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Implementing oesphageal Doppler in Enhanced Recovery

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Cardiac Output Monitoring

Cardiac Output Monitoring
Targeted Fluid Therapy
Anaesthesia
Surgery
Technology Implementation

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Implementing oesphageal Doppler in Enhanced Recovery Implementing oesphageal Doppler in Enhanced Recovery Presentation Transcript

  • Oesophageal Doppler: Enhancing Recovery from Major Surgery
    Daniel Conway
    Consultant Anaesthetist
    Manchester Royal Infirmary
  • Oesophageal Doppler. A Great British Invention
    Conflict of Interest: Dr Conway & NTAC have not received funding or financial interests in Deltex Medical
  • Oesophageal Doppler Monitoring
    Reduces Complications and Length of Stay for major surgery
    Should be available in all hospitals that perform major surgery
    Technology Adoption is achievable and cost-effective
  • Implementation Failure?
    Anaesthetists, Surgeons and the evidence-base all support its use
    Implementation across NW region is haphazard at best
    We now have an opportunity to implement as part of enhanced recovery with SHA support
  • How ODM Improves Outcomes
    Difficult to measure fluid loss with current monitoring
    Optimising Cardiac Output improves tissue perfusion
    Improved perfusion reduces complications – CVS, ileus, renal
    7 RCT plus 4 meta-analyses show LOS reduction with ODM
  • Optimisation with ODM
    stroke volume
    200ml
    200ml
    filling
  • Optimisation StudiesConway, Mayall, Latif, Gilligan, TackaberryAnaesthesia 2002
  • Fluid Challenge OptimisationBundegaard-Nielsen BJAnaes2006
  • Optimisation Studies Noblett, Snowden Br J Surg 2006
    108 colorectal surgical patients
    Fluid Challenge SV optimisation
    Hospital LOS 7 v 9 days p<0.005
    Diet 2 v 4 days
    ↓ Crit Care Admits
  • Optimisation Studies Noblett, Snowden Br J Surg 2006
    Hospital LOS 7 v 9 days p<0.005
    Diet 2 v 4 days
    ↓ Crit Care Admits
    ↓ IL-6 levels 6-48 hours post-op
  • Should ODM be a no-brainer ?
    I’ll have one of those, please
  • Implementation Failure? Why
    Capital and Consumable Costs
    Scepticism: RCT vs the real world
    Who pays – who benefits?
    Changing practice
    Needs training
    Implies current care may be sub-optimal
    Alternate Hypotheses eg fluid restriction
    Leadership Failure
    Fail at the first , second etc hurdle
    Can anaesthetists alter surgeons outcomes !!!!
    Competing priorities for resources
  • ODM. Implementation Failure
    ’97 used Doppler during training
    ’99-02 Two centre RCT showing benefit
    ’01 Consultant appointment. Unable to persuade the organisation to adopt
    ’05 Equipment Committee Lead
    ’06 Clinical Trial of ODM
    ’07 Business case…half monitor funded
  • Implementation Project
    To successfully introduce oesophageal Doppler guided fluid Rx for major surgical patients in 3 NHS Hospitals
    Derby, Whittington & MRI
    Oct 2008- Oct 2009
  • Successful Adoption
    Implemented in all surgical areas
    Used to optimise fluid therapy
    Helping to streamline discharge procedures
    Development of an adoption plan to share across the NHS
  • Stakeholders
    Clinical Team
    Company
    Trust
    Management Team
    Patients
    Commissioning
    and Procurement
    Strategic
    Health Authority
  • Patient Journey
    HOME
    Pre-op pre-hab
    fluid, drink
    Post-op care
    ?ODM Guided
    Intra-op Fluid
    ODM Guided
    Enhanced
    Recovery
    complications
  • Successful Adoption
    Engage Management
    Engage Clinicians
    Control Initial Roll-out
    Demonstrate Effective Implementation
    Develop of an adoption plan to share across the NHS
    How to Why To Guide
  • Project Team at MRI
    12 Anaesthetic Champions
    Surgeons
    Audit Facilitator
    Project Manager at NTAC
    Support of Middle Management
    Support from MD and Chair of Trust
  • The Challenge
    Silo Budgeting
  • Engaging Management:The Business Case
    Overcoming Divisional silos to recognise benefit for the organisation
    Address Fears
    What if ODM sits on shelf
    What if we use loads of probes
    Controlled Implementation
    Costs and benefits balance
    Get a manager to co-author document
  • Engaging Clinicians
    How will it improve patient care ?
    Critically appraise studies
    PROMs in the real world
    Limited Implementation
    Champion approach?
    Stick with narrow evidence base
    Survey Training Needs
  • Evidence & Guidelines
  • Centre for Evidence Based Procurement (PASA)
    in patients undergoing high risk surgery use of ODM guided fluid administration (sic) is likely to result in fewer deaths, complications and a shorter LOS
    costs seem likely to be compensated for by reductions in LOS
  • Progress since 2008
  • Progress Nov 09
    4 monitors purchased Oct 08
    32 probes per month
    Staff training completed
    200 Doppler patients and 200 pre-implementation controls
    Length of Stay
    Complications
  • Before and After Similar Patients
  • 4 Day ↓ Post-op LOS
  • 20% ↓ in CVC insertion rates
  • 25% ↓ in re-admission rate
  • 43% ↓ in Re-operation Rate
  • ↓Critical Care Use
  • Financial Impact
    Cost of Probe £55, Monitor £12k
    Cost of CVC £85 – catheter, disposables, X-Ray (insertion time and CRBSI not included)
    Cost of bed £250
    Increased Surgical Activity
  • Support Implementation ODM in 10 NW Trusts 2009-2010
    Demonstrate LOS reductions
    Develop core metrics for major surgery
    Springboard for establishing ERS
    Colorectal --- Upper GI
    Orthopaedic --- Urology
    Vascular --- Gynaecology
  • Enhancing Peri-Operative Pathways
    Evidence Base is starting point
    Need to Create Culture of Innovation
    Clinicians work with management
    New technology and working practice
    Improvements for patients are demonstrated
    Experiences shared
  • Any Questions?
    Step Change We Can Believe In