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- 1. Enhanced Recovery Program: Perioperative Nursing Interventions MODULE 2 Call
- 3. Maximizing health care efficiency to improve healthcare Healthcare = system Health care = actions Efficiency Healthcare Health Care Improved resource use Access to high- quality care Evidence-based best practices
- 4. Benefits of Enhanced Recovery Program Patient Outcomes Patient Experience (As reported by ERP Patients) Your Hospital Shortened length of stays(LOS) NO increases in readmissions Accelerated return to normal activities Decreased morbidities Better Patient Outcomes They felt better-prepared for surgery Their anxiety was reduced with better confidence in good outcomes The surgery and hospitalization went according to plan They were ready for discharge They were likely to recommend Better Patient Satisfaction Improved efficiency on nursing workflow (due to increased patient engagement) Improved public reporting Increased reimbursement and shared savings Overall Cost Savings
- 5. Essentials for Success Multidisciplinary Teamwork Planning Implementation through every phase Education Engagement Leadership Health care providers Development of customized ERP protocols and order sets Pre-surgical Intraoperative Post-surgical Analysis ERP Compliance Outcomes Patient feedback
- 6. Core Membership (LEADERSHIP) Integral Members (MANAGERS AND STAFF) ERP Key Players and the Role of Nursing
- 7. Impact of Nursing on ERP Nurses represent the “critical mass” required to sustain a powerful and effective Enhanced Recovery Program Assessment Diagnosis Planning Implementation Evaluation NURSING PROCESS Shared Decision Making Sustained Motivation Better Compliance with Initiatives Recovery Goals Met PATIENT RESULTS:
- 8. Enhanced Recovery Program Elements Preoperative Phase Presurgical counseling, education, conditioning, readiness and preparation. Explanation of hospitalization Testing/ labs Nutritional assessment PONV scoring Exercise monitoring Mobilization targets Smoking cessation/’fast’ Alcohol cessation Fluid management Pain management Perioperative Phase Intraoperative efficiency Metabolic/fluid conditioning Prevention of postop ileus Antiemetic prophylaxis Mechanical bowel prep with antibiotics (colectomy cases) Fluid management VTE prophylaxis Antimicrobial prophylaxis Skin prep Maintenance of normothermia BP and glucose maintenance Pain management Postoperative Phase Postoperative Interventions Early mobilization Antiemetic prophylaxis Early removal of urinary catheters Early removal of wound drains Glucose control Pain management Patient feedback Outcomes reporting and analysis
- 9. ERP-Perioperative Initiatives Nursing Interventions Preoperative Optimization Perioperative Initiatives Postoperative Recovery Extended Postoperative Recovery Home Hospital Home FOCUS on Nursing responsibilities for this time span Calling all Preop, Intraop and PACU nurses…
- 10. ERP and Post-Surgical Nursing Pre-Surgical Counseling and Education Pre-Surgical Conditioning and Readiness Pre-Surgical Preparation Intraoperative Efficiency Targeted Postoperative Interventions Patient Feedback and Outcomes Reporting and Analysis involve every phase of the Enhanced Recovery Program: Pre-Surgical Intraoperative Post-Surgical
- 11. ERP Nursing Responsibilities Clinical Guidelines Patient Engagement Contingency Planning Key Components of ERP Nursing Responsibilities
- 12. Postoperative Clinical Guidelines VTE prophylaxis Control of postoperative nausea and vomiting Postoperative pain control Early postoperative (oral) feeding Early mobilization Avoidance of nasogastric tubes Avoidance of wound drainage Fluid management Urinary catheter removed postoperative day (POD) 1-2 Alvimopan Postoperative glucose control Patient feedback / outcomes analysis Multidisciplinary communication and teamwork is a key element of success Clinical Guidelines
- 13. Patient Engagement “…the goal is to and with a view to obtaining maximum value and improved health outcomes.” Coulter (2012)
- 14. Arrival to Inpatient Floor Initiate post-surgical ERP checklist *History – Assess pre-surgical ERP compliance*
- 15. ERP Nursing Guidelines • Ensure patient is receiving mechanical and (timely) pharmacological prophylaxis • Assess VTE risk • Educate patients regarding importance • Notify physician of missed doses/refusals VTE PROPHYLAXIS • Perform PONV pre-surgical risk assessment • Perform regular patient assessments • Communicate during hand-off, any resuce anti- emetics used for the patient in recovery • Use multimodal treatment approach POSTOP NAUSEA AND VOMITING
- 16. ERP Nursing Guidelines • Reinforce and educate patients regarding pain expectations and targets • Perform regular pain assessments in recovery • Follow multimodal approach to treatment, encouraging non-narcotic medications PAIN CONTROL • Assess for compliance with carbohydrate loading and optimization of hydration in preop • If the patient’s case is delayed or expected to be delayed for >1 hour, notify the anesthesiology team. Preop feeding/hydration rescue measures may need to be initiated. NUTRITION
- 17. ERP Nursing Guidelines • Pre-warming of patients before surgery • Consider patients who may be exposed while having prolonged anesthetic procedures performed • The patient’s temperature should be regularly during surgery, and warming adjusted accordingly • Active warming of patients should continue postoperatively MAINTENANCE OF NORMOTHERMIA • Routine prophylaxis with IV antibiotics should be given 30- 60” before initiating colorectal surgery • Re-dosing of antibiotics should be administered during prolonged procedures. • Chlorohexidine-alcohol based skin preps are optimal for use in skin prep for surgery • Hair clipping (vs. shaving) is associated with fewer surgical site infections ANTIMICROBIAL PROPHYLAXIS/SKIN PREP
- 18. ERP Nursing Guidelines • Assess hydration optimization compliance preoperatively • Be sure to monitor case delays and intervene accordingly (in conjunction with the anesthesia team’s guidance) to avoid unnecessary fasting from fluids FLUID MANAGEMENT • Nasogastric tubes and wound drains should be avoided whenever possible • If necessary, assess and advocate for removal when appropriate: NG tubes inserted during surgery should be removed before reversal of anesthesia TUBES AND DRAINS
- 19. Contingency Planning Notice deviation from routine ERP course Form “contingency plan” with patient: Provide reassurance and education regarding options Set new “targets” for the patient to work toward Provide reinforcement through motivation toward new targets and encouragement of plan ** All changes should be communicated to surgeon/physician, nurse receiving patient from unit transfers, oncoming nurse at shift change and multidisciplinary team members**
- 20. Implementation “Ideas” Hold regular ERP team meetings where clinicians have the opportunity to discuss ERP. Review patient level data for ERP and non-ERP patients to demonstrate impact of the program. Select “clinical champions” from multiple areas that are excited about the program and willing to work to engage other clinicians. Acknowledge and celebrate ALL successes!
- 21. Next, refer to the Guide for the Postoperative Phase!
- 22. Our goal is that this guide will serve as a resource to help you guide patients to achieve optimal preparation for surgery and success in realizing the many benefits of the Enhanced Recovery Program. Through monitoring, educational efforts, system changes and coordination of services of the healthcare team and many hospital divisions, patients will attain improved length of stay, decreased readmission rates and reduced morbidity and mortality, and the hospital will demonstrate a return on investment which exceeds the incremental costs of these efforts.
Editor's Notes
- Today’s presentation of ERP is intended to: 1. Provide context and rationale for an Enhanced Recovery Program (Why ERP) 2. Introduce the Enhanced Recovery Program (What is ERP) 3. Identify the ‘key players’ and their respective roles (Who is ERP) 4. Locate areas for incorporation of elements from the Enhanced Recovery Program (Where ERP) 5. Provide education regarding phases and timing of Enhanced Recovery Program principles (When ERP)
- Health care and Healthcare, although often interchangeably used, are 2 fundamentally different concepts. While healthcare refers to a system to offer, provide, and deliver health care, health care refers to the provider-patient interactions that are conducted within that system. Healthcare has often been referred to as the “thing”: that doesn’t work well for anyone; costs too much; has frequent errors, and too few providers. As demands for high-quality, comprehensive care continue to increase, resources often remain stationary or may even decrease which creates a gaps within the healthcare system that must eventually be absorbed somewhere along the care pathway… How do we as providers maintain the standards for exceptional, high-quality health care without throwing off the balance between resource availability and use? By maximizing efficiency in how health care is delivered. Maximum efficiency is achieved by utilizing evidence-based best practices, improving access to high-quality care and reducing waste in resource(s). This is best accomplished through the deployment of standardized health care strategies and protocols that are developed within a systematic context of shared governance. The result is wide-spread engagement and accountability for the delivery of care which requires participation from individuals (providers and patients), institutions, and systems. As a comprehensive approach to maximizing healthcare efficiency, the MSQC-Enhanced Recovery Program objectifies the delivery of high-quality care through the use of evidence-based best practices, the partnership and building of relationships with patients and between providers for a common goal: optimized recovery for surgical patients. ERP efforts focus on reducing the perioperative stress response, attenuating organ dysfunction, and promoting optimal postoperative recovery. The results are shortened length of stays, reduced readmissions, accelerated return to baseline functioning, and decreased morbidities.
- Developing and implementing ERP begins with a strong commitment from leadership. A multidisciplinary steering committee is then established to plan customization of the program at the individual site. The multidisciplinary approach is essential in every aspect of ERP implementation. Along with leadership, all involved health care providers (pre-surgical, intraoperative and post-surgical) must be actively engaged in learning the ERP process and incorporating the program into practice for their patients. In addition, there must be systems in place to review compliance with the program and assess its ability to meet the needs of the patients, in terms of outcomes and feedback from the patient perspective.
- In order to achieve high reliability performance, strong leadership and skilled management are necessary. Representation from multiple disciplines will provide the greatest amount of depth and diversity for a comprehensive resource knowledge pool. Core Membership: The core members represent hospital and physician leadership. The core membership is responsible for developing a vision and aligning hospital subsystems to influence cultural change in the advancement of an enhanced recovery program. Layers of Membership: The “layers” of membership should be composed of skilled individuals who represent hospital management and staff from different departments. Engagement at the nursing management level is integral to the success of ERP by ensuring that staff is doing the correct things to stay true to the vision. Commitment at the staff level is essential in keeping the patient engaged in ERP initiatives throughout the different pathways of care. NOTE: MSQC-SCQR represents the Michigan Surgical Quality Collaborative-Surgical Clinical Quality Reviewer
- The nuclear fission reaction of Uranium-235 is self-sustaining because of its critical mass, producing very large amounts of energy. Likewise, an organization with strong nursing representation and buy-in possesses the “critical mass” necessary in creating and sustaining a powerful and effective Enhanced Recovery Program. Nurses have the ability to engage patients in an Enhanced Recovery Program in a way that is unique from all other disciplines involved because nurses are present in each and every phase of ERP. For this reason, nurses have the ability to greatly affect the success of patient outcomes. Application of the nursing process to each phase of the Enhanced Recovery Program will ensure initiation and continuation of patient engagement, facilitation of shared decision-making and sustained motivation for Enhanced Recovery Initiatives. Utilization of the nursing process in establishing and maintaining compliance with ERP initiatives will result in successful outcomes for the patient in meeting set goals for recovery.
- There are six basic elements to an Enhanced Recovery Program: Presurgical Counseling and Education; Presurgical Conditioning and Readiness; Presurgical Preparation, Intraoperative Efficiency, Targeted Postoperative Interventions and Patient Feedback and Outcomes Reporting and Analysis. Within these six elements, are a suggested list of evidence-based practices that result in improved outcomes for surgical patient. An efficient and effective Enhanced Recovery Program will require repeated and regular evaluation of each component for efficacy and improvement. Preadmission counseling: ERP Education: procedure, ERP elements, why Anticipatory Guidance: who, when, what will happen, why Patient-centered: goal setting, responsibilities, expected outcomes Pre-Surgical Conditioning and Readiness Surgical Optimization Smoking cessation Optimize nutrition Optimize mobility Eliminate alcohol intake Patient Readiness Identification of a patient-centered support network (provider) Surgery “buddy” (patient-chosen)—accompanies patient: second set of eyes and ears Anxiety assessment and short-term intervention strategies Presurgical Preparation Bowel Preparation: -mechanical bowel prep -antimicrobial prophylaxis Presurgical Carbohydrate Loading and Hydration: -clear (12.5%) carbohydrate drink (800mL) before midnight. -clear (12.5%) carbohydrate drink (400mL) 2-3 hours prior to induction. -patient freely consumed clear fluids until 2h before anesthesia for surgery Intraoperative Efficiency: Standardized Anesthetic Protocols -Minimal Use of Opioids -Measures to Optimally Sedate and Anesthetize Patients Standardized Thromboembolism and Antibiotic Prophylaxis Protocols Minimally Invasive Surgery Targeted Post Operative Interventions Early Postop Feeding Early Removal of Catheters/Drains Early Mobilization Pain Management Preop: administration of pain modulating medications Post-op: early assessment and intervention Discharge: good pain control with oral analgesia Patient Feedback and Outcomes Reporting and Analysis MSQC data collection and analysis allows for benchmarking of quality measure(s) performance specific to ERP
- Perioperative Initiatives are goal-directed activities that span the preoperative, perioperative, and immediate postoperative recovery phases of surgery. Beginning while the patient is still in the home environment, the PAT nurse facilitates the patient’s transition from home to the day of surgery, picking up responsibilities for ERP from the surgeon’s office. The PAT nurse, as part of the standard preop patient assessment and preparation for surgery, should incorporate the relevant ERP elements. The PAT nurse is responsible for reinforcing elements from the Preoperative Optimization phase of ERP and introducing the components from the Perioperative Initiatives phase of ERP. On the day of surgery, the preop, intraop and PACU nurses who assume direct care for the patient are responsible for facilitating ERP initiatives in partnership with the patient, surgeon, and anesthesiology team until he/she is transferred to the inpatient unit.
- The post-surgical nurse will need to focus on all phases of the Enhanced Recovery Program, not just the postoperative piece. It is essential to understand the patient’s compliance with the pre-surgical and intraoperative periods. This will contribute to post-surgical planning, patient coaching, and development of any contingency arrangements that may be necessary to get the patient “back on track” with their ERP program. Upcoming slides will address how each of these elements “fits into” post-surgical nursing care. In addition, there are resources and tracking tools designed to aid in implementation of this program. The notes detailing the basic elements (also provided with slide 4) are again provided for reference in discussing this slide. There are six basic elements to an Enhanced Recovery Program: Pre-surgical Counseling and Education; Pre-surgical Conditioning and Readiness; Pre-surgical Preparation, Intraoperative Efficiency, Targeted Postoperative Interventions and Patient Feedback and Outcomes Reporting and Analysis. Within these six elements, are a suggested list of evidence-based practices that result in improved outcomes for surgical patients. Initiating an Enhanced Recovery Program does not require the adoption of all practices, and is a dynamic process that evolves with each turn in the PDSA cycle. An efficient and effective Enhanced Recovery Program will require repeated and regular evaluation of each component for efficacy and improvement. ERP isn’t “all or nothing”…there’s something for everyone, resulting in improvement in outcomes for each participant. Preadmission counseling: ERP Education: procedure, ERP elements, why Anticipatory Guidance: who, when, what will happen, why Patient-centered : goal setting, responsibilities, expected outcomes Pre-Surgical Conditioning and Readiness Surgical Optimization Smoking cessation Optimize nutrition Optimize mobility Eliminate alcohol intake Patient Readiness Identification of a patient-centered support network (provider) Surgery “buddy” (patient-chosen)—accompanies patient: second set of eyes and ears Anxiety assessment and short-term intervention strategies Pre-surgical Preparation Bowel Preparation -mechanical bowel prep -antimicrobial prophylaxis Pre-surgical Carbohydrate Loading and Hydration: clear (12.5%) carbohydrate drink (800mL) before midnight. clear (12.5%) carbohydrate drink (400mL) 2-3 hours prior to induction. patient freely consumed clear fluids until 2h before anesthesia for surgery Intraoperative Efficiency: Standardized Anesthetic Protocols -Minimal Use of Opioids -Measures to Optimally Sedate and Anesthetize Patients Standardized Thromboembolism and Antibiotic Prophylaxis Protocols Minimally Invasive Surgery Targeted Post Operative Interventions Early Postop Feeding Early Removal of Catheters/Drains Early Mobilization Pain Management Preop: administration of pain modulating medications Post-op: early assessment and intervention Discharge: good pain control with oral analgesia Patient Feedback and Outcomes Reporting and Analysis MSQC data collection and analysis allows for benchmarking of quality measure(s) performance specific to ERP
- Three components must be considered to ensure success for the Enhanced Recovery Program patient: Clinical Guidelines – These are the evidence-based clinical care factors set forth by ERP. MSQC recommended ERP protocols have been customized for YOUR HOSPITAL NAME HERE. These outline the processes to follow through the entire program; including pre-surgical, intraoperative and post-surgical. It will be very important to understand your patient’s compliance with ERP protocols at the time they reach the post-surgical unit, as well as document and communicate their progress throughout the post-surgical phase. Patient Engagement – This includes “coaching” your patients toward their “postoperative targets” through continuous encouragement and reinforcement of their active role in their recovery. Contingency Planning – This component may not be necessary for every patient, but it will be important to always be prepared and ready to make changes to the “routine ERP course” (should the situation warrant). The nurse’s ability to quickly develop and adapt to an alternative plan will help get the patient back on their ERP course, make the patient comfortable and give them confidence in their “revised ERP course”. Patient engagement will be extremely important to cases requiring contingency planning, as deviation from the anticipated course may be discouraging and/or anxiety producing for the patient.
- This slide represents a list of the postoperative clinical guidelines. While these clinical components are specific to the postoperative phase, it is still very important to remember that nursing care for ERP patients requires the nurse to be aware of all phases of ERP. The clinical guidelines are evidenced-based recommendations, and have been used to create ERP protocols customized to your hospital. They are intended to be utilized along with a multidisciplinary approach to care.
- To maximally engage patients, they need to be well supported and informed. In addition, they must be provided opportunities to participate in their care and decision making. For patients that require contingency planning, the patient should be at the center of the planning process and involved in determining the alternate plan. Motivation and reinforcement of the ERP process will help keep patients actively engaged. There are multiple facets to patient engagement: Health Literacy: A fundamental piece of patient engagement as patients must be able to understand and process health information. This also involves addressing patient expectations of care. Patient empowerment is key to meeting this facet. Decision Making: Ensuring patients are well-informed and taking their preferences into account in deciding treatment(s) results in shared decision making, a goal of patient engagement. Use of coaching and question prompts can help patients improve this facet. Self-Care: Patients need to take actions to maintain physical and mental health. Self-Management: Patients need to play an active role in managing the day to day aspects of their chronic conditions (if applicable). Educating patients on self-management and helping them to self-administer treatments can help patients improve this facet. Patient Safety: Patients can advocate for the safest care possible by being actively involved in monitoring care processes, recognizing and informing health care providers of complications, and effectively managing treatment. Positively reinforcing treatment regimens can help patients improve this facet. It is important that health professionals are granted the means to gain the necessary expertise and skill to effectively engage patients.
- When the patient arrives to the post-surgical floor, the first actions to take are to obtain their “ERP history” – their compliance with the ERP pre-surgical and intraoperative phases, assess key initial postoperative ERP clinical factors, and initiate the postoperative ERP checklist. The key initial postoperative ERP clinical factors consist of: VTE Prophylaxis: It is important to ensure the patient has pharmacological prophylaxis (SQ heparin / low molecular weight heparin ordered) and scheduled for administration; and also that the patient has compression stockings and intermittent pneumatic compression devices / sequential compression devices applied and turned on. Postop Nausea and Vomiting (PONV): The patients postoperative score should be assessed (see PONV Risk Assessment), and treated using a multimodal approach. Be especially alert for patients that are at high risk for developing PONV (again) on the post-surgical floor; patients that have a PONV risk score of moderate or high and/or received a rescue antiemetic in PACU. Pain Control: It is important to assess and intervene early. Medicate for relief, if necessary. Reinforce the pain expectations that were discussed pre-surgically. Early Oral Feeding: Assess if the patient has tried oral fluids and/or food yet. They should be taking oral fluids as soon as possible after surgery; so it is likely this will have been started in PACU. Inquire how the patient tolerated the fluids/food (if provided). Alvimopan: Verify through surgeon orders and medication schedule. Fluid Management: Begin recording fluid type and amount received. The goal will be to discontinue IV fluids on postoperative day 1. Refer to clinical guideline specific nursing tip sheets and Nursing Pocket Card for supporting rationale and interventions.
- Patient engagement and contingency planning (as necessary) are to be continued throughout the post-surgical hospital stay, until discharge from the hospital. VTE Prophylaxis: (see VTE Prevention Nursing Tip Sheet and MSQC Recommended VTE Risk Scoring System Pocket Card) Pharmacological = SQ heparin/low molecular weight heparin Ensure timely administration and adherence to schedule, reoffer missed doses (unless too close to next administration time) Document and notify surgeon/physician of any missed doses or patient refusals Mechanical = compression stockings and sequential compression devices/intermittent pneumatic compression devices SCD/IPC devices should be worn continuously Ensure patient compliance Continuously reinforce rationale for prophylaxis Encourage patients to become actively involved in making sure they are complying with appropriate prophylaxis Postop Nausea and Vomiting: (see PONV Risk Assessment Nursing Tip Sheet and ERP Nursing Pocket Card) PONV score needs to be assessed upon arrival to preop Like pain assessments, PONV assessments should be done at regular intervals through 48 hours past discharge from PACU It is very important to communicate PONV assessments/interventions during shift change and unit transfers Educate patients on PONV as it pertains to their particular assessed risk, including providing intervention strategies Encourage patients to be involved in managing their PONV, including communicating associated needs Know the PONV risk for each patient and be aware of the medications they have ordered/available De Novo PONV patients are those that have a PONV Risk Score of moderate or high and/or received a rescue antiemetic in PACU, and are therefore at high risk for developing PONV that “begins again” on the post-surgical unit: if you’ve administered a rescue anti-emetic you will want to communicate this during hand-off communication Managing these symptoms is essential to ERP patients being able to meet “targets”, as PONV can delay the patient from engaging in activities to promote recovery Complications associated with PONV include: suture dehiscence, aspiration of gastric contents, and esophageal rupture
- Patient engagement and contingency planning (as necessary) are to be continued throughout the post-surgical hospital stay, until discharge from the hospital. Pain Control: Goal = good pain relief – but must also be such that the patient can participate in mobilization and early oral feeding Early assessment and intervention will be important to ERP progression, as poor pain control will inhibit patients from participating in other ERP activities Postoperative ERP protocol may be dependent upon surgical approach (open vs. laparoscopic) Use of opioids should be avoided when possible, and should be prescribed for break-through pain only Opioids can delay return of gut function and cause PONV Multimodal treatment approach is utilized, which includes NSAIDS and IV Acetaminophen Encourage patients to become advocates of their pain control and communicate associated needs Nutrition: ◊ Note to hospital nursing staff: As the preoperative nurse evaluates, keep in mind that the ‘cut-off’ time for the patient’s last solid food intake may vary between surgeons due to individual interpretation of ERP protocols. The patient’s last solid intake before anesthesia should be ≥6 hours. ◊ Preoperative nursing staff: because of the dynamic nature of the surgical environment, situations may present where a patient’s case delay is foreseeable due to the cascade effect of late/delayed surgical cases preceding the patient’s. In these situations, timely communication with the anesthesiology team is necessary to allow for initiation of ‘rescue maneuvers’ (i.e., fluids, carbohydrate-rich drink) in order to avoid placing the patient in an undesirable state of fasting.
- Maintenance of Normothermia RATIONALE for maintaining normothermia: -normothermia contributes to the maintenance of normal body homeostasis -patients who have become hypothermic have a greater chance for wound infection, cardiac events and bleeding -in recovery, patients who are hypothermic have a higher risk of shivering which increases oxygen consumption at a critical time. -patients with normothermia have better controlled pain Prewarming of patients before surgery has been shown to improve core temperature. This is especially important if the patient has had a prolonged anesthetic procedure (monitoring catheters, epidural insertion) where they were exposed. INTRAOPERATIVELY: forced air warming blankets, heating mattresses, and circulating water garment systems all have been shown to be effective at maintaining normothermia during surgery. IV fluids should be warmed from the start of administration The patient’s temperature should be monitored to enable warming to be adjusted and to avoid hyperpyrexia which may occur in prolonged procedure if the patient develops a systemic inflammatory response syndrome (SIRS) POSTOPERATIVELY: active warming should be continued until the patient’s temperature is ≥36 ⁰C
- Patient engagement and contingency planning (as necessary) are to be continued throughout the post-surgical hospital stay, until discharge from the hospital. Fluid Management: Patients may drink clear fluids up to 2h of anesthesia While Anesthesiology will monitor and maintain fluid volume/balance intraoperatively, proper preop maintenance of hydration will minimize intraoperative fluid resuscitation. Tubes and Drains: Tubes and drains should be avoided if possible NG tubes may contribute to pulmonary complications and delay return of gut function Avoidance/early removal of tubes/drains will help prevent postop ileus
- It is important to remember that the ERP patient will have been preparing for every phase of the program as soon as the decision to have surgery was made. They will have followed protocols to get them in the most optimal pre-surgical condition, learned what to expect from their hospitalization and planned “targets” for their recovery. Deviation from this planned out course has the potential to make the patient feel discouraged, scared and/or anxious. It is crucial that the nurse be able to quickly recognize any deviations and immediately begin contingency planning to get the patient back on the ERP course. In doing so, it will be necessary to remember to educate and involve the patient in developing the alternate plan; to provide reassurance; and to reinforce the redirected focus. In addition, any changes should be communicated to the surgeon/physician, oncoming nurse for the next shift, and any other necessary members of the multidisciplinary team. In training post-surgical staff for implementation of ERP, it may be helpful to have open discussion about different “potential scenarios” of patients deviating from the routine ERP course.
- Helpful implementation ideas are also a great topic for discussion at ERP meetings. Encouraging “front line” staff to present their thoughts and ideas about the most beneficial way(s) to implement a new program (especially one that involves potentially involves such a culture shock) will increase their engagement and likely offer viable solutions as they are well aware what will work best in their everyday practice and routines.