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Enhanced recovery pathways
- 1. ENHANCED RECOVERY PATHWAYS COLLECTIVE LEARNING ------------------------------------- IAN BAYLEY ORTHOPAEDIC SURGEON
- 2. Collaborative Life Cycle Local work Continuous Improvement Team asked begins Topic to join the programme Reference Celebration Initiation/LS1 LS2 LS3 Panel Other support mechanisms Faculty, Support from WSC Team Web site, E Mail & Phone contact, Reports, Development Sessions
- 3. JAN July JAN July JAN July JAN July JAN July 00 01 02 03 04 BCWD First & Fast Joints IV 6 NOF III 12 #NOFs II 26 National Back Pain I & II & III #NOFs I 23 Joints III 33 Joints II 24 Joints I 30 Action on Orthopaedics
- 4. Ten Top Tips Ten Must Do’s
- 5. TORR Torbay Orthopaedic Rapid Recovery John Marshall Clinical Director – Trauma and Orthopaedics South Devon Healthcare NHS Foundation Trust
- 6. Northumbria Fast Track Total Hip & Total Knee Replacement Leigh Kelly Acute Pain Specialist Nurse & Clare Casson Senior Specialist Physio
- 7. Managing the Process of Implementing an Enhanced Recovery Pathway Tom Wainwright The Royal Bournemouth Hospital Department of Health, London – 23/09/2009
- 8. Enhanced Recovery Programmes in Orthopaedics‐ Becoming the Gold Standard Mr David Houlihan‐Burne Consultant Knee Surgeon The Hillingdon and Mount Vernon Hospitals NHS Trust
- 9. Example of enhanced recovery elements Referral from •Optimising pre operative Primary Care health state e.g. Hb levels Pre- •Managing co morbidities e.g. Operative diabetes •Fit for surgery Admission Intra- Operative Post- Operative Follow Up 9
- 10. 10
- 11. Example of enhanced recovery elements Referral from • Optimised health / medical condition Primary Care • Informed decision making with companion Pre- • Pre operative health & risk Operative assessment e.g. (CPEX) Admission Intra- Operative • PT information and expectation managed • DX planning (EDD) Post- • No / reduced oral bowel prep (bowel Operative surgery) • Pre-operative therapy instruction where Follow appropriate Up 11
- 12. Welcome to the Joint School
- 13. Example of enhanced recovery elements Referral from • Optimised health / medical condition Primary Care • Informed decision making with companion Pre- • Pre operative health & risk Operative assessment e.g. (CPEX) Admission Intra- Operative • PT information and expectation managed • DX planning (EDD) Post- • No / reduced oral bowel prep (bowel Operative surgery) • Pre-operative therapy instruction where Follow appropriate Up 13
- 14. Patient satisfaction of TKR Satisfaction questions were completed by 8095 patients Overall - 81.8% were satisfied - 11.2% were unsure - 7.0% were not satisfied The OKS varied according to patient satisfaction (p<0.001) 14
- 15. Decision Aids reduce rates of discretionary surgery RR=0.76 (0.6, 0.9) O’Connor et al., Cochrane Library, 2009 15
- 16. 16
- 17. Example of enhanced recovery elements Referral from •Optimise fluid hydration Primary Care •Optimise Nutrition •No / reduced oral bowel Pre- preparation (where appropriate) Operative Admission Intra- Operative •Admission on the day of surgery Post- •Carbohydrate loading Operative •No pre med (sedative) Follow Up 17
- 18. Example of enhanced recovery elements Referral from Primary Care • Minimally invasive surgery where appropriate Pre- • Use of transverse incisions Operative (abdominal) if appropriate Admission Intra- Operative • Use of regional anaesthesia Post- • LA with sedation Operative • Individualised goal directed fluid management Follow Up 18
- 19. LIA TECHNIQUE FOR TOTAL KNEE REPLACEMENTS LIA TECHNIQUE FOR TOTAL KNEE REPLACEMENTS 150 mls Ropivicaine 0.2 % 150 mls Ropivicaine 0.2 % Pre mix 100ml 0.2% Ropivicaine with 1ml 1:1,000 adrenaline and 50 mls 0.2% Ropivicaine plain 50ml syringes with 18 G (Pink) Spinal needle Pre mix 100ml 0.2% 1.BEFORE PROSTHESIS INSERTED Ropivicaine with 1ml 1:1,000 50mls with adrenaline into posterior capsule / gutters / extensor mechanism adrenaline and 50 mls 0.2% Ropivicaine plain 2. AFTER PROSTHESIS INSERTED 50ml syringes with 18 G (Pink) 50mls with adrenaline into posterior capsule / gutters / extensor mechanism Spinal needle 3. BEFORE CLOSING THE SKIN 50mls without adrenaline into skin/ subcut tissues before clips applied
- 20. NHCFT fast-track anaesthesia paracetamol 1g iv +/- NSAID (as appropriate) judicious intra-operative vasopressor & iv fluids no (routine) urinary catheter intra-operative infiltration LA: 100ml levobupivacaine 1.25mg/ml intra-articular LA catheter no surgical drains
- 21. Example of enhanced recovery elements Referral from • Planned mobilisation (24hrs post Primary Care op) • Rapid hydration & nourishment Pre- Operative • Appropriate IV therapy • No wound drains • No nasogastric tubes (bowel Admission surgery) Intra- • Catheters removed early Operative • Regular oral analgesia • Paracetamol and NSAIDS Post- • Avoidance of systemic opiate- Operative based analgesia where possible or administered topically Follow Up 21
- 22. 15 mins
- 23. 15 mins
- 24. Example of enhanced recovery elements Referral from • DX when criteria met Primary Care • Therapy input (e.g. stoma / physio / dietician) Pre- Operative • 24 hour follow up call Admission Intra- • Audit & monitor outcomes Operative • Feedback Post- Operative Follow Up 24
- 25. MDT discharge criteria Independent with all transfers (bed/chair/toilet) Independently mobile with appropriate walking aid Safe on stairs /step if indicated Able to perform exercises correctly & happy to continue at home THR: patients aware of hip precautions TKR: flexion >80°, good quadriceps control, moderate oedema.
- 28. Comparison of the length of stay (LOS) and demographics between the two groups Traditional Fast Track P value Number 3000 1571 Age (years) 69 68 THR 1368 657 TKR 1632 914 Mean LOS 8.5 4.8 <0.001* Median LOS 6 3 <0.001*
- 29. Lengths of stay - reduction over time
- 30. Progress so far…. Hips :- n = 700 Median LOS 4.5 days
- 31. Progress so far…. Knees :- n = 800 Median LOS 4 days
- 32. Team Benefits •Optimised pre admission • Easier / more informed consent • Better educated patients • Better pain management Standardised treatment pathways
- 34. Trust Benefits • Increase efficiency and reduced costs • Increase turnover of cases • Reduced complications • Patient expectations exceeded • Positive Press
- 35. Patient Benefits • Comprehensive education • Less stressful hospital experience • Family involvement and education • Quicker return to home and desired activities
- 36. COMMISSIONER BENEFITS ?