implementation of enhanced recovery in orthopaedics across...
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NHS National Waiting Times Centre
Implementation of Enhanced Recovery Implementation of Enhanced Recovery in Orthopaedics across Scotland-in Orthopaedics across Scotland-
the story so far…….the story so far…….
Mr. David A McDonaldMr. David A McDonald
CALEDonian CoordinatorNational ERP Clinical Implementer
NHS National Waiting Times Centre
NHS National Waiting Times Centre
NHS National Waiting Times Centre
NHS National Waiting Times Centre
The future of elective care -day surgery or enhanced recovery?
NHS National Waiting Times Centre
NHS National Waiting Times Centre
NHS National Waiting Times Centre
The key to success is the understanding of the word multidisciplinary by all the disciplines
NB Once a surgeon and an anaesthetist are on your side anything is possible
Dr Nick Scott
NHS National Waiting Times Centre
Enhanced Recovery Programme Scotland – Aims and Objectives
•Audit Scotland Report (2010) suggested reductions in length of stay, without compromising quality of care, is better for patients and will ensure better use of resources (Par 47).
•ERP is a multidisciplinary programme that aims to accelerate patient rehabilitation and reduce peri-operative morbidity thereby safely reducing hospital length of stay.
•Programmes should not be exclusive to the young, fit and healthy and, if conducted properly, every patient should benefit.
•The project aims to utilise evidenced based good practice and spreading it across Scotland to provide an equitable experience of patient care.
•The project is engaging with NHS Boards to understand their current pathways and then utilise the current expertise to support spread and adoption and support implementation of local action plans.
NHS National Waiting Times Centre
ERP – National Programme engagement
• What is the current practice in Scotland?
• Do we know what everyone is doing?
• National ‘snap shot audit’• All THR and TKR patients over a six week period
• n= 1342
• 22 units in Scotland• Audited pre, peri and post operative components
NHS National Waiting Times Centre
Who is using ERP
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Demographics
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Co-morbidities
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NHS National Waiting Times Centre
Type of anaesthesia
Hips
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General SpinalSpinal and regional/Nerve block Spinal and EpiduralSpinal and LIA General and Regional/Nerve blockOther
NHS National Waiting Times Centre
Post-op Analgesia
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LIA + any other Nerve block w ith any other (not LIA)IV/IM/SC opioids+oral opioids+non opioids * Oral opioids+non opioids *IV/IM/SC opioids+non opioids* Other **
NHS National Waiting Times Centre
IV Fluids Stopped
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NHS National Waiting Times Centre
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Pre-op Intra-op Post-op catheterised, but timing unknown None
NHS National Waiting Times Centre
Blood Transfusion
HIPS
KNEES
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Pre-op Intra-opPost-op Both intra and post-opBoth pre and post-op None
NHS National Waiting Times Centre
Post op Mobilisation
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Per
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On day of op First day post-opSecond day post-op OtherNR
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Post-operative length of stay
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<=3 days 4-5 days 6-7 days >1 week
NHS National Waiting Times Centre
Key Opportunities
•8 units have developed an ERAS programme and only one has developed this for every patient.•Blood transfusion rates are high •Fasting and Fluids•Most patients are now receiving regional (mainly spinal) anaesthesia •Only 18% of patients had fluids discontinued within 12 hours of surgery•High urinary catheterisation rate•Only 29% of patients were admitted to hospital on the day of surgery.
Hospitals that had higher transfusion rates, longer use of IV fluids and patient-controlled analgesia had lower early mobilisation rates and longer lengths of post-operative length of stay
NHS National Waiting Times Centre
Spread and adoption
• Utilised audit data to discuss local variation
• Supported boards develop local programme• Site visits• Team visits to leading centres• Buddy list
• Sharing of practice
• Developed webpage
NHS National Waiting Times Centre
ERP – NHS Borders Improvement Programme
Previous joint pathway ERP pathway (in first month)
Length of Stay 8.5 days 4.2 days
Same day admit 0% 75%
Use of High Dependency Unit
100% 0%
Blood Transfusion 30-40% < 5%
Urinary Catheterisation 100% < 10%
Mobilisation of patients on theatre day
0% 98%
NHS National Waiting Times Centre
Second Audit Summer 2011
• Repeat audit across Scotland
• n = 1245• All 22 sites• Added post-op Hb• Anaesthetist
NHS National Waiting Times Centre
One year comparison
Summer 2010 Summer 2011
Number of sites 8/22 15/22
Same day admit 29% 41%
Median post op LoS 5 days 4 days
Urinary Catheterisation 35% 26%
Blood Transfusion 14% 11%
IV Fluids stopped in <12hours
22% 29%
Mobilisation of patients within 24 hours
81% 92%
NHS National Waiting Times Centre
Findings Summer 2011 – Blood Transfusion
• Although seldom necessary to transfuse patients with a post-op Hb >90, this group accounts for almost 50% of the total number of patients transfused.
• Hospitals that had lower transfusion rates had higher early mobilisation rates (p=0.001) and shorter lengths of post-operative length of stay (p=0.003).
NHS National Waiting Times Centre
Other findings
• Patients who had pre-op education from physiotherapy had statistically significant reduction in length of stay
• Hospitals that had lower use of PCA had higher early mobilisation rates (p=0.01) and shorter lengths of post-operative length of stay (p=0.03).
• Hospitals that had shorter use of IV fluids had higher early mobilisation rates (p<0.001) and shorter lengths of post-operative length of stay (p=0.015).
NHS National Waiting Times Centre
Blood transfusion
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10
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25
ERP patient Not an ERP patient
% of patients
transfused
NHS National Waiting Times Centre
IV fluids discontinued
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ERP patient Not an ERP patient
IV fluids discontinued
(% of patients)
Not Recorded
Other
Second day post-op
First day post op but >12hrs post-op
Same day or <12hrs post-op
NHS National Waiting Times Centre
Urinary catheterisation
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80
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ERP patient Not an ERP patient
Urinary catheterisation (% of patients)
None
Timing unknown
Post-op
Intra-op
Pre-op
NHS National Waiting Times Centre
Post op mobilisation
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ERP patient Not an ERP patient
Post-op Mobilisation
(% of patients)
Not known
Other
Second day post-op
First day post-op
On day of op
NHS National Waiting Times Centre
Post-operative length of stay
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ERP patient Not an ERP patient
Post-oplength of stay
(% of patients)
>1 week
6-7 days
4-5 days
<=3 days
NHS National Waiting Times Centre
Change is possible – and we are getting there
Full ERP One surgeon performing ERP No ERP
Summer 2010 End of 2011
NHS National Waiting Times Centre
‘ …transformation doesn't have a finish line and success is not an entitlement, it has to be earned. We are not celebrating, we still have a lot to do’
Howard Schultz
Chairman & CEO
Starbucks
NHS National Waiting Times Centre
…..Yesterday is history,
Tomorrow a mystery,
But today is a gift……
That is why they call it the present!
Master OogwayKung Fu Panda
NHS National Waiting Times Centre
When things go wrong, as they sometimes will, When the road you're trudging seems all uphill, When the funds are low and the debts are high,
And you want to smile, but you have to sigh, When care is pressing you down a bit- Rest if you must, but don't you quit.
Life is queer with its twists and turns, As every one of us sometimes learns,
And many a fellow turns about When he might have won had he stuck it out.Don't give up though the pace seems slow –
You may succeed with another blow.Often the goal is nearer than
It seems to a faint and faltering man;Often the struggler has given up
When he might have captured the victor's cup; And he learned too late when the night came down,
How close he was to the golden crown.Success is failure turned inside out -The silver tint in the clouds of doubt,
And you never can tell how close you are, It might be near when it seems afar; So stick to the fight when you're hardest hit –
It's when things seem worst that you must not quit.Unknown