Breakout 1.1 - Dr Kerri Jones


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Breakout 1.1 - Dr Kerri Jones
Consultant Anaesthetist & Associate Medical Director
Adviser Dept Health Enhanced Recovery Programme
Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013,
Guoman Tower Hotel, London
How to deliver quality and value in chronic care:sharing the learning from the respiratory programme

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Breakout 1.1 - Dr Kerri Jones

  1. 1. Better value, better outcomes How to deliver quality and value in chronic care: sharing the learning from the respiratory programme London Feb 21st 2013 Dr Kerri Jones Consultant Anaesthetist & Associate Medical Director Adviser Dept Health Enhanced Recovery ProgrammeContent what is ‘Enhanced Recovery’ what is the proposition? are the concepts transferable to medical admissions? the Torbay pilot (S Devon Healthcare NHS future developments 1
  2. 2. What is ‘enhanced recovery’?Henrik Kehlet, Professor of Surgery, Copenhagen1980s showed the use of epidurals for major abdominal surgery improved recovery by  managing pain  reduce stress responseHe thought patients still stayed too long in hospital and by 2000 was describing a multimodal approach to care...Fast-track/Accelerated/Rapid or Enhanced Recovery 3 Physiological problem 2
  3. 3. His propositionLooked at factors influencing recovery Designed a pathway to tackle each elementWhat did he do? created a structured approach involved the patient set expectations realistically held his team to account  is the patient on track with the pathway?  ‘why is this patient in hospital today?’ 3
  4. 4. Colorectal Surgery: Length of stay Large Intestine: Major Procedures 16 14 12 10 days 8 6 4 2 0 UK Kehlet UK adoption sporadic clinicians approached the DH for help to spread country-wide programme evidence-based; Kehlet & others pathway defined  MSK, colorectal, gynae, urology  other specialties proving to be very successful 4
  5. 5. Enhanced recovery elements identified • optimise pre operative Referral from haemoglobin levels • admit on day of surgery • manage pre existing co • optimised fluid • planned mobilisation Primary Care hydration • rapid hydration & morbidities e.g. diabetes • CHO Loading nourishment • reduced starvation • appropriate IV therapy Pre- • no / reduced oral bowel • no wound drains Operative preparation ( bowel • no NG (bowel surgery) surgery) • catheters removed early • regular oral analgesia • paracetamol and NSAIDS Admission • avoid systemic opiate- based analgesia where • optimise health / medical possible or administered condition topically • informed decision making Intra- • pre-operative health & risk assessment • minimally invasive surgery Operative • patient information and • use of transverse incisions expectation managed (abdominal) • discharge planning (EDD) • no NG tube (bowel surgery) Post- • pre-operative therapy • regional / LA with sedation • epidural management (inc Operative Follow instruction as appropriate thoracic) Up • optimise fluid management • individualised goal directed • discharge when criteria met fluid therapy • therapy support (stoma, physio) • 24hr telephone follow upAre the principles transferable to medicine? illness is ‘stress’ just like an operation simple adherence to fluid, nutrition & mobilisation plus information are key and could be applied to all inpatients no evidence base as yet – but from 2010, Kehlet has run a research study in 2 patient groups  acute pneumonia  ‘off legs’ he reports impact is ‘incredible’ though has found it difficult patient/carer information is relevant to chronic disease with repeated acute exacerbations 5
  6. 6. ENHANCED RECOVERY: MEDICINEProf Ben BenjaminConsultant Acute Medicine and Director of R&DSouth Devon Healthcare NHS FT2012 – 2013 Why do it? To reduce To gain early Improve length of independence patient stay and carer experience To improve To reduce To reduce mobilisation readmissions deterioration during admission 6
  7. 7. What is it? a new approach to caring for patients admitted as a medical emergency to Torbay Hospital involves patients and families/carers in decisions patients are partners in their own care  patients, carers, families, nurses, therapists and doctors all work together to agree a plan for Rx and recovery big focus on nutrition & mobility What has happened so far??Core project team  Director of Nursing and Quality – executive sponsor  Prof Ben Benjamin – clinical lead  Emergency Admissions Unit (EAU) manager and test lead  Matron for acute medicine  ER medicine project manager  OT  Carers’ lead  dietician, radiographer, matrons, consultants, ward managersWards/Units  EAU (medical assessment unit) – test bed  COTE  respiratory ward 7
  8. 8. Which patients? Getting you home; safely and at the right time  patients admitted as an emergency, requiring medical interventions  patients requiring an inpatient stay on the EAUs, respiratory patients), COTE wardsWhat’s happened so far? current state and future state mapping sessions baseline measurement – LoS, patient interviews testing the concepts on patients with sepsis communications – patient and carer information pre hospital care – sepsis alert – antibiotic PGD daily target setting carers’ lead promoting the message in the community GP engagement and awareness raising focus on nutrition, mobility 8
  9. 9. Daily target setting Energy drink Plan transport Day clothes, early no PJsMobilisation Decision-making between the patient, medical team and families/carers Oral fluids 9
  10. 10. Measures length of stay  will take time as the culture change occurs bed days patient experience and satisfaction oral/iv switch  pulling notes and drug charts to capture iv/oral switch is time consuming time to mobilisation 10
  11. 11. Project Reflections so far executive and clinical leadership – essential for success baselining – walking the patient journey to identify waste in the system was compelling for the whole team – to get out of their silos ask the people doing the job how best to change it; improvements have come from a bottom up rather than top down approach time to carry out improvement – regular weekly huddles, an enthusiast seconded to drive improvements + service improvement project support work across primary-secondary-social care boundaries measurement for ER medicine has been challenging Next steps  testing carried out on other EAU ward  roll out to other wards  CQUIN 2013/14 target  continued involvement of carers and GPs  learning and sharing best practice with colleagues across the UK through  NHS South workshops  participation in RCP working group 11
  12. 12. Further information POSTERjane.dewar@nhs.net 12