Enhanced Recovery Partnership 

Enhanced Recovery Programme: The Whipps 
Cross University Hospital Experience
Stefano M. A...
Enhanced Recovery Partnership

• Back ground Hospital
• Local population
• How we started and how we
carried on
• Our Resu...
• North East London
• Covering Waltham Forest and
Redbridge PCT
• Population 350,000
• Built 1900
• 700 Beds
Socially Deprivated
Area
• Market Factor
• High % advanced stage cancer
• Cancer Survival compared to national
average
Income deprivation by London borough
More than 20% 
employees are 
paid less than 
£7.50 per hour
• Social deprivation is an independent risk 
factor for increased postoperative hospital 
stay for colorectal patients. 
10 NHS Trusts with longest length of stay
for bowel surgery in England 2006/07
Trust

Average LOS  Days above 
–Days‐
nati...
How we started ERP
Shifting Mentality
• Danish surgeon: Henrik Kehlet

Q: Why is the patient still in hospital?
Q: What can be done to safely...
• within my team
– Reg, SHO, FY1
– CNS
– Stoma Nurse

• Looking for motivated people
– Ward
– Theatre
– Anesthetic departm...
Success Factor = Cultural
Shift
• Funding
• St Mark’s ERP course
> 60 people attended
•
•
•
•
•
•
•
•

Anesthetists
Ward n...
Steering Group Established

• Representative from each single
specialties involved
• Creation Pathway for each specialty
•...
• Appointment project manager
• Meetings: Once a month
• Baseline Study: Retrospective review
using HES
• Support from NHS...
Ideal Patient Pathway
• Pt Information – ERP explained
• Pt Assessment (Health and Risk)
• Referral to relevant specialtie...
Prospective Audit
• How much are we implementing ERP?
• All colorectal cancer 1st January – 31st
June, 2010
– 1st Audit Ja...
• Easy to collect data
• Prospective data
collection
Expected vs Actual LoS
29
P atien t id en tifier

25
21
17

LoS

13
9
5
1
0

5

10

15

20

Length of stay (days)

Since 2...
Whipps Cross ERP Colorectal Audit 2010
14

12

Average LoS

10

8

11.6

~6 days

~3 days
10

(26 
cases)
7.1

6

(29 
cas...
ERP Audit
January – November 2010
(not July)
Total number of Surgical patients = 65
Number of patients included in ERP Aud...
Factors essential for
Successful
Implementation ERP
Strong leadership with motivation
Core group
Project Manager
What about sustain these results?
Implementation and
sustainability
•
•
•
•
•

Education
Management of Expectation
Reinforce of ERP concept and practice
Emp...
LOS
ERP – patients overview
ERP – patients overview
ERP – patients overview
Patients - overview
Patients - overview
Surgery
Quality data collection
Adherence to ERP protocol

Overall adherence to protocol
mean
69%
median
68%
Adherence to ERP protocol
•
•

Prospective cohort study before and after ERP protocol
953 patients with colorectal cancer: 
– 2002‐2004 Adherence 43...
Adherence
%

Mean
LOS
Days

p

50

9.4

< 0.001

70

7.4

80

7

90

6

< 0.001
< 0.001
< 0.001
Overall LOS

7.76
6

mean
median
max
min

days
7.76
6
25
2
Surgery
Laparoscopy in Combination with Fast Track Multimodal Management is
the Best Perioperative Strategy in Patients Undergoing...
Results
Lap/FT
• Postop LOS Median

5

Open/FT
6

Lap/standard Open/standard
6

7 days

• Laparoscopy was the only indepen...
Complications
Total
Pts with 1 
complication
Pts with >1 
complication

36

39%

30

33%

6

7%
Complications
Severity of complications

N°

tot
grade 1 or 2
grade 3 or 4
death
 Reoperations
 Readmissions

36
27
11
1...
2011
2011
• 4 RCTs
• 237 patients with colorectal surgery:
119 ERP
vs 
118 conventional
Results
ERAS

Control

13 per 1000

25 per 1000

0.53
(0.12 to 2.38)

tot

54

105

0.51
(0.39 to 0.67)

minor

29

50

0....
Cochrane
• Quantity and quality of data are low
• ERP seems safe
• Lack of sufficient outcome parameters and 
poor quality...
• 12 Spanish hospitals
• 300 patients with elective colorectal surgery for cancer 
following an ERP
Compliance overall
65 %
Results
• LOS

Median 6 days
(range 3 to 89)

• Complications
tot 89 (29.7 %)
surgical 71 (23.7 %)
• Mortality

3 (1 %)

•...
Conclusions
• Sustain ERP is more challanging than its 
implementation
• Creation of a single document: paper pathway 
• E...
Thank you
• Whipps Cross Staff
• ERP core group
• Colorectal Unit
Enhanced recovery Whipps Cross
Enhanced recovery Whipps Cross
Enhanced recovery Whipps Cross
Enhanced recovery Whipps Cross
Enhanced recovery Whipps Cross
Enhanced recovery Whipps Cross
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Enhanced recovery Whipps Cross

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Enhanced Recovery Programme: The Whipps 
Cross University Hospital Experience
Stefano M. Andreani
Consultant Colorectal Surgeon

Published in: Health & Medicine, Technology
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Enhanced recovery Whipps Cross

  1. 1. Enhanced Recovery Partnership  Enhanced Recovery Programme: The Whipps  Cross University Hospital Experience Stefano M. Andreani Consultant Colorectal Surgeon
  2. 2. Enhanced Recovery Partnership • Back ground Hospital • Local population • How we started and how we carried on • Our Results in view of the most recent literature
  3. 3. • North East London • Covering Waltham Forest and Redbridge PCT • Population 350,000 • Built 1900 • 700 Beds
  4. 4. Socially Deprivated Area • Market Factor • High % advanced stage cancer • Cancer Survival compared to national average
  5. 5. Income deprivation by London borough More than 20%  employees are  paid less than  £7.50 per hour
  6. 6. • Social deprivation is an independent risk  factor for increased postoperative hospital  stay for colorectal patients. 
  7. 7. 10 NHS Trusts with longest length of stay for bowel surgery in England 2006/07 Trust Average LOS  Days above  –Days‐ national Average Southport and Ormskirk Hospital NHS 27.94 12.05 Hammersmith Hospitals NHS Trust 22.47 6.58 Stockport NHS Fundation Trust 22.31 6.41 Royal Free Hampsted NHS Trust 22.07 6.17 Whipps Cross University Hospital NHS  Trust 21.43 5.53 Pennine Acute Hospital NHS Trust 20.8 4.9 The Hillingdon Hospital NHS Trust 20.71 4.81 Barts and The London NHS Trust 20.46 4.56 Surrey and Sussex Healthcare NHS Trust 20.05 4.15 City Hospitals Sunderland NHS Fundation T 19.96 4.06 www.reducinglengthofstay.org.uk
  8. 8. How we started ERP
  9. 9. Shifting Mentality • Danish surgeon: Henrik Kehlet Q: Why is the patient still in hospital? Q: What can be done to safely discharge him?
  10. 10. • within my team – Reg, SHO, FY1 – CNS – Stoma Nurse • Looking for motivated people – Ward – Theatre – Anesthetic department – Dietitian – ………..
  11. 11. Success Factor = Cultural Shift • Funding • St Mark’s ERP course > 60 people attended • • • • • • • • Anesthetists Ward nurses Theatre Nurses Physiotherapists CNS Stoma nurses ODA Dietitians
  12. 12. Steering Group Established • Representative from each single specialties involved • Creation Pathway for each specialty • Specialty LEAD responsible to produce their pt care pathway • Creation multispecialty pathway
  13. 13. • Appointment project manager • Meetings: Once a month • Baseline Study: Retrospective review using HES • Support from NHS improvement team • Pilot site for ERP
  14. 14. Ideal Patient Pathway • Pt Information – ERP explained • Pt Assessment (Health and Risk) • Referral to relevant specialties • Managing Pts Expectations • Discharge Planning • Theatre – Laparoscopic/Open • Epidural, CArdioQ • NGT out before Patient Awake • Pt Stable • Recovery –encourage pt to drink a      glass of water • Pt to sit up whilst on the profiling bed • Transfer Pt to ward • Ward Observation • IV fluids – discontinued • Remove catheter • Recommended Diet – Build up drinks • Pain team, Surgical team – Review pt • Discharge – Pt informed of plans • Pt Medically fit to go home •Pt information Leaflet •Emergency Contact details •Stoma Care ‐ Community •Follow Up appointment Referral From  Primary Care Pre‐Op  Assessment Admission • Managing Pre Existing co‐ Morbidities      e.g.  diabetes/hypertension • Optimising Haemoglobin levels • Analgesia Review with Pt • Pre‐Op drinks • Stoma Marked • Continual Pt education on ERP Intra‐Op Post‐Surgery Post‐Op Day  1 Post‐Op Day  2‐4 Discharge &  Follow Up • Monitor Catheter • Observe Stoma • Wound Review • Out of bed 6hrs Post‐Op • Pt reminded of ERP requirements • Surgical and Anaesthetic team review • Ward Observation • Out of bed – 8 hours in total • Recommended Diet – Build up  drinks • Pain team, Surgical team – Review  pt • Discharge – Pt informed of plans
  15. 15. Prospective Audit • How much are we implementing ERP? • All colorectal cancer 1st January – 31st June, 2010 – 1st Audit Jan- March – 2nd Audit April-June • Total number of patient = 38 • Number of patients included in ERP Audit = 29
  16. 16. • Easy to collect data • Prospective data collection
  17. 17. Expected vs Actual LoS 29 P atien t id en tifier 25 21 17 LoS 13 9 5 1 0 5 10 15 20 Length of stay (days) Since 2008, the LoS stay has been reduced from an  average of 11.6 days to 7.1 days.  25
  18. 18. Whipps Cross ERP Colorectal Audit 2010 14 12 Average LoS 10 8 11.6 ~6 days ~3 days 10 (26  cases) 7.1 6 (29  cases) 4 2 0 WX Inpatient Audit National HES ERP Implemented (Dec 2008) Database (2008/09) (Jan-Mar 2010)
  19. 19. ERP Audit January – November 2010 (not July) Total number of Surgical patients = 65 Number of patients included in ERP Audit = 51 Length of Stay Total number of procedures in 10 months Total number of bed days: Mean LoS (days): Enhanced Recovery Partnership Programme Total 51 344 6.75
  20. 20. Factors essential for Successful Implementation ERP Strong leadership with motivation Core group Project Manager
  21. 21. What about sustain these results?
  22. 22. Implementation and sustainability • • • • • Education Management of Expectation Reinforce of ERP concept and practice Empowering nurses ERP Nurse – Keep the things going – Educate – Audit results
  23. 23. LOS
  24. 24. ERP – patients overview
  25. 25. ERP – patients overview
  26. 26. ERP – patients overview
  27. 27. Patients - overview
  28. 28. Patients - overview
  29. 29. Surgery
  30. 30. Quality data collection
  31. 31. Adherence to ERP protocol Overall adherence to protocol mean 69% median 68%
  32. 32. Adherence to ERP protocol
  33. 33. • • Prospective cohort study before and after ERP protocol 953 patients with colorectal cancer:  – 2002‐2004 Adherence 43.3% in 464 patients  – 2005‐2007 Adherence 70.6% in 489 Patients • – Postoperative complications and symptoms declined significantly.  30‐day morbidity and readmissions were significantly reduced with  increasing adherence to the ERP protocol (>70%, >80%, and >90%)  compared with low ERP adherence (<50%)
  34. 34. Adherence % Mean LOS Days p 50 9.4 < 0.001 70 7.4 80 7 90 6 < 0.001 < 0.001 < 0.001
  35. 35. Overall LOS 7.76 6 mean median max min days 7.76 6 25 2
  36. 36. Surgery
  37. 37. Laparoscopy in Combination with Fast Track Multimodal Management is the Best Perioperative Strategy in Patients Undergoing Colonic Surgery: A Randomized Clinical Trial (LAFA-study). Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF, Gerhards MF, van Wagensveld BA, van der Zaag ES, van Geloven AA, Sprangers MA, Cuesta MA, Bemelman WA; on behalf of the collaborative LAFA study group. Ann Surg. 2011 May 18. [Epub ahead of print] • Multicenter RCT • 9 centers in the Netherlands  • 400 patients eligible for segmental colectomy were randomized to: ‐ laparoscopic or open colectomy ‐ ERP or standard care 
  38. 38. Results Lap/FT • Postop LOS Median 5 Open/FT 6 Lap/standard Open/standard 6 7 days • Laparoscopy was the only independent predictive factor to reduce hospital stay and morbidity: Author’s conclusion: “Optimal perioperative treatment for colonic cancer is laparoscopic resection embedded in a FT program. If open surgery is applied, it is preferentially done in FT care”
  39. 39. Complications Total Pts with 1  complication Pts with >1  complication 36 39% 30 33% 6 7%
  40. 40. Complications Severity of complications N° tot grade 1 or 2 grade 3 or 4 death  Reoperations  Readmissions 36 27 11 1 3 5 Reoperations 2 anastomotic leak   ‐ ileostomy 1 perineal wound infection   ‐ wound debridment Readmissions within 30 day FU 2 Acute urinary retention 2 Acute renail failure 1 Splenic infarction
  41. 41. 2011 2011 • 4 RCTs • 237 patients with colorectal surgery: 119 ERP vs  118 conventional
  42. 42. Results ERAS Control 13 per 1000 25 per 1000 0.53 (0.12 to 2.38) tot 54 105 0.51 (0.39 to 0.67) minor 29 50 0.57 (0.38 to 0.85) major 14 28 0.50 (0.28 to 0.92) • Readmissions 10 13 • Length of stay ‐ 2.51 days • Mortality RR (95% CI) • Complications 0.79 (0.36 to 1.76) 95% CI ‐3.54 to ‐1.47 p < 0.00001
  43. 43. Cochrane • Quantity and quality of data are low • ERP seems safe • Lack of sufficient outcome parameters and  poor quality of trials do not justify  implementation of ERP as the standard of care • Role of laparoscopy not clarified • Protocol compliance not investigated
  44. 44. • 12 Spanish hospitals • 300 patients with elective colorectal surgery for cancer  following an ERP
  45. 45. Compliance overall 65 %
  46. 46. Results • LOS Median 6 days (range 3 to 89) • Complications tot 89 (29.7 %) surgical 71 (23.7 %) • Mortality 3 (1 %) • Readmissions 8 (2.7%) • Reoperations 21 (7 %)
  47. 47. Conclusions • Sustain ERP is more challanging than its  implementation • Creation of a single document: paper pathway  • ERP Nurse is essential and it pays in the long  run
  48. 48. Thank you • Whipps Cross Staff • ERP core group • Colorectal Unit

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