2. What is ERP
A new approach since 2010, to assist patients get
better sooner after surgery by reducing stress
responses (and enhancing cost-effectiveness of surgery to hospitals)
• When ERP was first developed it was offered to
healthier patients.
• Subsequently health care teams realised that it
would speed up recovery in all patients,
compared to conventional care.
• The ERP is now widely used for more…..
• However, not all patients will be suitable for ERP
3. Two Cardinal Principles
• Clear communication: a full range of
information and explanation
– Clear leaflets, interpreters, healthcare teams
• A fully structured and well organised
sequence of clinical care
– All healthcare professionals will work from a care
pathway
– Allows all elements of care to follow each other
promptly and efficiently.
4. During Consenting for Surgery
• A doctor or nurse will make sure patients
understand the benefits and risks of operation,
and alternative treatments.
• What the patient can do to improve chance of
rapid recovery.
• Also proposed anaesthetic and pain relief; and
choices will be explained.
• Leaflets
– A patient diary which describes what to expect on
each day after surgery
– Also information about to expect at home
5. Components of ERP
• Pre-operative planning assessment
– Consenting, planning and preparation before admission
• Involving primary carers / referring doctors
• Reducing the physical stress of the operation
– High energy, carbohydrate drinks
– Allow clear fluids until 2 hours before surgery
– Avoiding traditional bowel preps
• Early mobilisation
• Early nutrition
• Early discharge
6. Those Not Eligible for ERP
• Those not well motivated / or with no mental
capacity
• Those living alone at home / No relatives
• Diabetic patients who should not take the
carbohydrate drinks
• Very elderly patients
• If surgeon or anaesthetists has concerns
because of co-morbidity
7. Pre-operative care by the hospital
team
• Pre-assessment clinic visit
– Comprehensive history and pre-op examination
• Talking to the surgeon again
• Therapy advice from other health care
professionals:
– e.g stoma or wound care nurses
– physiotherapists,
– and/or occupational therapists
8. Involving Primary Carers / Referring
Doctors
• Give patient information to make an informed
choice about:
– (a) Having the operation or not
– (b) Contributing personally towards getting a high
quality outcome
• Correct anaemia
• Manage hypertension
• Improve diabetic control
• Stop smoking
• Encourage weight loss
9. Reducing the physical stress of the
operation
• Carbohydrate drinks: A key part - Most pathways
include carbohydrate nutritious drinks before
arrival at the hospital to reduce physiological
stress.
• Clear Drinks: New evidence-based guidelines
show it is safe to drink water until two hours
before operation.
• Traditional bowel preps: New evidence-based
guidelines discourages old methods:
– can cause large amounts of loose motions leading to
dehydration and imbalance electroytes
13. Plan of Carbohydrate Drinks
Date Drink Morning List (Admit 7:00am) Afternoon list (Admit 10:ooam
1 8.pm (Day before
operation)
10pm (day before
operation)
2 9pm 11pm
3 10pm 7am (day of operation)
4 11pm 8am
5 6.am (day of operation) 10.am
6 6.30 am 11am
Clear
Drink
Until 6.am Until 11am
16. Day of Surgery
• Appropriate anaesthesia
• Limited Local anaesthetic infiltration to the
wound in minimal-access surgery
• Minimal-access surgery or transverse curved
incisions
• Peri-operative antibiotics where indicated
• Avoid nasogastric tubes or surgical drains if
possible
17. Early Mobilisation
• Analgesia
• Thromboprophylaxis
• Something to eat
• Breathing exercises
• Assisted with coughing
• Sit out of bed after 6 hours for two hours at
intervals
• Support walking along corridors (60 metres)
• Encourage early bladder function
18. Early nutrition
Aim is to stimulate gut motility
• Early oral diets
–From day 0 for hysteroscopic / laparoscopic
• 3 high protein drinks daily
• Oral diet as tolerated from day ½
• 10-15 drinks per day from day 2
21. Early discharge
• Healthcare professional support:
– means that all the practical support at home are
in place.
• Discharge planning:
– mean that everything patient needs at home is
ensured.
• 24 hour telephone helpline
• Discharge leaflets
22. Early Discharge Targets for ERP
Procedure Days
Total abdominal hysterectomy +/- bilateral
salpingo-oophorectomy (Midline line cut)
3 days
Total abdominal hysterectomy +/- bilateral
salpingo-oophorectomy (bikini line cut)
2 days
Total Laparoscopic Hysterectomy 2 days
Laparoscopic Assisted / Or Vaginal Hyst. 1 days
Other Laparoscopic Surgery 1
Anterior and / or posterior repair 1 day
Hysteroscopic Surgery 0 day
23. Benefits to the Hospital
• ERP means early discharges
– Evidence show 0.5-3.5 days saved per patient
• ERP is Cost effective
– NHS tariffs for day-case costs for (Surgery + 1 day)
• Each extra days is a loss (approx. £300) to hospital
– NHS tariff for in-patient costs for (surgery + 3days)
• Each extra day is a loss (£300-£660) to the hospital
– However; avoidable readmissions within 30 days
are not reimbursed
24. Conclusions
• Enhanced recovery enables patients recover
from operation sooner by reducing the stress
responses on the body
• The aim is to ensure patients are active
participants in their own recovery process
• Benefits also accrue to the hospitals too
