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Enhanced recovery care pathways
This document summarizes an enhanced recovery care pathway for patients undergoing surgery. It discusses: - The key components of enhanced recovery pathways for thoracic surgery, maternity care, and medicine based on experiences at various hospitals. - How enhanced recovery aims to get patients recovering sooner by preparing them before surgery and providing standardized post-operative care and early mobilization. - Evidence that enhanced recovery pathways improve patient experience and outcomes like reduced length of hospital stay while increasing day-of-surgery admissions without increasing readmissions. - Future goals of expanding enhanced recovery principles to non-elective care and developing systems to better risk-stratify patients and optimize their fitness before surgery.
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Enhanced recovery care pathways
- 1. Enhanced Recovery CarePathway: a better journey for patients seven days a week and better deal for the NHS Sue Cottle Improvement Manager Acute care and seven day services NHS Improving Quality
- 2. • National overview •ER in Thoracic Surgery Amy Kerr, Heart of England Foundation Trust • ER in Maternity Care – Sheffield Teaching Hospital experience • ER in Medicine – Torbay Hospital experience
- 3. Enhanced Recovery isbecoming the norm
- 4. Endorsed by RoyalColleges and Associations “We believe that enhanced recovery should now be considered as standard practice for most patients undergoing major surgery across a range of procedures and specialties”.
- 5. A patient centredapproach • Patient involvement and shared decision making at the heart of ER Designed by patients for patients • The potency of patient involvement helps to drive spread and adoption of ER
- 6. Aligned to theNHS Outcomes Framework ER is “big cog” in a whole pathway “Enhanced Recovery is a solid platform to build upon, ER is a strong concept and we have the opportunity to widen this further along the care pathway and continue to generate evidence of its impact” Professor Keith Willett
- 7. The next threeto five years improvement programme - dedicated support, dedicated investment
- 8. Progress and levelof ambition • Good progress made • Extend principles of ER beyond elective practice • Integrate ER across the whole system
- 9. 92% 89% 86% 78% 74% Progress: Improved patientexperience Patient Experience: Enhanced Recovery compared to National Inpatient Survey 1 94% 86% 0.9 0.8 95% 92% 78% 89% 84% 74% 0.7 0.6 0.5 0.4 0.3 0.2 as much as you How much information about 0.1 t your care and your condition or treatment was 0 ent? given to you? Were you involved as much as you How much information about wanted to be about your care and your condition or treatment was treatment? given to you? Did you feel you were involved in Did hospita decisions about your discharge contact if y from hospital? your condi Did you feel you were involved in Did hospital staff tell you who to decisions about your discharge contact if you were worried about yo from hospital? your condition or treatment after you left hospital? 2011-Enhanced Recovery Recovery 2010-National Inpatient Survey - elective only 2011-Enhanced 2010-National Inpatient Survey - elective only
- 10. Steps to gettingbetter sooner
- 11. It’s the patient’sjourney • • • • Key word is ‘My’ Key concepts are ‘active role’ and ‘responsibility’ It’s a conditional deal: steps you can take to get better sooner Most people buy that: wouldn’t you? ‘I didn’t know I had a role’ Nick, ER patient
- 12. Progress: ER increasesday of surgery admission Increasing day of surgery admissions No change in readmissions
- 13. Progress: ER reduceslength of hospital stay Falling length of stay 170,000 fewer bed days Increasing day of surgery admissions No increase in readmissions
- 14. We know theJob is not done ………………… But it’s a job worth doing
- 15. We know theJob is not done - variation exists Variation in - spread and adoption to other elective surgical procedures - momentum of spread in existing procedures Early testing in - emergency and acute medical - maternity pathways
- 16. Future levels ofambition • Increase patient engagement to empower patients • Ensure all patients get the same standard of care seven days a week – spread to non-elective care • Develop systems to optimise patients fitness for referral and risk stratification to improve patient safety • Develop internationally comparable outcome measures to further build the evidence
- 17. Enhanced Recovery CarePathway: Thoracic Surgery Amy Kerr Research nurse Heart of England NHS Foundation Trust Regional Thoracic Surgery Unit
- 18. What is ER? •Number of individual peri-operative interventions • Evidence-based • Referral to discharge Underlying principle Enable patients to recover from surgery and leave hospital sooner by minimising the stress responses on the body during surgery
- 19. Lung Cancer SurgeryGuidelines
- 20. Patients are olderand less fit
- 22. Active patient involvement Referral Pre-operative Admission Intra-operative Post-operative So,what are the components of an enhanced recovery pathway in thoracic surgery? Whole team involvement Follow up
- 23. Referral • Managing preexistingmedical conditions • Informed decision making Referral • Managing pre-existing conditions • Informed decision making
- 24. Referral • Managing preexistingmedical conditions • Informed decision making 1. Pulmonary Rehabilitation 2. Smoking Cessation 3. Patient self-management and education 4. Nutritional Intervention
- 25. Referral • Managing preexistingmedical conditions • Informed decision making Outcomes (Apr 2010 – Jan 2012) ROC (n=58) Standard Care (n=305) PPC Rate 9% 16% HDU median LOS 1 days 2 days Hospital LOS 5 days 5 days Readmission rate 5% 14%
- 26. Pre-operative • Health &risk assessment • Good quality patient information • Shared decision making • Managed expectations • Discharge planning • Pre-operative assessment clinic • Maximising hydration Pre-operative • Pre-operative assessment clinic – Assess risk and identify co-morbidities – EDD and expectations • Informed decision making – Patient information – DVD
- 28. Pre-operative • Health &risk assessment • Good quality patient information • Shared decision making • Managed expectations • Discharge planning • Pre-operative assessment clinic • Maximising hydration Pre-operative • Minimising dehydration – Carbohydrate drinks ? 1,2 – Admission letter …You must ensure that you have nothing to eat after 3.00 am on the day of your admission. Please drink two large glasses of water (at least 500ml) before 06.30am the morning of your surgery. Please don’t have anything to drink after 06.30am. No chewing gum, mints or sweets… 1. Brady M, Kinn S, Stuart P. Perioperative fasting for adults to prevent peri-operative complications. Cochrane Database of Systemic Reviews 2003; 4: CD004423 2. Noblett WE, Watson, DS, Huong H, Davison B, Hainsworth PJ, Horgan AF. Pre-operative oral carbohydrate loading in colorectal surgery: a randomised controlled trial. Colorectal Disease 2006; 8 563-569
- 29. Admission • Admit onday of surgery • Optimise fluid hydration • Reduced starvation • Avoidance of sedative medication Admission • Day of surgery admission1 • Optimise fluid hydration – Minimising dehydration strategies • Reduce starvation2,3 • Avoidance of sedatives 1. Rasburn N, Batchelor T, Casali G, Evans C. The first UK experience of an enhanced recovery program in thoracic surgery. Enhanced Recovery after Surgery Society UK, 2011. www.erasuk.org 2. Brady M, Kinn S, Stuart P. Perioperative fasting for adults to prevent peri-operative complications. Cochrane Database of Systemic Reviews 2003; 4: CD004423 3. Noblett WE, Watson, DS, Huong H, Davison B, Hainsworth PJ, Horgan AF. Pre-operative oral carbohydrate loading in colorectal surgery: a randomised controlled trial. Colorectal Disease 2006; 8 563-569
- 30. Intra-operative • Minimally invasive surgery •Pain minimising surgical approach • Avoidance of fluid overload • Use of regional anaesthetic • Hypothermia prevention • VTE prophylaxis Intra-operative • Minimally invasive surgery1 1. Whitson BA, Groth SS, Duval SJ, Swanson SJ, Maddaus MA. Surgery for Early-Stage Non-Small Cell Lung Cancer: A Systematic Review of the Video-Assisted Thoracoscopic Surgery Versus Thoracotomy Approaches to Lobectomy. Ann Thorac Surg 2008; 86: 2008-2018
- 31. Intra-operative • Minimally invasive surgery •Pain minimising surgical approach • Avoidance of fluid overload • Use of regional anaesthetic • Hypothermia prevention • VTE prophylaxis Intra-operative • Goal directed fluid therapy ? • Avoidance of crystalloid overload1 – Fluid maintenance: 1-2ml/Kg/hr – Positive fluid balance < 1.5L • Hypothermia prevention – Active warming (WHO checklist) • Physiotherapy adjuncts – Mini-tracheostomy 1. Evans RG & Naidu B. Does a conservative fluid management strategy in the perioperative management of lung resection patients reduce the risk of acute lung injury? ICVTS 2012; 15: 498-504
- 32. Post-operative • Active, planned mobilisation •Early oral hydration & nourishment • Drain management protocol • IV fluids stopped early • Routine catheters avoided or removed early • Regular & breakthrough multi-modal oral analgesia • Minimise use of systemic opiatebased analgesia Post-operative • Active, planned mobilisation1,2 – Standardised protocols • Physiotherapy adjuncts – Incentive spirometry • Early oral hydration & nourishment – Drink in recovery – Eating same day • IV fluids stopped early 1. Novoa N, Ballesteros E, Jimenez MF, Aranda JL, Varela G. Chest physiotherapy revisited: evaluation of its influence on the pulmonary morbidity after pulmonary resection. Eur J Cardiothorac Surg 2011; 40: 130-135 2. Varela G, Ballesteros E, Jimenez MF, Novoa N, Aranda JL. Cost-effectiveness analysis of prophylactic respiratory physiotherapy in pulmonary lobectomy. Eur J Cardiothorac Surg 2006; 29: 216-220
- 33. Post-operative • Active, planned mobilisation •Early oral hydration & nourishment • Drain management protocol • IV fluids stopped early • Routine catheters avoided or removed early • Regular & breakthrough multi-modal oral analgesia • Minimise use of systemic opiatebased analgesia Post-operative • Routine catheters avoided or removed early • Minimise use of systemic opiate based analgesia • Paravertebral catheters +/- PCA1,2,3 • Regular & breakthrough multi-modal oral analgesia -Standardised prescription bundle 1.Powell ES, Cook D, Pearce AC, Davies P, Bowler GMR, Naidu B, Gao F and UKPOS Investigators. A prospective, multicentre, observational cohort study of analgesia and outcome after pneumonectomy. BJA 2011; 106(3): 364-370 2. Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy- a systematic review and meta-analysis of randomised trials. Br J Anaesth 2006; 96: 418-426 3. Elsayed H et al. Thoracic epidural or paravertebral catheter for analgesia after lung resection: Is the outcome different? J Cardiothorac Vasc Anaesth 2012; 26: 78-82
- 34. Post-operative • Active, planned mobilisation •Early oral hydration & nourishment • Drain management protocol • IV fluids stopped early • Routine catheters avoided or removed early • Regular & breakthrough multi-modal oral analgesia • Minimise use of systemic opiatebased analgesia Post-operative prescription bundle
- 35. Post-operative • Active, planned mobilisation •Early oral hydration & nourishment • Drain management protocol • IV fluids stopped early • Routine catheters avoided or removed early • Regular & breakthrough multi-modal oral analgesia • Minimise use of systemic opiatebased analgesia Post-operative Extra for Thoracic ER programme: • Standardised drain management (e.g. Digital chest drains1) • Key benefits: – Facilitate Mobilisation – Earlier removal – Reduced number of CXRs – Safety 1. Cerfolio RJ, Varela G, Brunelli A. Digital and smart chest drainage systems to monitor air leaks: The birth of a new era. Thorac Surg Clin 2010; 20: 413-420
- 36. Follow up • Dischargewhen criteria met • Telephone follow up Follow up • Discharge criteria – Nurses/physiotherapist • Telephone follow up • Drain clinic – Weekly nurse led clinic – Facilitates earlier discharge
- 37. Other Professional Bodies Nurseled Telephone follow up • Detects early signs of complications • Manage distressing side effects • Reduce rate of re-admission • Improve patients satisfaction of their care Angela Longe, NLCFN, TSG
- 39. Thoracic Core Components • Rehabilitation • Avoidfluid overload • Patient optimisation • Digital drains • Good quality patient information • Standardised analgesia guideline • POAC • Early physiotherapy • DOSA • Early oral fluids and nutrition • Minimally invasive surgery • Drain clinic
- 40. Referral Pre-operative Active patient involvement Admission Gettingthe patient in best possible condition for surgery •Managing preexisting medical conditions •Informed decision making •Pulmonary rehabilitation •Health & risk assessment •Good quality patient information •Shared decision making •Managed expectations •Discharge planning •Pre-operative assessment clinic •Maximising hydration •Admit on day of surgery •Optimise fluid hydration •Reduced starvation •Avoidance of sedative medication Intra-operative …best possible management during surgery •Minimally invasive surgery •Pain minimising surgical approach •Avoidance of fluid overload •Use of regional anaesthetic •Hypothermia prevention •VTE prophylaxis Whole team involvement Post-operative Follow up ...experiences the best possible post-operative rehabilitation •Active, planned mobilisation •Early oral •Discharge when hydration & criteria met nourishment •Telephone follow •Drain management up protocol •Pulmonary •IV fluids stopped rehabilitation post early surgery •Routine catheters avoided or removed early •Regular & breakthrough multi-modal oral analgesia •Minimise use of systemic opiatebased analgesia
- 41. National Implementation Plan • • • • • NationalSurvey Beacon units Dissemination Areas of research Guidance Document
- 42. National Survey UK– 2013 Areas for development • • • • • • Pre-Operative Assessment Clinic Dehydration NPO > 6hrs Patient information needs improving Thoracic specific Analgesia Thoracic specific Physiotherapy Post discharge follow up 1/4 1/4 1/3 1/3 1/3 3/4
- 43. Other Beacon Units ClinicalGuidelines: Evidence based or Consensus
- 44. Dissemination in 2013-14 ThoracicForum Feb Society of Cardiothoracic Surgery Mar Association of Anaesthetists Mar European society of Thoracic surgery May Industry Ethicon event Oct National Lung Cancer Nurse Forum Nov British Thoracic Oncology Group Jan
- 45. SCTSthe NHS 2013 10:45 ERASin 11:30 Barriers to Starting a Programme M. Mythen; London/UK M. Shackcloth; Liverpool/UK 11:40 Key to a Successful Programme 11:00 Components of a Thoracic Programme N. Rasburn; Bristol/UK T. Batchelor; Bristol/UK 11:50 State of Play Nationally for Thoracic Surgery R. Wotton; Birmingham/UK 11:10 The Patient Pathway: Information and Discharge. A. Kerr National Lung Cancer 12:00 A Danish Perspective Nurse Forum R. Petersen; Copenhagen/DK 11:20 Patient Experience 12:15 Discussion R. Kyle 11:25 Patient Experience Panel
- 46. Where do wego from here? Research • • • • Epidural – Paravertebral Minimally invasive surgery Rehabilitation Carbohydrate loading RfPB funded 2nd stage HTA 1st stage HTA in preparation
- 47. National Implementation Plan • • • • • NationalSurvey Beacon units Dissemination Areas of research Guidance Document
- 48. Conclusions Improved patient outcomesand experience drives efficiencies, not vice versa • ER can be successfully applied in Thoracic surgery • It is an ethos, whereby every care pathway can be evaluated and optimised • Application principles must not be limited to elective cases
- 49. Thank you foryour attention Any Questions?
- 50. Enhanced Recovery CarePathway: Maternity – Elective caesarean section Sue Cottle National perspective Sheffield Teaching Hospitals NHS Trust Experience
- 51. National perspective • ERprinciples supported by the National Clinical Director for Maternity and Women’s Health • Engaging with the Royal College of Obstetricians and Anaesthetic association • Scoping of practice has identified evidence of implementation of ER in practice • Variation in practice and length of stay • Obstetric Anaesthetic survey in publication
- 52. Obstetrics: Elective C- Section
- 53. What changes weremade? Pre – operative management • Patient selection • Preadmission counselling • Clear fluids up to 2 hours pre- op: Carbohydrate loading • Analgesia – oromorphine regime • TTO’s prescribed in theatre
- 55. New Oramorph regime: C.Meer,B.Kasa, R.Goyal • Formerly parenteral regime with subcutaneous cannula – service evaluation of 67 patients: – 79% - not used – 63% - Pain or erythema – 39% - taken out as uncomfortable • Change to hourly oramorph regime – service evaluation of 128 women: – 94% rated pain control good or excellent (as before) – 98% of midwives – less work (oramorph not controlled drug – one qualified only)
- 56. Postoperative management: • Clearfluids up to 1 hour post op • Postoperative mobilisation – Spinal anaesthesia takes 4 to 9 hours to wear off – 8 hours post op is in the evening for most – Fewer staff then - ?safe to mobilise? – Patients ambivalent about early mobilisation – Elected to mobilise day after surgery as before. • Removal of urinary catheters on mobilising • Post operative checklist
- 57. What changes weremade? The neonate • Breast feeding – Problems with breast feeding commonly delay discharge – Skin to skin contact at birth between mother and baby improves breast feeding rates – low rates in theatre – New initiative to encourage this in theatre • Delayed cord clamping – Increases the amount of blood going to the newborn from the placenta – Increases blood haemoglobin levels – Should improve neonatal recovery – Obstetricians have instituted a new protocol for this and it is being used
- 59. Telephone service evaluation: • • • • • 19women were followed up by telephone on discharge 100% reported they were able to do daily activities 96% reported feeling ‘back to normal’ 82.3% reported no pain. 76.5% breastfeeding rate; 100% reported no problems at all in looking after the baby • No readmissions or problems reported in women or neonates discharged on day 1
- 60. Testing the pinciplesof ER in Medicine Torbay Hospital Experience South Devon Healthcare NHS Foundation Trust
- 61. Enhanced Recovery –Application of ER principles in medicine Professor Ben Benjamin The Torbay Hospital Experience South Devon Healthcare NHS Foundation Trust
- 62.
- 63. Enhanced recovery carepathway: A better journey for patients seven days a week and better deal for the NHS www.nhsiq/enhancedrecovery
- 64. To what extentis your organisation delivering Enhanced Recovery Care Pathways to ensure consistent standards of care delivery seven days a week?