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.

1. Enhanced Recovery Care Pathway:
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 is becoming the norm

4. Endorsed by Royal Colleges 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 centred approach
• 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 the NHS 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 three to five years improvement programme
- dedicated support, dedicated investment

8. Progress and level of 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 patient experience
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 getting better sooner

11. It’s the patient’s journey
•
•
•
•
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 increases day of surgery admission
Increasing day of surgery
admissions
No change in readmissions

13. Progress: ER reduces length of hospital stay
Falling length of stay
170,000 fewer bed days
Increasing day of surgery
admissions
No increase in readmissions

14. We know the Job is not done
…………………
But it’s a job worth doing

15. We know the Job 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 of ambition
• 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 Care Pathway:
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 Surgery Guidelines

20. Patients are older and 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 preexisting medical
conditions
• Informed decision
making
Referral
• Managing pre-existing conditions
• Informed decision making

24. Referral
• Managing preexisting medical
conditions
• Informed decision
making
1. Pulmonary Rehabilitation
2. Smoking Cessation
3. Patient self-management and education
4. Nutritional Intervention

25. Referral
• Managing preexisting medical
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 on day 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
• Discharge when
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
Nurse led 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
•
Avoid fluid 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
Getting the 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
•
•
•
•
•
National Survey
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
Clinical Guidelines: Evidence based or Consensus

44. Dissemination in 2013-14
Thoracic Forum
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 ERAS in
 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 we go 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
•
•
•
•
•
National Survey
Beacon units
Dissemination
Areas of research
Guidance Document

48. Conclusions
Improved patient outcomes and 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 for your attention
Any Questions?

50. Enhanced Recovery Care Pathway:
Maternity – Elective caesarean
section
Sue Cottle
National perspective
Sheffield Teaching Hospitals NHS Trust Experience

51. National perspective
• ER principles 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 were made?
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:
• Clear fluids 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 were made?
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:
•
•
•
•
•
19 women 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 pinciples of 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. http://www.sdhct.nhs.uk/patientcare/patientinformation/enh
ancedrecoveryinmedicine/

63. Enhanced recovery care pathway: A
better journey for patients seven days
a week and better deal for the NHS
www.nhsiq/enhancedrecovery

64. To what extent is your organisation
delivering Enhanced Recovery Care
Pathways to ensure consistent standards of
care delivery seven days a week?