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Enhanced Recovery Programme
- 1. Enhanced Recovery Programme BolarindeOla FRCOG Consultant Gynaecologist
- 2. What is ERP Anew approach since 2010, to assist patients get better sooner after surgery by reducing stress responses (and enhancing cost-effectiveness of surgery to hospitals) • When ERP was first developed it was offered to healthier patients. • Subsequently health care teams realised that it would speed up recovery in all patients, compared to conventional care. • The ERP is now widely used for more….. • However, not all patients will be suitable for ERP
- 3. Two Cardinal Principles •Clear communication: a full range of information and explanation – Clear leaflets, interpreters, healthcare teams • A fully structured and well organised sequence of clinical care – All healthcare professionals will work from a care pathway – Allows all elements of care to follow each other promptly and efficiently.
- 4. During Consenting forSurgery • A doctor or nurse will make sure patients understand the benefits and risks of operation, and alternative treatments. • What the patient can do to improve chance of rapid recovery. • Also proposed anaesthetic and pain relief; and choices will be explained. • Leaflets – A patient diary which describes what to expect on each day after surgery – Also information about to expect at home
- 5. Components of ERP •Pre-operative planning assessment – Consenting, planning and preparation before admission • Involving primary carers / referring doctors • Reducing the physical stress of the operation – High energy, carbohydrate drinks – Allow clear fluids until 2 hours before surgery – Avoiding traditional bowel preps • Early mobilisation • Early nutrition • Early discharge
- 6. Those Not Eligiblefor ERP • Those not well motivated / or with no mental capacity • Those living alone at home / No relatives • Diabetic patients who should not take the carbohydrate drinks • Very elderly patients • If surgeon or anaesthetists has concerns because of co-morbidity
- 7. Pre-operative care bythe hospital team • Pre-assessment clinic visit – Comprehensive history and pre-op examination • Talking to the surgeon again • Therapy advice from other health care professionals: – e.g stoma or wound care nurses – physiotherapists, – and/or occupational therapists
- 8. Involving Primary Carers/ Referring Doctors • Give patient information to make an informed choice about: – (a) Having the operation or not – (b) Contributing personally towards getting a high quality outcome • Correct anaemia • Manage hypertension • Improve diabetic control • Stop smoking • Encourage weight loss
- 9. Reducing the physicalstress of the operation • Carbohydrate drinks: A key part - Most pathways include carbohydrate nutritious drinks before arrival at the hospital to reduce physiological stress. • Clear Drinks: New evidence-based guidelines show it is safe to drink water until two hours before operation. • Traditional bowel preps: New evidence-based guidelines discourages old methods: – can cause large amounts of loose motions leading to dehydration and imbalance electroytes
- 10. Effects of Starvation •Increased glucagon • Increased cortisol • Catabolism • Increased Insulin Resistance • Gluconeogenesis • Hyperglycaemia
- 11. Effects of Surgery Theseare exacerbated by starvation • Inflammatory response • Increased cortisol / cytokines • Catabolism / gluconeogenesis • Insulin resistance • Hyperglycaemia
- 12. Sum Effects ofStarvation and Surgery
- 13. Plan of CarbohydrateDrinks Date Drink Morning List (Admit 7:00am) Afternoon list (Admit 10:ooam 1 8.pm (Day before operation) 10pm (day before operation) 2 9pm 11pm 3 10pm 7am (day of operation) 4 11pm 8am 5 6.am (day of operation) 10.am 6 6.30 am 11am Clear Drink Until 6.am Until 11am
- 14. Overseas Example ofNon-Gas Carbohydrate Drink
- 15.
- 16. Day of Surgery •Appropriate anaesthesia • Limited Local anaesthetic infiltration to the wound in minimal-access surgery • Minimal-access surgery or transverse curved incisions • Peri-operative antibiotics where indicated • Avoid nasogastric tubes or surgical drains if possible
- 17. Early Mobilisation • Analgesia •Thromboprophylaxis • Something to eat • Breathing exercises • Assisted with coughing • Sit out of bed after 6 hours for two hours at intervals • Support walking along corridors (60 metres) • Encourage early bladder function
- 18. Early nutrition Aim isto stimulate gut motility • Early oral diets –From day 0 for hysteroscopic / laparoscopic • 3 high protein drinks daily • Oral diet as tolerated from day ½ • 10-15 drinks per day from day 2
- 19. Examples of HighProtein Drink
- 20. Local High ProteinDrinks
- 21. Early discharge • Healthcareprofessional support: – means that all the practical support at home are in place. • Discharge planning: – mean that everything patient needs at home is ensured. • 24 hour telephone helpline • Discharge leaflets
- 22. Early Discharge Targetsfor ERP Procedure Days Total abdominal hysterectomy +/- bilateral salpingo-oophorectomy (Midline line cut) 3 days Total abdominal hysterectomy +/- bilateral salpingo-oophorectomy (bikini line cut) 2 days Total Laparoscopic Hysterectomy 2 days Laparoscopic Assisted / Or Vaginal Hyst. 1 days Other Laparoscopic Surgery 1 Anterior and / or posterior repair 1 day Hysteroscopic Surgery 0 day
- 23. Benefits to theHospital • ERP means early discharges – Evidence show 0.5-3.5 days saved per patient • ERP is Cost effective – NHS tariffs for day-case costs for (Surgery + 1 day) • Each extra days is a loss (approx. £300) to hospital – NHS tariff for in-patient costs for (surgery + 3days) • Each extra day is a loss (£300-£660) to the hospital – However; avoidable readmissions within 30 days are not reimbursed
- 24. Conclusions • Enhanced recoveryenables patients recover from operation sooner by reducing the stress responses on the body • The aim is to ensure patients are active participants in their own recovery process • Benefits also accrue to the hospitals too