It reduces demand on resources such as critical care, surgical beds and patient uptake of procedures

Trusts with varying experience of enhanced recovery pathways

North East

Gateshead NHS Foundation Trust (M)Newcastle Hospitals NHS Trust (C)City Hospitals Sunderland NHS Foundation Trust (U)

Northumbira NHS Trust (MSK)

South Tees Hospitals NHS Foundation Trust (C,G,U)

North West

Aintree University Hospitals NHS Foundation Trust (M)East Lancashire Hospitals NHS Trust (C)Hope Hospital, Salford (C)Wirral University Teaching Hospital NHS Foundation Trust (C)(M)

Aintree University Hospitals NHS Foundation Trust (C,M,UPGI,Li)

Yorkshire & The Humber

Sheffield Teaching Hospitals NHS Foundation Trust (G)York Hospitals NHS Foundation Trust (C)Scarborough Healthcare NHS Trust (C)

Leeds Teaching Hospitals NHS Trust (C,G)Calderdale and Huddersfield NHS Foundation Trust (C,G)

West Midlands

City Hospital NHS Trust, Birmingham (C)Good Hope Hospital (C)University Hospitals Birmingham NHS Foundation Trust (C) Birmingham Heartlands NHS Trust

(C)University Hospital of North Staffordshire NHS Trust (C,U,G)

Robert Jones & Agnes Hunt NHS Trust

East Midlands

Derby Hospitals NHS Foundation Trust (G)Queen’s Medical Centre (C)Sherwood Forest Hospitals NHS Foundation Trust (C) (G)

The University Hospitals of Leicester NHS Trust (C,M,G,U)

East of England

Colchester Hospital University NHS Foundation Trust (C)West Suffolk Hospital NHS Trust (M)Cambridge University Hospitals NHS Foundation Trust (Addenbrookes Hospital)(G)

West Hertfordshire Hospitals NHS Trust (C,M,G,U)

South East Coast

Brighton and Sussex University Hospital NHS Trust (C)Darent Valley Hospital (Dartford and Gravesham NHS Trust) (M)Royal Surrey County Hospital NHS Trust (C)Worthing Hospital (C)East Kent Hospitals University NHS Foundation Trust (Queen Elizabeth, the Queen Mother Hospitals)(G)Medway NHS Foundation Trust(C)Medway NHS Foundation Trust (C,M,G,U)Brighton and Sussex University Hospitals (C,M,G,U)

London

Barnet & Chase Farm Hospitals NHS Trust (C)Guy’s & St Thomas’ NHS Foundation Trust (C)Hillingdon Hospital NHS Trust (M)Imperial College Healthcare NHS Trust (C)South West London Elective Orthopaedic Centre (M)St George’s Healthcare NHS Trust (C)(U)St Mark’s Hospital (North West London Hospitals NHS Trust) (C)The Whittington NHS Trust (C) (M)UCLH NHS Foundation Trust (C)Whipps Cross University Hospital NHS Trust (C)

The Hillingdon Hospital NHS Trust (C,G)North Middlesex University Hospital NHS Trust (C,M,G)

South West

North Devon Healthcare NHS Trust (C)South Devon Healthcare NHS Foundation Trust (C)(M)(G)Royal Devon and Exeter NHS Foundation Trust (U)Royal Bournemouth Hospital (M)North Bristol NHS Trust (Southmead Hospital)(U)Yeovil District Hospital NHS Foundation Trust (C)(M)Salisbury NHS Foundation Trust (C)Dorset County Hospital NHS Foundation Trust (C)Plymouth Hospitals NHS Trust (C)West Dorset NHS Trust (C)

South Devon Healthcare NHS Foundation Trust (Torbay Hospital) (C,M,G,U)South Central

Isle of Wight Healthcare NHS Trust (C)Milton Keynes Hospital NHS Foundation Trust (C)Royal Berkshire NHS Foundation Trust (C)Portsmouth Hospitals NHS Trust (C)Southampton University Hospitals NHS Trust (C)Oxford Ratcliffe(C)NHHT M)Winchester & Eastleigh NHS Trust (C,M,G)Royal Berkshire NHS Foundation Trust (C,M,G,U)

Legend

The following denotes a trust is working in this specialty:

(M) Musculoskeletal

(C) Colorectal

(U) Urology

(G) Gynaecology

Enhanced Recovery Innovation Sites are shown in red

Scotland

NHS Lothian (M)Gold Jubilee National Hospital (M)

Drivers for Implementation

Bella Talwar

Implementation Plan

1. Understanding your current service2. Team working3. Action planning4. Stakeholder analysis5. Stakeholder engagement6. Testing and making changes to your

pathway Understanding the risks7. Understanding the investment required8. Maintaining momentum9. Sustaining the change

Audience: Patients

Enhanced Recovery is a new way of improving the experience and well-being of patients who need major surgery.

• It helps people to recover sooner so that life can return to normal as quickly as possible

• It gives people a better overall experience due to higher quality care and services

• It lets people choose what’s best for them throughout the course of their treatment with help from their GP and the wider healthcare team (“No decision about me without me.”)

• Many people who have experienced Enhanced Recovery say that it makes a hospital stay much less stressful

Enhanced Recovery is a new, evidence-based pathway that creates fitter, patients who recover faster from major surgery

• It give patients a better overall experience through higher quality care and services

• It introduces innovative best practices that empower and motivate staff

• It accelerates the clinical decision-making process by empowering MDTs • It doesn’t increase MDT workload

• It ensures the most-efficient use of healthcare resources

• Best-practice is day surgery or an Enhanced Recovery pathway

Audience: Multi-Disciplinary Teams

Mapping your pathway against the Enhanced

Recovery Elements

BellaTalwar

Understanding your current service

Identify elements in place on enhanced recovery pathway map

Audit of compliance with clinical elements on an individual patient basis

Process map / Walk the patient journey

Track patient journeys

Patient ExperienceLength of Stay

Re-operation ratesReadmission ratesComplication rates

CLINICAL INTERVENTIONS CLINICAL SYSTEM

OUTCOMES

Understanding your current

serviceReferral

fromPrimary

Care Pre-Operative

Admissio

n

Intra-Operative

Post-Operative

FollowUp

•Optimised health / medical condition

•Informed decision making

•Pre operative health & risk assessment

•PT information and expectation managed

•DX planning (EDD)•Pre-operative therapy instruction as appropriate

•Minimally invasive surgery•Use of transverse incisions (abdominal)

•No NG tube (bowel surgery)

•Use of regional / LA with sedation

•Epidural management (inc thoracic)

•Optimised fluid management Individualised goal directed fluid therapy

•Planned mobilisation•Rapid hydration & nourishment

•Appropriate IV therapy

•No wound drains•No NG (bowel surgery)

•Catheters removed early

•Regular oral analgesia•Paracetamol and NSAIDS

•Avoidance of systemic opiate-based analgesia where possible or administered topically

•Admission on day•Optimised Fluid Hydration

•CHO Loading•Reduced starvation•No / reduced oral bowel preparation ( bowel surgery)

•DX when criteria met

•Therapy support (stoma, physio)

•24hr telephone follow up

•Optimising pre operative haemoglobin levels

•Managing pre existing co morbidities e.g. diabetes

Care Pathway Project Plan

Short-term investment

Support to change the pathway (e.g. service improvement, change manager, facilitator etc)

Training – new skills e.g. pre-assessment

Equipment – invest to save

Communication/awareness

Find out what is already in place & going on Make the connections

What investment may be required?

Financial

Training

CommunicationSystematic

improvement Approach

Team-working

Change management

Skills

LeadershipEngagement & accountability

TimeFocus

Commitment

Enhanced Recovery

Finance is not the only

investment

What else is ER aligned to?

TCAB

Top Tips

Actual Bed Time

Nurse Dispensing

Protocol LedDischarge

Ticket Home

Discharge Lounge

Productive Wards

Pre – 11 am Discharge

ERP

Understanding and improving systems and processes

Patient Pathway

Undertake mapping and tracking

Understanding your current service - Exercise On the map provided: Understanding your

current service - Exercise

Mark the interventions you already have in place You should also consider when, where and how they

are provided and whether there is further opportunity for improvement

Identify the interventions you need to establish and start to consider the sequence for implementation

Stakeholder AnalysisJanine Roberts

Identifying the team

Implementation requires a number of factors: Changing clinical interventions Changing care systems and processes Creating a team to work across the patient

pathway Both require technical and behavioural change

management Lets start with thinking about who to engage and

how to structure the project team

Essential Roles

Sponsors:• authority to sanction change

(organisational alignment / benefit)Change Agents:• facilitate change, require knowledge, skills

and credibilityChampions:• respected opinion leaders who positively

promote workLeaders:• lead by example

Satisfy

•Opinion formers

•Keep satisfied

•Review regularly

Manage

Key Stakeholders need to be fully engaged through full communication & consultation

Inform / Monitor

Not crucial to the process but useful to keep informed

Involve

•Voices that need to be heard

•Need to be proactive

High Influenc

e

Little / No

Influence

Little / No Interest

High interest

Stakeholder Analysis

Stakeholder Engagement

Full guide to stakeholder analysis and management:

NHS Institute for Innovation and Improvement‘The Handbook of Quality and Service

improvement Tools’ Section 3 Stakeholder and User Involvement

Action planning and potential challenges

Sophia Mavrommatis

Action Planning

Take time to deliberate; but when the time for action arrives, stop thinking

and go in’

-Andrew Jackson quoting Napoleon Bonapart

Agreementamongst thekey players

Certaintythat the changewill work

Justdo itJDI

high

low

low

high

Test ona very small scale

Managing Improvement

Just Do it!

Little risk Minimal cost Broad agreement Easy to do

Testing Changes for Improvement

Sophia Mavrommatis

Enhanced Recovery Action PlanAction Owner Resources 30 60 90

Action Planning & Challenges On your table provided start to fill in from the earlier

work today which actions need to be completed

Who can deliver these actions

What is the timescale – 30, 60 or 90 days

Resourse – flag up what support you may need here to deliver the action – eg connection into the local PCT, facilitator to deliver a workshop

Include in this the top three challenges that you think

you will encounter and the actions you will put in place to work through these challenges.

Measuring OutcomesBella Talwar

Outcomes

Patient / staff

Clinical - elements of the pathway

Financial

Understanding Your Current Service

Identify elements in place on enhanced recovery pathway map

Audit of compliance with clinical elements on an individual patient

basis

Process map / Walk the patient journey

Track patient journeys

Patient ExperienceLength of Stay

Re-operation ratesReadmission ratesComplication rates

CLINICAL INTERVENTIONS CLINICAL SYSTEM

OUTCOMES

55

Referral fromPrimary Care

Pre-Operative

Admission

Intra-Operative

Post-Operative

FollowUp

• Optimised health / medical condition

• Informed decision making• Pre operative health & risk

assessment - CPEX• PT information and

expectation managed• DX planning (EDD)

• Minimally invasive surgery

• Use of transverse incisions

• No NG tube (bowel surgery)

• Use of LA with sedation• Epidural management (inc thoracic)

• Optimised fluid management

• Planned mobilisation• Rapid hydration & nourishment

• Appropriate IV therapy• No wound drains• No NG (bowel surgery)• Catheters removed early• Regular oral analgesia• Paracetamol and NSAIDS

• Avoidance of opiate-based analgesia where possible or administered topically

• Optimised Fluid Hydration

• Reduced starvation• No / reduced bowel

preparation ( bowel surgery)

• DX on planned day• Therapy support (stoma, physio)

• 24hr telephone follow up

• Optimising pre operative haemoglobin levels

• Managing pre existing co morbidities e.g. diabetes

• Audit & outcome measures

Making your baseline assessment

Enhanced Recovery Pathway‘Implementation & Sustainability’

Median LOS for Prostectomy

-2

0

2

4

6

8

Apr-0

9

Jun-

09

Aug-

09

Oct

-09

Dec-

09

Feb-

10

Apr-1

0

Jun-

10

Aug-

10

Oct

-10

Dec-

10

Feb-

11

Apr-1

1

Jun-

11

Median LOS for Abdominal Hysterectomy

2

3

4

5

6

7

8

Apr-0

9

Jun-

09

Aug-

09

Oct

-09

Dec

-09

Feb-

10

Apr-1

0

Jun-

10

Aug-

10

Oct

-10

Dec

-10

Feb-

11

Apr-1

1

Jun-

11

Median LOS for Primary Hip Replacement

3456789

10

Apr-0

9

Jun-

09

Aug-

09

Oct

-09

Dec-

09

Feb-

10

Apr-1

0

Jun-

10

Aug-

10

Oct

-10

Dec-

10

Feb-

11

Apr-1

1

Jun-

11

Median LOS for Colectomy

0

5

10

15

20

Apr-0

9

Jun-

09

Aug-

09

Oct

-09

Dec-

09

Feb-

10

Apr-1

0

Jun-

10

Aug-

10

Oct

-10

Dec-

10

Feb-

11

Apr-1

1

Jun-

11

ERP implementedRobotic Surgery

ERP implemented

CQUINS

Ann’s story to the Deputy Prime Minister

“ I had two hip replacements last year. One in June

and one in December.

The second one was much better,

the service is fabulous!”

Benefits RealisationJanine Roberts

Benefits Realisation

Next StepsJanine Roberts

Next steps

Making it happen?

• What ongoing support can we provide?• Implementation plan• Follow-up session

Next Steps

What will be your first change you will test or implement?

• Remember the importance of a quick win as well as a plan for sustainability

Next Steps

Advice guidance and support – to change

Implementation guide Enhanced Recovery Toolkit SHA support Local Network events UCLH Implementation team E-learning / DVD / Top Tips http://insight/departments/Projects/QEP/Pages/

home.aspx www.improvement.nhs.uk