Enhanced recovery pathways

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Enhanced recovery pathways

  1. 1. ENHANCED RECOVERYPATHWAYS COLLECTIVE LEARNING ------------------------------------- IAN BAYLEY ORTHOPAEDIC SURGEON
  2. 2. Collaborative Life Cycle Local work Continuous Improvement Team asked begins Topic to join the programmeReference Celebration Initiation/LS1 LS2 LS3 Panel Other support mechanisms Faculty, Support from WSC Team Web site, E Mail & Phone contact, Reports, Development Sessions
  3. 3. JAN July JAN July JAN July JAN July JAN July00 01 02 03 04 BCWD First & Fast Joints IV 6 NOF III 12 #NOFs II 26 National Back Pain I & II & III #NOFs I 23 Joints III 33 Joints II 24Joints I 30 Action on Orthopaedics
  4. 4. Ten Top TipsTen Must Do’s
  5. 5. TORR Torbay Orthopaedic Rapid Recovery John MarshallClinical Director – Trauma and Orthopaedics South Devon Healthcare NHS Foundation Trust
  6. 6. Northumbria Fast TrackTotal Hip & Total KneeReplacement Leigh KellyAcute Pain Specialist Nurse & Clare Casson Senior Specialist Physio
  7. 7. Managing the Process of Implementing an Enhanced Recovery Pathway Tom Wainwright The Royal Bournemouth Hospital Department of Health, London – 23/09/2009
  8. 8. Enhanced Recovery Programmes   in Orthopaedics‐ Becoming the Gold Standard Mr David Houlihan‐Burne Consultant Knee SurgeonThe Hillingdon and Mount Vernon Hospitals  NHS Trust
  9. 9. Example of enhancedrecovery elements Referral from •Optimising pre operative Primary Care health state e.g. Hb levels Pre- •Managing co morbidities e.g. Operative diabetes •Fit for surgery Admission Intra- Operative Post- Operative Follow Up 9
  10. 10. 10
  11. 11. Example of enhancedrecovery elements Referral from • Optimised health / medical condition Primary Care • Informed decision making with companion Pre- • Pre operative health & risk Operative assessment e.g. (CPEX) Admission Intra- Operative • PT information and expectation managed • DX planning (EDD) Post- • No / reduced oral bowel prep (bowel Operative surgery) • Pre-operative therapy instruction where Follow appropriate Up 11
  12. 12. Welcome to theJoint School
  13. 13. Example of enhancedrecovery elements Referral from • Optimised health / medical condition Primary Care • Informed decision making with companion Pre- • Pre operative health & risk Operative assessment e.g. (CPEX) Admission Intra- Operative • PT information and expectation managed • DX planning (EDD) Post- • No / reduced oral bowel prep (bowel Operative surgery) • Pre-operative therapy instruction where Follow appropriate Up 13
  14. 14. Patient satisfaction of TKR  Satisfaction questions were completed by 8095 patients  Overall - 81.8% were satisfied - 11.2% were unsure - 7.0% were not satisfied  The OKS varied according to patient satisfaction (p<0.001) 14
  15. 15. Decision Aids reduce rates of discretionarysurgery RR=0.76 (0.6, 0.9) O’Connor et al., Cochrane Library, 2009 15
  16. 16. 16
  17. 17. Example of enhancedrecovery elements Referral from •Optimise fluid hydration Primary Care •Optimise Nutrition •No / reduced oral bowel Pre- preparation (where appropriate) Operative Admission Intra- Operative •Admission on the day of surgery Post- •Carbohydrate loading Operative •No pre med (sedative) Follow Up 17
  18. 18. Example of enhancedrecovery elements Referral from Primary Care • Minimally invasive surgery where appropriate Pre- • Use of transverse incisions Operative (abdominal) if appropriate Admission Intra- Operative • Use of regional anaesthesia Post- • LA with sedation Operative • Individualised goal directed fluid management Follow Up 18
  19. 19. LIA TECHNIQUE FOR TOTAL  KNEE REPLACEMENTS LIA TECHNIQUE FOR TOTAL KNEE REPLACEMENTS 150 mls Ropivicaine 0.2 % 150 mls Ropivicaine 0.2 % Pre mix 100ml 0.2% Ropivicaine with 1ml 1:1,000 adrenaline and 50 mls 0.2% Ropivicaine plain 50ml syringes with 18 G (Pink) Spinal needle Pre mix 100ml 0.2%  1.BEFORE PROSTHESIS INSERTEDRopivicaine with 1ml 1:1,000  50mls with adrenaline into posterior capsule / gutters / extensor mechanism adrenalineand 50 mls 0.2% Ropivicaine plain 2. AFTER PROSTHESIS INSERTED50ml syringes with 18 G (Pink)  50mls with adrenaline into posterior capsule / gutters / extensor mechanism Spinal needle 3. BEFORE CLOSING THE SKIN 50mls without adrenaline into skin/ subcut tissues before clips applied
  20. 20. NHCFT fast-track anaesthesiaparacetamol 1g iv+/- NSAID (as appropriate)judicious intra-operativevasopressor & iv fluids no (routine) urinary catheterintra-operative infiltration LA: 100ml levobupivacaine 1.25mg/mlintra-articular LA catheterno surgical drains
  21. 21. Example of enhanced recoveryelements Referral from • Planned mobilisation (24hrs post Primary Care op) • Rapid hydration & nourishment Pre- Operative • Appropriate IV therapy • No wound drains • No nasogastric tubes (bowel Admission surgery) Intra- • Catheters removed early Operative • Regular oral analgesia • Paracetamol and NSAIDS Post- • Avoidance of systemic opiate- Operative based analgesia where possible or administered topically Follow Up 21
  22. 22. 15 mins
  23. 23. 15 mins
  24. 24. Example of enhanced recoveryelements Referral from • DX when criteria met Primary Care • Therapy input (e.g. stoma / physio / dietician) Pre- Operative • 24 hour follow up call Admission Intra- • Audit & monitor outcomes Operative • Feedback Post- Operative Follow Up 24
  25. 25. MDT discharge criteria Independent with all transfers (bed/chair/toilet) Independently mobile with appropriate walking aid Safe on stairs /step if indicated Able to perform exercises correctly & happy to continue at home THR: patients aware of hip precautions TKR: flexion >80°, good quadriceps control, moderate oedema.
  26. 26. Comparison of the length of stay (LOS) anddemographics between the two groups Traditional Fast Track P value Number 3000 1571 Age (years) 69 68 THR 1368 657 TKR 1632 914 Mean LOS 8.5 4.8 <0.001* Median LOS 6 3 <0.001*
  27. 27. Lengths of stay - reduction over time
  28. 28. Progress so far…. Hips :- n = 700 Median LOS 4.5 days
  29. 29. Progress so far…. Knees :- n = 800 Median LOS 4 days
  30. 30. Team Benefits•Optimised pre admission• Easier / more informed consent• Better educated patients• Better pain managementStandardised treatment pathways
  31. 31. Surgeon benefits•Consistent and predictable processes•Greater efficiency•Documented outcomes•Improved outcomes / happier patients• Quicker discharges and lower complications rates•More operating
  32. 32. Trust Benefits• Increase efficiency and reduced costs• Increase turnover of cases• Reduced complications• Patient expectations exceeded• Positive Press
  33. 33. Patient Benefits• Comprehensive education• Less stressful hospital experience• Family involvement and education• Quicker return to home and desired activities 
  34. 34. COMMISSIONER BENEFITS ?

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