How To Safely Implement A Fast Track Program

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  • How To Safely Implement A Fast Track Program

    1. 1. How to Safely Implement a Fast Track Program in your Hospital <ul><li>PETER HEWETT MBBS FRACS DEPARTMENT OF SURGERY THE QUEEN ELIZABETH HOSPITAL ADELAIDE SOUTH AUSTRALIA </li></ul>
    2. 2. How to Safely Implement a Fast Track Program in your Hospital <ul><li>The concept of fast track recovery programs is based on single evidence based interventions combined in a multimodal effort to enhance post operative recovery. </li></ul><ul><li>Kehlet Lancet 2003 </li></ul>
    3. 3. How to Safely Implement a Fast Track Program in your Hospital <ul><li>The implementation of a fast track recovery program for colorectal surgery requires a 180 degree reversal in policy affecting current practice of three different disciplines : surgery, anaesthiology and nursing. </li></ul><ul><li>Polle et al. Digestive Surgery. 2007 </li></ul>
    4. 4. How to Safely Implement a Fast Track Program in your Hospital <ul><li>Lack of awareness of evidence based data </li></ul><ul><li>Lack of belief the institution can do fast track recovery </li></ul><ul><li>Time limitation </li></ul><ul><li>Unavailability of outcome data </li></ul><ul><li>Insufficient expertise/staff support </li></ul><ul><li>Reimbursement problems </li></ul><ul><li>Liability issues </li></ul>
    5. 5. How to Safely Implement a Fast Track Program in your Hospital <ul><li>Broad agreement on fast track interventions </li></ul><ul><li>Check list of fast track interventions (Education) </li></ul><ul><li>Responsible person for these interventions </li></ul><ul><li>Regular review of implementation of interventions </li></ul>
    6. 6. Measurement of Safety <ul><li>Low mortality </li></ul><ul><li>Low morbidity </li></ul><ul><li>Short LOS </li></ul><ul><li>Low readmission rates </li></ul><ul><li>High patient satisfaction. (number of fast track interventions achieved) </li></ul><ul><li>High staff satisfaction. (number of fast track interventions achieved) </li></ul><ul><li>Financially viable </li></ul>
    7. 7. How to Safely Implement a Fast Track Program in your Hospital <ul><li>AGE </li></ul><ul><li>74 patients > 70 years </li></ul><ul><li>>80% achieved successful oral intake on Day 1 </li></ul><ul><li>Discharge on Day 5 </li></ul><ul><li>Scharfenberger M et al. Int J Colorectal Disease 2007 </li></ul>
    8. 8. Optimum Length of Stay <ul><li>30 day readmission rates of 11 and 11.7% with initial post op stays of 9 & 6 days. + </li></ul><ul><li>2 days : readmission rate 20.1% </li></ul><ul><li>3 days : readmission rate 11.3% </li></ul><ul><li>Patient satisfaction increased to 90% with a 3 day stay* </li></ul><ul><li>+ Goodney et al. Annals of Surgery 2003 </li></ul><ul><li>*Anderson et al. BJS 2007 </li></ul>
    9. 9. Readmission <ul><li>Patient comorbidities not procedures </li></ul><ul><li>COPD </li></ul><ul><li>Poor cardiac function </li></ul><ul><li>“ General functional capacity/social circumstances” </li></ul><ul><li>Steroid administration </li></ul><ul><li>Preoperative anticoagulation </li></ul><ul><li>*Anderson et al. BJS 2007 </li></ul>
    10. 10. Readmission <ul><li>Time for readmission (median 8 days post discharge) </li></ul><ul><li>Ileus/SBO : 5.4+/- 5.7 days </li></ul><ul><li>Septic complications : 12.2+/- 8.32 days </li></ul><ul><li>Medical complications: 11.8+/- 8.7 days </li></ul>
    11. 11. Prehabilitation <ul><li>Smoking increases anastomotic leak rate by a factor of 3.1 plus pulmonary and wound complications. </li></ul><ul><li>Heavy alcohol intake increases anastomotic leak rate by a factor of 7.1 plus bleeding, wound sepsis, cardiopulmonary complications and delerium. </li></ul><ul><li>Poor nutrition </li></ul><ul><li>Sorensen LT et al Br J Surg 1999 </li></ul>
    12. 12. Prehabilitation <ul><li>Cease smoking 4 weeks prior to surgery </li></ul><ul><li>Cease alcohol intake 4 weeks prior to surgery </li></ul><ul><li>Enhanced nutritional support 10-14 days prior to surgery.* </li></ul><ul><li>*Zargar-Shoshtari & Hill ANZ J Surg 2008 </li></ul>
    13. 13. Role of the preoperative physician <ul><li>Identify risk factors </li></ul><ul><li>Stratify risk/benefit of operative procedure </li></ul><ul><li>Correct risk factors </li></ul><ul><li>Educate patients and surgeons as to realistic expectations of postoperative outcomes. </li></ul>
    14. 14. Perioperative Fluid Administration <ul><li>RCT >5litres vs <3litres IV fluid on day of op : >5l more complications, ileus and longer hospital stay + . </li></ul><ul><li>Reduced intravenous fluid administration. </li></ul><ul><li>Fixed rate (1,640mls) vs liberal(5,050mls) :improved pulmonary function but more complications!* Holte K B.J.Anaesthesia 2007 </li></ul><ul><li>+ Brandstrup B. Ann Surg 2003 </li></ul><ul><li>* Holte K B.J.Anaesthesia 2007 </li></ul>
    15. 15. Perioperative Fluid Administration <ul><li>Goal directed intravenous therapy </li></ul>
    16. 16. Delerium <ul><li>Alcohol withdrawal </li></ul><ul><li>Sedative withdrawal </li></ul><ul><li>Dementia </li></ul><ul><li>Narcotics </li></ul><ul><li>Hypoxia </li></ul>
    17. 17. Enviromental Factors <ul><li>Post operative elective unit dedicated to rehabilitation with access to natural light and open outside spaces. </li></ul><ul><li>Enthusiastic staff to implement protocols but sensitive to variations that require intervention. </li></ul><ul><li>Appropriate followup checks with an emergency number for 24 hour access. </li></ul>
    18. 18. How to Safely Implement a Fast Track Program in your Hospital <ul><li>LOS </li></ul><ul><li>Specialist preoperative physician involvement in patient selection for preoperative intervention. </li></ul><ul><li>Prehabilitation </li></ul><ul><li>Optimum fluid replacement </li></ul><ul><li>Optimum ward enviroment </li></ul><ul><li>Negotiate adequate financial incentives. </li></ul>
    19. 19. How to Safely Implement a Fast Track Program in your Hospital <ul><li>Agreement </li></ul><ul><li>Education </li></ul><ul><li>Implementation </li></ul><ul><li>Review </li></ul><ul><li>24 hour emergency number. </li></ul>

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