Enhanced Recovery The Efficient Way to Help Patients Get Better Sooner After Surgery

November 2012

Overview

• Background • Patients’ journey • Aim of the program • How have we performed? • Can we do more? • Questions?

Length of Stay Why?

• Historical reasons • Patient expectations • Patient worries • No help/ continuity at home • Pain • Wound healing • Anaemia • Slower rehabilitation

What is Enhanced Recovery?

• A growing movement within surgery which aims, through a variety of methods, to help patients to get better sooner after major surgery

Key principles

• Patient education / communication • Anaesthetic factors • Surgical factors • Nutrition • Rehabilitation • Process

Benefits • Improved patient experience • Patients fitter sooner • Reduced length of stay • Improved clinical outcomes • Cost efficiency savings • Increased bed capacity for trusts • Helps to meet quality and operational

standards • Team building

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

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

Yorkshire & The Humber Leeds Teaching Hospitals NHS Trust (C,G) Calderdale and Huddersfield NHS Foundation Trust (C,G)

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

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

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

South East Coast Medway NHS Foundation Trust (C,M,G,U) Brighton and Sussex University Hospitals (C,M,G,U)

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

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

South Central 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

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

Areas

• Orthopaedics – Hips & Knees • Gynaecology – Hysterectomy • Colorectal – Upper and Lower GI • Back Surgery. • Shoulder Procedures • ENT Procedures

Multi-Disciplinary Team

• Enhanced Recovery Nurse • Consultant Orthopaedic Surgeon • Consultant Anaesthetists • Junior Doctors • Matron • Ward Sisters • Ward Clerks • Theatre Staff

• Pain Nurse • Pre-op Assessment Staff • Physiotherapists • Occupational Therapists • Allied Health Professionals • Pharmacists • Porters • Discharge facilitator

Enhanced Recovery Nurses

• Co-ordinate running of ER • Point of contact • Advice & information • Post-discharge • Runs weekly school • Audit & Research

Patient Education • Starts at the out-patient appointment

• Continues at Pre-operative assessment

• Comprehensive coverage at weekly

educational sessions

Hip and Knee School

• What to expect • Pain relief • Physiotherapy • Occupational therapy

Attendance up from 17% to 98%

“Better educated patients are better recovering patients”

Alleviating patient worries

• Know what to expect • Sleep well before op • Already will have met ward staff

Anaesthetic factors

• Avoidance of pre-medication • Individualised, goal-directed fluid

therapy (carbohydrate-loading) • Regional anaesthesia • Short acting anaesthetic agents • Prevention of hypothermia • Effective opiate-sparing analgesia • Minimise post-op nausea and vomiting

Surgical factors • Minimally traumatic vs. minimally invasive • Laparoscopic surgery • Reduced tourniquet time • Careful Haemostasis; Floseal, Tranexamic acid • Careful tissue handling • Local anaesthetic infiltration • Leave the dressing 48 hrs • Training

Nutrition

• Maximising patients pre-operative hydration

• Individualised and targeted prevention of

nausea and vomiting

• Early post-operative oral hydration

Rehabilitation

• Front-loading • Same day mobilisation • 365 day service • Encouragement of patient self-care • Own clothes (and make-up!)

Process

• Admit patients on day of surgery • Planned discharge criteria • Telephone and follow up support

immediately post-discharge • Auditing and monitoring the outcomes

What have we achieved?

• Over 2600 patients have gone through the Enhanced Recovery Pathway to date

• Length of stay in hospital has reduced by an average of:

• 2 -3 days for orthopaedic patients • 2 days for colorectal surgery patients • 4 days for upper GI patients • 2 days for gynaecology patients • 1 day for back procedures- discectomies and

decompressions

• The number of patients readmitted to hospital has also decreased

• Patient feedback has been incredibly positive

Results - Orthopaedics

• 2100 +patients • March 2010 – October 2012

• Median length of stay for Total Hip

Replacement is 3 days • Median length of stay for Total Knee

Replacement is 4 days

Readmission rate

• Admission for any reason within 28 days of surgery (42 for orthopaedics)

• Ortho - Unchanged at 5.5% • Gynae – reduced from 7.6% to 1.9% • Colorectal – reduced from 27.3% to

15.5% • Over 50% of readmissions unrelated to

original surgery

Section 1 - To be completed at Pre-Operative Assessment

ASA Grade (please select one)I - Normal healthy adultII - Mild systemic disease that does not limit activityIII - Severe systemic disease that limits activity but is not incapacitatingIV - Incapacitating systemic disease wich is constantly life-threateningV - Moribund, not expected to survive 24 hours with or without surgery

History of Insulin Dependent Diabetes Melitus?History of Ischaemic Heart Disease (MI, NSTEMI, Angina)?History of CVA or TIA?History of LVF or CCF?History of CPD?Haemoglobin level less than WHO recommendations?Pre Operative anaemia corrected?Did patient receive blood transfusion?

Preoperative serum Creatinine (mmol)

Preoperative haemoglobin level (g/dl)

Patient assessed as fit for surgery?Patient given written and verbal explanation of enhanced recovery pathway?Preoperative therapy education e.g. physio/OT?

Section 2 - To be completed at Surgical Admissions Lounge

Date and time of admission

Preoperative assessment completed?Oral bowel preparation avoided?Patient admitted on day of surgery?Carbohydrate drinks given preoperatively?Avoidance of long acting sedative premedication?

Section 3 - To be completed by theatres

Date and time of surgery

The administration of appropriate antibiotics prior to skin incision?Epidural or regional analgesia used?Individualised goal directed fluid therapy?Hypothermia prevention? (intraoperative warning)NG tube removed before exit from theatre?The aviodance of abdominal drains except following total mesoretal excision?

Attach patient label

ENHANCED RECOVERY PROGRAMME PROFORMA - ORTHOPAEDICSThis form only to be filled out for patients identifed for the enhanced recovery trial Section 4 - Type of procedure

Hip replacement right Revision knee replacementHip replacement left Spine fusionBilateral hip replacement Hip and knee replacementKnee replacement right Revision hip and knee replacementKnee replacement left Shoulder replacementBilateral knee replacement Revision shouder replacementRevision hip replacement

Section 5 - To be completed by ward post-operation

Avoiding postoperative crystalloid overload?Avoidance of systemic opiates used post-operatively?Early post-operative nutrition / solid food?Targeted individualised nausea and vomiting control?Early planned mobilisation within 24 hours?

Patient experienceIs this patient's experience being measured?Which method are you using? Questionaire Patient discussion groups Patient/Carer Diary Other (please describe below)

Postoperative morbity score (to be completed one week after operation if not discharged)Are any of the following present 7 days after surgery? Pulmonary Neurological Infectious Wound Renal Hematological requirement GI Pain CVS Patient has died

If patient dies in hospital - Date of death

No. of days on ITU bed No. of days on HDU bed

Date and time of discharge

Section 6 - For office use only

ICD10 code enteredReadmission within 42 days? Reoperation within 42 days?

Readmission date Discharge date

Type of reoperation (choose from supplied list)

Date of death (if after discharge)

Audit – ER Pathway

• attendance at pre-op education programmes • anaesthetic safety • individualised fluid management • hypothermia prevention • avoidance of sedatives • targeted treatment of post-operative nausea • early nutrition • early mobilisation • early post-discharge telephone follow-up

Patient Experience 10 I was given enough privacy when discussing my treatment?

1 2 3 4 5 11 I felt reassured by having an Enhanced Recovery Nurse or Link Nurse overseeing my

care?

1 2 3 4 5 12 I felt involved in decisions about my discharge from hospital?

1 2 3 4 5

13 When you were discharged from hospital were you given written/printed information about

what you should or should not do?

YES NO NOT SURE 14 Were you told about what medication side effects to watch out for when you went home?

YES NO NOT SURE 15 Were you told who to contact about your condition after you leave hospital?

YES NO NOT SURE 16 Is there anything that we could do to improve your care further?

Your response is valued and we will use it for developing further improvements to the

Enhanced Recovery Programme

The Enhanced Recovery Team at West Hertfordshire Hospitals NHS Trust would like to wish you well with your recovery

• “All the staff were so caring and attentive. Such detail is made and given to me re my discharge. Thank you so much for your care and kindness”.

• “All was very good. Everyone was very helpful and very caring”. • “Everybody from surgical staff, sisters, nurses, physio and OT were

so very kind and understanding. I also think the cleaning staff are exemplary. My stay at St Albans Hospital has been very comfortable. I would be very happy (if I need) to come again”.

• “I cannot find anything that could be improved on. The nurses and staff were absolutely top class”.

• “Everything was covered as far as I know. I live on my own and have no family near me so was quite anxious about going home but it was all covered and explained to me.”

Patient Satisfaction

Patient satisfaction

• Patients returning to hip & knee school

• Patient ownership

Sustainability • Regular Project Group meetings • Flexibility to adapt to

– Emerging and evidence based treatment – Patient feedback – Audit results

• Marketing and promotion – Feedback to stakeholders – Local and national articles – Website

Next steps • Continue to increase the number of Colorectal

Surgery patients admitted on the day of surgery

• Continue to reduce opiate usage post-operatively

• Expansion of the ER Orthopaedic Programme other procedures- Back and Shoulder Surgery

• Expand to Breast Surgery, and ENT procedures.

Summary

• We have been very successful in achieving our initial aims

• LOS dramatically reduced safely with no increase in morbidity

• Reduced readmissions • Minimal cost – huge savings • Bed days saved • Happy and safe patients

Questions