Implementing oesphageal Doppler in Enhanced Recovery

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Cardiac Output Monitoring
Targeted Fluid Therapy
Anaesthesia
Surgery
Technology Implementation

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Implementing oesphageal Doppler in Enhanced Recovery

  1. 1. Oesophageal Doppler: Enhancing Recovery from Major Surgery Daniel Conway Consultant Anaesthetist Manchester Royal Infirmary
  2. 2. Oesophageal Doppler. A Great British Invention Conflict of Interest: Dr Conway & NTAC have not received funding or financial interests in Deltex Medical
  3. 3. Oesophageal Doppler Monitoring a. Reduces Complications and Length of Stay for major surgery b. Should be available in all hospitals that perform major surgery c. Technology Adoption is achievable and cost-effective
  4. 4. Implementation Failure? • Anaesthetists, Surgeons and the evidence-base all support its use • Implementation across NW region is haphazard at best • We now have an opportunity to implement as part of enhanced recovery with SHA support
  5. 5. Optimisation with ODM 200ml 200ml stroke volume filling
  6. 6. Optimisation Studies Conway, Mayall, Latif, Gilligan, Tackaberry Anaesthesia 2002
  7. 7. Optimisation Studies Noblett, Snowden Br J Surg 2006 • 108 colorectal surgical patients • Fluid Challenge SV optimisation • Hospital LOS 7 v 9 days p<0.005 • Diet 2 v 4 days • ↓ Crit Care Admits
  8. 8. Implementation Failure? Why Scepticism: RCT vs the real world Changing practice 1. Needs training 2. Implies current care may be sub-optimal Fail at the first , second etc hurdle Alternate Hypotheses eg fluid restriction Who pays – who benefits? Competing priorities for resources Leadership Failure Capital and Consumable Costs Can anaesthetists alter surgeons outcomes !!!!
  9. 9. Implementation Project To successfully introduce oesophageal Doppler guided fluid Rx for major surgical patients in 3 NHS Hospitals Derby, Whittington & MRI Oct 2008- Oct 2009
  10. 10. Successful Adoption • Engage Management • Engage Clinicians • Control Initial Roll-out • Demonstrate Effective Implementation • Develop of an adoption plan to share across the NHS – How to Why To Guide
  11. 11. Project Team at MRI • 12 Anaesthetic Champions • Surgeons • Audit Facilitator • Project Manager at NTAC Support of Middle Management Support from MD and Chair of Trust
  12. 12. The Challenge Silo Budgeting
  13. 13. Engaging Management: The Business Case • Overcoming Divisional silos to recognise benefit for the organisation • Address Fears – What if ODM sits on shelf – What if we use loads of probes • Controlled Implementation • Costs and benefits balance • Get a manager to co-author document
  14. 14. Engaging Clinicians • How will it improve patient care ? – Critically appraise studies – PROMs in the real world • Limited Implementation – Champion approach? – Stick with narrow evidence base • Survey Training Needs
  15. 15. Evidence & Guidelines
  16. 16. Centre for Evidence Based Procurement (PASA) in patients undergoing high risk surgery use of ODM guided fluid administration (sic) is likely to result in fewer deaths, complications and a shorter LOS costs seem likely to be compensated for by reductions in LOS
  17. 17. Progress since 2008
  18. 18. Progress Nov 09 • 4 monitors purchased Oct 08 • 32 probes per month • Staff training completed • 200 Doppler patients and 200 pre- implementation controls – Length of Stay – Complications
  19. 19. Before and After Similar Patients 36 37 34 36 32 33 34 35 36 37 38 Intervention Control Mean POSSUM score Median POSSUM score
  20. 20. 4 Day ↓ Post-op LOS 15 24 11 15 0 5 10 15 20 25 30 Intervention Control Mean LOS Median LOS
  21. 21. 20% ↓ in CVC insertion rates 58% 72% 0% 10% 20% 30% 40% 50% 60% 70% 80% Intervention Control
  22. 22. 25% ↓ in re-admission rate 12% 16% 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% Intervention Control
  23. 23. 43% ↓ in Re-operation Rate 8% 14% 0% 2% 4% 6% 8% 10% 12% 14% 16% Intervention Control
  24. 24. ↓Critical Care Use 17% 25% 42% 53% 0% 10% 20% 30% 40% 50% 60% Intervention Control ITU HDU
  25. 25. • Support Implementation ODM in 10 NW Trusts 2009-2010 • Demonstrate LOS reductions • Develop core metrics for major surgery • Springboard for establishing ERS – Colorectal --- Upper GI – Orthopaedic --- Urology – Vascular --- Gynaecology
  26. 26. Enhancing Peri-Operative Pathways • Evidence Base is starting point • Need to Create Culture of Innovation –Clinicians work with management –New technology and working practice –Improvements for patients are demonstrated –Experiences shared
  27. 27. Any Questions? Step Change We Can Believe In

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