Enhanced Recovery after Surgery Programme Care Pathway_… · Enhanced recovery programme – Upper...

Enhanced recovery programme – Upper GI –Total Gastrectomy Cardiff and Vale UHB: version2 13/01/11

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Enhanced Recovery after Surgery Programme

Total Gastrectomy Integrated Care Pathway

Age:

Consultant:

Pre Operative Assessment Outcome:

Suitable for Day of surgery admission (DOSA)? Y N

Day before Surgery Admission (DBSA) Y N Admit .........days pre-op.

Critical care bed required post-op?

Booked Yes □ No □

Y N Level 2 or 3

Is the patient allergic to latex? Y N If Yes theatre informed:

Date:

Time:

Is the patient’s BMI > 40? Y N If Yes theatre informed:

Date:

Time:

Does the patient need to be first on list? Y N

Is the patient suitable for carbohydrate loading Y N

Assessing Nurse: Signature: Date:

Date of Admission:

Operation:

Date of surgery:

Predicted date of discharge

(PDD):

Actual date of

discharge:

Length of stay

Removed from pathway

Date: Reason

Addressograph

Unit no.: DoB:

Name:

Address:


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1. This Integrated Care Pathway (ICP) is a multidisciplinary document and replaces all other documentation to

form the patient’s sole record of care. It is intended as a guide to good practice and is evidence based. (NB

point

2. The ICP is not a rigid document and clinicians are free to use their own professional judgement as appropriate,

recording as a variance any alterations to the practice outlined, or any deviation from the expected plan of

treatment.

3. When using the pathway, sign yourself on below stating your discipline. Always use black ink

4. All sections should be fully completed. Please follow all instructions.

5. It is essential that all entries are signed and dated as indicated. Sign only for care that YOU have carried out or

outcomes that have been met.

6. When completing the pathway insert:

� Your initials if the outcome / plan has been met

� A X if it has not been met

� A 0 If the outcome / plan is not applicable to that patient

7. Any variation from the expected plan/ outcome of care: anything that happens that is not expected outcome /

plan is recorded as a VARIANCE.

8. In recording variances, please give as much information as possible

9. All variances must be recorded on the variance / multi-disciplinary notes sheet. Document the variance code

for the relevant action / outcome alongside the written detail of the variance

10. The Cardiff and Vale UHB generic risk assessment book must be used alongside this ICP to ensure that

patients undergo appropriate risk assessment during their stay

11. It may also be appropriate to use a nursing care plan as an adjunct to the pathway. Please make a record

below of the care plans in place and ensure each one is evaluated TDS in the multidisciplinary notes.

All patients Generic risk assessment book

Diabetic patients Diabetes core care plan

Relevant acute

pain team care

plans

Epidural care plan

PCA care plan

Intrathecal morphine care plan

12. If an outcome of care is not applicable to that patient write (N/A)

13. If the pathway is no longer suitable for a patient, discontinue the pathway, document why as a variance and

fill in the date in the table on page 1.


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SIGNATURE PRINT NAME INITIALS JOB TITLE Bleep

/Extension


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SOCIAL ASSESSMENT

Patient lives with:

Are they fit and well? Yes � No

Are they coping at home at present? Yes � No �

Are there stairs / steps in the home? Yes � No �

Does the patient care for anyone? Yes � No �

If Yes who?

Does the patient have a carer? Yes � No �

If Yes who?

Would patient or family like to see a Social

Worker Yes � No � If yes, reason:

Is OT assessment required Yes � No �

Does the patient have complex discharge needs?

Yes � No �

Are patient and family happy with social

circumstances and to organise own support

on discharge?

Yes � No �

Are there any adaptations / rails in the home?

Yes � No �

Date: Nurse signature:

Patient details Patient Known as:

Home telephone: Mobile telephone:

Email address Marital status:

Occupation Religion

1st Language Translator required Yes � No �

First contact Second contact

Name: Name:

Relationship to patient: Relationship to patient:

Address:

Address:

Home telephone: Home telephone:

Work telephone: Work telephone:

Mobile telephone: Mobile telephone:

To be contacted:

In an emergency: Yes � No �

At night: Yes � No �

To be contacted:

In an emergency: Yes � No �

At night: Yes � No �

GP details

Telephone number:

Practice address:

If social work referral required / discharge is complex complete Unified Assessment forms


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Presenting Symptoms: (include dysphagia, vomiting, weight loss, anaemia, mass, appetite loss, pain, GI

bleed)

Pre-op chemotherapy? yes ☐☐☐☐ no ☐☐☐☐ regime regime regime regime ☐☐☐☐ date completeddate completeddate completeddate completed ☐☐☐☐

Pre-op chemoradiotherapy? yes ☐☐☐☐ no ☐☐☐☐ date completeddate completeddate completeddate completed ☐☐☐☐

Previous

anaesthetic problems:

Family history of anaesthetic problems:

Previous motion sickness or post-operative nausea/vomiting: yes ☐☐☐☐ no ☐☐☐☐

Pre-operative clerking


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Cardiovascular Y N Expand here:

MI □ □

Angina / Chest pain □ □

Hypertension □ □

AF / Arrhythmia □ □

Heart failure □ □

Stroke / TIA □ □

Previous cardiac surgery □ □

Coronary artery stents □ □

Pacemaker □ □

DVT / PE □ □

Palpitations / faints / syncope □ □

Rheumatic fever □ □

Peripheral vascular disease □ □

Respiratory

Asthma □ □

COPD / bronchitis / emphysema □ □

TB □ □

Sleep apnoea / snoring □ □

Cough □ □ Productive □ Haemoptysis □

Endocrine

Diabetes □ □ diet □ tablets □ insulin □

Thyroid disease □ □

Haematological

Excessive bleeding / bruising □ □

Anaemia / blood disorders □ □

Sickle cell disease □ □

GI/GU

Liver disease / jaundice / hepatitis □ □

Heartburn / acid reflux □ □

Hiatus hernia □ □

Stomach / duodenal ulcer □ □

Past medical history


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Kidney / bladder problems □ □

CNS

Epilepsy / fits □ □

Neurological disorder □ □

Anxiety / Depression □ □

Psychiatric Illness □ □

Other

Arthritis/joint problems □ □

LMP …………….. Could you be pregnant? Yes No

Inoculation risk □ □

Other □ □ Maximum walking distance on flat …………… (yards / metres)

□ bed bound □ wheelchair bed to chair □ 5m end of room

□ 25m end of ward □ 100m length of football pitch □ 400m

□ 2km 30min walk □ >2km normal pace, no exercise limitation ��

Walking limited by □ joint pain □ breathing □ chest pain □ leg pain

□ balance □ fatigue □ other

Do you get SOB walking up a flight of 12 stairs? Y N Do you get chest pain walking up a flight of 12 stairs? Y N Orthopnoea Y N (State no. of pillows ……..) PND Y N Peripheral Oedema Y N


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Abdomen

WEIGHT LOSS:

Weight pre illness:

Weight loss in KG:

Time frame of weight

loss:

Hand Signs:


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Neurological

Investigations ordered (*=essential)

□ FBC* Hb: Plat: WCC: MCV:

□ U&E* Na: K: Ur: Creat:

□ G+S*

□ LFT*

□ Coagulation screen

□ Blood Glucose

□ HbA1c

□ TFT

□ Sickle cell

□ Arterial blood gases

□ MSU

□ MRSA swabs

□ ECG

□ CXR

□ Echocardiogram

□ Pulmonary function tests

□ CPX

□ Other

* NB: Please document FBC, U+E results and any other abnormal results above

Possum-O

Calculate Possum-O on-line - http://www.riskprediction.org.uk/op-index.php

Score = ………………….


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Signature ………………… Date ……………..

Commence Drug chart

Prescribe the following, unless contraindicated for this patient

Complete thromboprophylaxis risk assessment Yes ☐

Enoxaparin (Clexane) Yes ☐ N/A ☐

� dose as per thromboprophylaxis risk assessment

� Commence at 1800 if admitted day before surgery (Do not give on morning of surgery)

Thromboembolism

Anti-embolism stockings (AES) Yes ☐ N/A ☐

Is bowel prep indicated and required Yes ☐ No ☐ Bowel Preparation

Refer to consultant instruction

Picolax Prescribed if indicated at management plan Yes ☐ N/A ☐

Omit any ACE inhibitors or Angiotensin II Receptor blockers on the morning

of surgery. Yes ☐ N/A ☐

Aspirin/Clopidogrel - stop 7days before surgery (discuss with anaesthetist)

Yes ☐ N/A ☐

Continue patients other usual medications (See anaesthetic guidelines on

‘Management of Perioperative Medicines’) Yes ☐ N/A ☐

Medications

Warfarin – discuss management with POAC anaesthetist Yes ☐ N/A ☐

Analgesia Paracetamol 1g qds (IV/oral) from post-op day 0 Yes ☐

Anti-emetics Cyclizine 50mg tds IV/oral Yes ☐ Ondansetron 4mg tds IV/oral Yes ☐

Antibiotics Co-Amoxiclav 1.2mgs IV on induction Yes ☐

Metronidazole 500mg IV on induction Yes ☐

Oxygen Oxygen therapy continually post-operation Yes ☐

Nutrition Carbohydrate loading: Refer to ward protocol Yes ☐ N/A ☐ document to be given 2-3 hours before surgery on drug chart � NB: Do not give within 4 hours of operation if previous gastric surgery or

severe reflux


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Contra indications to NSAIDs Caution to NSAID use

Renal impairment Pregnancy / breast feeding

History of peptic ulceration Asthma

Hypersensitivity to NSAIDs CCF

Asthma hypersensitivity to aspirin Concurrent anti-coagulant therapy

Coagulopathy Hepatic impairment

Preoperative nursing assessment

Baseline assessment to be added in here

Doctors name: Signature: Date:


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Baseline assessment to be added in here


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Risk assessments completed and documented in generic risk assessment book

Initials

Waterlow Pressure ulcer risk assessment tool

Malnutrition risk assessment (WAASP) Weight……....Kgs (actual not estimated)

Pat-e-bac risk assessment

Falls and bedrails Risk assessment

Thromboprophylaxis risk assessment (doctor to complete)

Unified Assessment: Not to be completed for simple discharges

Patient education record:

Relative/carer present: Yes ☐ No ☐ Relationship to patient:

Teaching provided. Date: Yes N/A Initials

Understanding of Enhanced Recovery Programme & patient’s role

Fasting instructions

Pain control

Bowel preparation

Mobilisation post-op

Carbohydrate loading

Pre and post operative dietary advice

Nutritional supplements

Thromboprophylaxis therapy

Deep breathing, leg exercises and preventing pressure ulcers

Smoking cessation advice

Written information provided:

Enhanced recovery programme

Surgery

Anaesthesia/analgesia

Discharge plans discussed

Family/social support plans for discharge discussed

Patient contract signed

Patient Diary given


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Referrals

Y

Reason for

referral

Name/contact

referred to

Anaesthetist for notes review

Upper GI CNS

Dietician

Physiotherapist

Occupational Therapist

Acute pain team

Social services

Smoking cessation

Other

MRSA screen:

Full MRSA screen required if patient is being admitted from a nursing home or another hospital,

or if they are known to have had MRSA in the past:

MRSA screen sent: Yes ☐ No ☐ Not applicable ☐

Name of pre-assessment nurse:

Signature: Date


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Physiotherapy – Preoperative Check List

Yes No Reason

Pain relief, in relation to Physiotherapy

Attachments, in relation Physiotherapy

Suitable clothing and footwear

Getting in and out of bed

Early mobilisation

Generic exercises

Breathing exercises taught and practiced

Supported cough

Return to normal activities

Driving

Booklet provided

Scholes Score: High Low

At risk of PPC?

Chest assessment : complete for all patients with a high Scholes score, chronic chest disease or cough

HABAM Score: Balance Transfers Mobility

At risk of mobility problems?

Taking into account complete assessment findings - is the Patient for routine postoperative Physiotherapy review?

Sign: Date: Print:


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Nutrition and Dietetic - Preoperative Checklist

Yes No Reason

WAASP completed

MUST completed

SGA completed

Advised on carbohydrate loading

Food fortification advice

Advised on need for nutritional supplements x 3 day and explain different types available

Post operative dietary advice - early oral diet

Weight history and anthropometric assessment

Record of dietary intake

Diet sheet provided

Snacks and high protein options discussed

Any special dietary requirements?

Catering informed of special dietary requirement (as appropriate)

Nutritional requirements calculated Energy…………kcal Protein……….g

Malnutrition Risk Screening - WAASP

W A A S P Overall Risk of

Malnutrition

Malnutrition Universal Screening Tool - MUST

Step 1 Step 2 Step 3 Overall risk of Malnutrition

Sign: Date: Print:


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Anaesthetic /CPX Clinic Revised Cardiac Risk Index Score: Score 1 point for each variable:

High-risk surgery (includes any intraperitoneal, intrathoracic, or suprainguinal vascular procedures)

History of ischemic heart disease (history of MI or a positive exercise test, current complaint of chest pain considered to be secondary to myocardial ischemia, use

of nitrate therapy, or ECG with pathological Q waves; do not count prior coronary revascularization procedure unless one of the

other criteria for ischemic heart disease is present).

History of heart failure

History of cerebrovascular disease

Diabetes mellitus requiring treatment with insulin

Preoperative serum creatinine >177 µmol/L

TOTAL

CPX test Y N

ASA status 1 2 3 4 5

Peri-operative medicines instructions:

Continue all medicines on day of surgery ☐ or Continue all meds except list below ☐

Drug chart amended re: above instructions Yes ☐ No ☐

Anaesthetist name & signature: Date:


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Variances/ Multidisciplinary Notes

Please record all variances or multidisciplinary notes below

Date, Time and

Variance code

Details, reason and action taken

Signature and

bleep number


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Pre-operative Admission Day. Date:……………

Doctor: pm night Variance Code

Record changes in health status since POA in multidisciplinary notes PDr1

Record changes in medicines since POA in multidisciplinary notes PDr2

Check consent form has been signed and white copy has been given to patient PDr3

X-rays and ECG available PDr4

Investigations completed and results available PDr5

FBC/U&E/LFT performed within 14 days? Yes ☐ No ☐

If no then repeat on admission Yes ☐ N/A ☐

PDr6

If patient on warfarin INR check Yes ☐ Anaesthetist informed if INR > 1.4 Yes ☐ PDr7

G+S sample sent (2nd G+S sample for electronic blood issue) PDr8

Prescription chart written PDr9

Bowel preparation: Discussed with consultant / Registrar and prescribed if required – please make a record on variance sheet if required

PBp

On admission:

Patient fully aware of planned surgery PT1

Patient orientated to ward [NB: access to nutritional supplements] PT2

Repeat observations. (T, P, R, BP, SpO2 + weight) POb

Enoxaparin given at 1800 hours PM1

If prescribed patient measured for Anti-embolic stockings and stockings provided PAes

Identity band in place, patient details confirmed PN1

Referrals: Referred to pain control nurse PNr1

Inform physiotherapist of admission PNr2

Inform dietician of admission PNr3

Referred to Social worker, OT and Discharge liaison if required

Please document these referrals on variance sheet PNr4

Nutrition

Normal diet and fluids – stop diet 6 hours pre theatre: Time diet to stop:

(Unless undergoing bowel preparation) ………… PNU1

Bowel preparation: Administered as prescribed

Record weight (kg) Insert weight………..(KG) PNW

Recalculate Malnutrition risk assessment and record changes (WAASP) PNA

Ensure Plus x2 supplement drinks are given 1 ☐ 2 ☐ PNS

If on the morning theatre list - Carbohydrate loading give 4 x 200ml ‘pre-op’

drinks evening before surgery 1 ☐ 2 ☐ 3 ☐ 4 ☐ NIGHT STAFF:NIGHT STAFF:NIGHT STAFF:NIGHT STAFF: please refer to operation day 0day 0day 0day 0 re: administration of ‘Pre-Op’ drinks x 2 between 05.00 and 06.00. NB: Do not give within 4 hours of operation

if previous gastric surgery or severe reflux

PClam

Insert initials if achieved, a x if

not achieved and 0 if not

applicable


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If on the afternoon theatre list: Commence carbohydrate loading as soon as patient awake on day of surgery.

PClpm

Patient Education

Importance of mobility post op and deep breathing and limb exercises PEm

Surgery / treatment plan PST

Importance of post op nutrition and early enteral feeding PN2

Patient’s and relatives’ roles in recovery process PEr

Discharge arrangements PDis

Operation Day (day 0) Date:...................

Preoperative: Estimated time of surgery:

Yes Signature

Doctor :

Confirm G+S sample sent (2nd G+S sample for electronic blood issue)

No food for 6 hours prior to surgery

If morning list - Carbohydrate loading x2 ‘Pre-op’ drinks and clear fluids (up to 2 hr before start of theatre list) NB: Do not give within 4 hours of operation if previous gastric surgery or severe reflux

If afternoon list – ‘Pre-op’ drinks x6 to commence as soon as awake. Up to 2hrs before start of theatre list then nil by mouth for 2hrs. NB: Do not give within 4 hours of operation if previous gastric surgery or severe reflux

Theatre check list completed

Wearing AES (Anti-embolism stockings)

Patient’s usual medications given as prescribed

(omit ACE inhibitors or Angiotensin II Receptor blockers

on day of surgery)


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Operation Notes Date: Consultant: Surgeon 1: Surgeon 2: Surgeon 3: Surgeon 4: Anaesthetist: Scrub Nurse: Anaesthetic time started: Time into theatre: Operation time started: Time finished: Site of cancer: Operation title: Cancer treatment intent:

Blood loss:

HDU/ICU admission (please circle): Planned Unplanned


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Yes No Long-acting sedative premed avoided Seen in preop Anaesthetic Clinic CPX test performed DOSA Long-acting sedative pre-med avoided Carbohydrate loading taken 2-3hours preop Spinal Intrathecal Diamorphine Intrathecal Diamorphine with 0.5% heavy Bupivacaine TAP block Epidural Intraop Dexamethasone given as antiemetic Intraop Ondansetron given as antiemetic Bair Hugger Temp probe Warmed iv fluids Temp on leaving theatre Antibiotics prior to skin excision Cardiac output monitor used Volume (mls)

Total intraop crystalloid volume given Total intraop colloid volume given

Anaesthetic data (to be completed in theatre by anaesthetist


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Plan: Pain well controlled, IV fluids, oxygen, catheter insitu diet, fluids and mobilise

PM Night Variance

Code

Admitted to High Dependency Unit 0HDU

Observations and EWS score completed ½ hrly for 2 hrs, 1 hrly for 2 hrs and then

2 hrly. Actions taken as per EWS chart: document actions on variance sheet 0Ob

Deep breathing promoted, patient able to deep breath and cough. 0Db

Sputum clear 0Sp

Oxygen in place as prescribed and oxygen saturations maintained above 97% 0O2

Fluid balance chart completed hourly 0Fb

Administer IV fluids (1.5L Hartmanns over 24 hrs = 62.5 mls/hr) Follow

GIFTASUP recommendations

0ivi

Hourly catheter measurements (maintain 0.3 ml/kg/hour averaged over 4 hours)

Expected 1hourly output =…………….ml/hr Expected 4 hourly rate: …………..

0Uc

Jejunostomy insitu - Administer sterile water at 10ml/hr for 12 hours using an enteral feeding pump

Sterile water should commence at 6pm post operative unless contra-indicated.

0Jej

Pain assessed with each set of observations at rest and deep breathing and pain well controlled (0-1) ( If pain not well controlled actions taken as per protocol and relevant care plans (PCA / epidural) and documented on variance sheet)

0Pa

Epidural site: checked 8 hourly, no redness, oozing or swelling present ( If redness / oozing / swelling refer to per protocol and epidural care plan and document on variance sheet)

0Ep

If epidural insitu: straight leg raises checked 4 hourly – patient able to raise leg

(If patient unable to SLR refer to protocol and epidural care plan and document on variance sheet)

0Slr

Strictly Nil By Mouth 0Nbm

Patient checked for signs of paralytic ileus – ie: nausea / vomiting, increased pain, pulse >100 and/or abdominal distension – nil present

0Pi

NG tube insitu on free drainage only – no fresh blood noted

Do NOT aspirate or repass a tube without consultant direction

0Ng

Nausea assessments with each set of observations – nausea well controlled 0Na

VIP score completed for all venflons insitu 0Vip

Wound observed when observations recorded - no bleeding / signs of infection 0W

Insert initials if achieved,

a x if not achieved and

0 if not applicable

Post op: Day 0 (Day of operation)


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PM Night Variance Code

Abdominal drains checked, drainage measured and recorded before 12MN, blood

and haemoserous fluid draining volume is less than 200 mls

Number of drains insitu: …………………….

0Ad

Patient assisted to reposition 2 hourly by day / ………….. hourly by night 0Rep

Pressure areas checked all blanching with no discolouration / broken areas 0Pr

AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken areas present) 0Aes

6 hours after return to ward patient sat out of bed (only if this is before 7pm).

Sit in chair for 30 mins: Time of return to ward:…………………..

Time sat out in chair: ………………… to ………………

0Si

Waterlow, Pat-e-bac, falls and WAASP risk assessments recalculated post op 0Ra

Doctor: Blood tests (FBC, U & E) taken 0Dr1

Doctor: Blood tests (FBC, U & E) results reviewed and normal 0Dr2

Doctor: Review drug chart, change medications to IV whilst NBM 0Dr3

Physiotherapy – respiratory assessment/treatment 0Ph1

Physiotherapy – mobility assessment 0Ph2


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Date, Time and

Variance code


Signature and

bleep number


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Plan am pm night Variance Code

Transfer to ward C2 1C2 Observations and EWS score recorded 2 hourly. Actions taken as per EWS chart: document actions required on variance sheet

1Pb

Deep breathing promoted, patient able to deep breathe and cough. 1Db

Sputum clear 1Sp

Oxygen in place as prescribed and oxygen saturations maintained

above 97%

1O2

Fluid balance chart completed hourly 1Fb

Flatus passed 1Fl

Bowels opened 1Bo

Administer IV fluids (1.5L Hartmanns over 24 hrs = 62.5 mls/hr) Follow GIFTASUP recommendations

1ivi

VIP score completed for all venflons in situ – Score 0 1Vip

Nil By Mouth 1Nbm

Jejunostomy insitu - If tolerating10ml/hr sterile water for 12 hours commence feed.

1Jejw

Commence Osmolite at 20ml/hr unless contra-indicated, increase rate by 10mls per every 6 hours until a max of 80mls/h is reached. Flush 6hrly with 30mls of sterile water.

1Jejf

Clean jejunostomy site daily with normal saline, check integrity of sutures. (If suture not intact secure jejunostomy and inform team)

1Jejc

Patient checked for paralytic ileus - i.e. nausea/vomiting, increased pain, pulse> 100 and/or abdominal distension, nil present

1Pi

Pain assessed 2 hourly at rest and deep breathing and pain well controlled (0-1) ( If pain not well controlled actions taken as per protocol and relevant care plans (PCA / epidural) and documented on variance sheet)

1Pa


1Ep

If epidural insitu: straight leg raises checked 4 hourly – patient able to raise leg (If patient unable to SLR refer to protocol and epidural care plan and document on variance sheet)

1Slr

NG tube insitu and reviewed by consultant, haemoserous fluid / bile draining. Free Drainage Only

1Ng

Nausea assessed 2 hourly and actions taken as per protocol 1Na

Catheter insitu - Monitor urine output 1 hourly (maintain minimum of 0.3 ml/kg/hour averaged over 4 hours)

1Uc

Hygiene needs met 1Hy

Post-op: Day 1. Date:............................

Insert initials if achieved,

a x if not achieved and

0 if not applicable


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Wound observed no bleeding / signs of infection noted 1W

am pm night Variance Code

Abdominal drains monitored and reviewed by Registrar / Consultant

1Ad

Out of bed x 2 times in total and record length of time sat out

1 ☐ ……………… 2 ☐ ……………… 1Sc

Walks x 2 (Tick once each walk achieved and estimate distance)

1 ☐ …………… 2 ☐ ……………

1Wa

Pressure areas checked all blanching with no discolouration / broken areas

1Pr

Patient assisted to reposition 2 hourly by day / ………….. hourly by night

1Rep

AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken

areas present) 1Aes

AES completely removed once in 24 hours for maximum of 30 mins for hygiene care and skin inspection

1Aesr


Doctor: Blood tests (FBC, U & E) results reviewed and normal 1Dr2

Doctor: Review drug chart, change medications to IV whilst NBM 1Dr3

Doctor: Book Gastrografin swallow if required for Day 5 or 7 (if day 5 is a weekend)

1Dr4

Physiotherapy – respiratory assessment/treatment 1Ph1

Physiotherapy – mobility assessment 1Ph2


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Date, Time and

Variance code


Signature and

bleep number


31

Postoperative Morbidity Survey (POMS) Day 1 post-op

* If no scores above then please state reason why patient still in hospital:

Morbidity type Criteria Tick if

present*

Pulmonary Has the patient developed a new requirement for oxygen or respiratory support.

Infectious Currently on antibiotics and/or has had a temperature of

>38°C in the last 24hr.

Renal Presence of oliguria <500 ml/24 hr; Increased serum creatinine (>30% from preoperative level); Urinary catheter in situ.

Gastrointestinal Unable to tolerate an oral diet for any reason including nausea, vomiting, and abdominal distension.

Use of antiemetic.

Cardiovascular Diagnostic tests or therapy within the last 24 hr for any of the following:

• new myocardial infarction or ischemia,

• hypotension (requiring fluid therapy >200 mL/hr or pharmacological therapy),

• atrial or ventricular arrhythmias,

• cardiogenic pulmonary oedema,

• thrombotic event (requiring anticoagulation).

Neurological New focal neurological deficit, confusion, delirium, or coma.

Haematological Requirement for any of the following within the last 24 hr: packed erythrocytes, platelets, fresh-frozen plasma, or cryoprecipitate.

Wound Wound dehiscence requiring surgical exploration or drainage of pus from the operation wound with or without isolation of organisms.

Pain New postoperative pain significant enough to require IV or IM opioids or regional analgesia.

Date: Doctor’s signature: Bleep no:


32

Plan: AM PM Night Variance

code

Observations and EWS chart score recorded 2hourly whilst PCA and

epidural insitu, Actions taken as per EWS recommendations: document

all actions on variance sheet

2Ob


Sputum clear 2Sp

Oxygen in place as prescribed and oxygen saturations maintained

above 94%- 97%

2O2

Fluid balance chart completed 1 hourly 2Fb


Administer IV fluids (1.5L Hartmanns over 24 hrs = 62.5 mls/hr)

Follow GIFTASUP recommendations

2ivi

Nil By Mouth 2Nbm

Continue Osmolite via jejunostomy unless contra-indicated, increase rate by 10mls per every 6 hours until a max of 80mls/h is reached. Flush 6hrly with 30mls of sterile water.

2Jejf


2Jejc


2Ng

Flatus passed 2Fl

Faeces passed. 2Bo

Patient checked for paralytic ileus - i.e. nausea/vomiting, increased

pain, pulse> 100 and/or abdominal distension, nil present

2Pi

Weight recorded ………Kgs 2Wt

If weight gain>3kgs request surgical review 2Wtg


2Pa


2Ep

If epidural insitu: straight leg raises checked 4 hourly – patient able to raise leg (If patient unable to SLR refer to protocol and epidural care plan and document on variance sheet)

2Slr

Nausea assessed 2 hourly and anti-emetics given as per protocol if

required – nausea well controlled

2Na


unachieved and 0 if not

applicable

Post op day 2 Date:


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AM PM Night Variance

code

Catheter insitu - Monitor urine output 1 hourly

(maintain minimum of 0.3 ml/kg/hour averaged over 4 hours)

OUc

Wound observed, no bleeding or signs of infection noted 2W

Abdominal drains monitored and reviewed by Registrar / Consultant 2Ad

Hygiene needs met. 2Hy


1 ☐ ……….…. 2 ☐ ………… 3 ☐ …………… 4☐ ……………

2Sc


1 ☐ ………… 2 ☐ ………………3☐ ……………… 2Wa

Foot exercises whilst in bed / whilst sat out in chair 2Fe

AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken

areas present) 2Aes

AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 2Aesr


2Pr

Patient reminded to reposition 2 hourly by day and ……… by night 2Rep

Risk assessment scores reassessed if any change in condition 2Ra

Remind patient of ERAS programme requirements 2Pe


Doctor: (FBC, U & E) results reviewed and normal 2Dr2

Doctor: Review drug chart, change medications to appropriate route for administration

2Dr3

Physiotherapy: respiratory assessment/treatment 2Ph1

Physiotherapy: Mobility assessment 2Ph2


34



Date, Time and

Variance code


Signature and

bleep number


35



present*




Renal Presence of oliguria <500 mL/24 hr; Increased serum creatinine (>30% from preoperative level); Urinary catheter in situ.


Use of antiemetic.













36

Plan: mobile and pain well controlled, AM PM Night Variance

code

Observations and EWSC completed 2hourly whilst PCA and epidural

insitu, 4 hourly once discontinued. Actions taken as per EWSC

document all actions on variance sheet

3Ob


Sputum clear 3Sp

Stop oxygen (if mobile and oxygen saturations > 94%-97% on room

air)

3O2





3ivi

Nil By Mouth 3Nbm

Continue target feeding regimen via jejunosotmy as devised by dietician unless contra-indicated

Flush 6hrly with 30mls of sterile water.

3Jejf


3Jejc

Catheter insitu - Monitor urine output 1 hourly (maintain minimum of 0.3 ml/kg/hour averaged over 4 hours)

3Uc


3Ng

Nausea assessed 2 hourly and anti-emetics given as per protocol if required – nausea well controlled

3Na

Flatus passed 3Fl

Faeces passed. 3Bo



3Pi



Consider discontinuing epidural /PCA and commencing IV / oral analgesia. (Document if epidural / PCA discontinued on variance sheet)

3Epi


3Pa


3Ep

Post op day 3 Date: Insert initials if achieved, a x if

unachieved and O if not

applicable


37


code

Straight leg raises checked 4 hourly – patient able to raise leg (If patient unable to SLR refer to protocol and epidural care plan and document on variance sheet)

3Slr





1 ☐ ……….…. 2 ☐ ………… 3 ☐ …………… 4 ☐ ……………

5 ☐ ………… 6 ☐ …………

3Sc


1 ☐ ………… 2 ☐ ………………3☐ ……………… 3Wa


AES in situ (Legs, feet and heels checked 8 hourly all blanching and no discolouration /

broken areas present) 3Aes

AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection

3Aesr


3PR

Patient reminded to reposition 2 hourly by day and as required by night

3Rep






3Dr3



Confirm discharge plan with patient and relatives 3Disp


38



Date, Time and

Variance code


Signature and

bleep number


39


If no score above then please state reason why patient is still in hospital

Morbidity type

Criteria Tick if

present*





Gastrointestinal

Unable to tolerate an oral diet for any reason including nausea, vomiting, and abdominal distension.

Use of antiemetic.

Cardiovascular

Diagnostic tests or therapy within the last 24 hr for any of the following:







Haematological

Requirement for any of the following within the last 24 hr: packed erythrocytes, platelets, fresh-frozen plasma, or cryoprecipitate.





40


code

Observations and EWS chart completed 6 hourly. Actions taken as

per EWS recommendations: document all actions on variance sheet

4Ob


Sputum clear 4Sp

Oxygen saturations > 94%-97% on room air 4O2





4ivi

Nil By Mouth 4Nbm



4Jejf

Clean jejunostomy site daily with normal saline, check integrity of

sutures. (If suture not intact secure jejunostomy and inform team)

4Jejc

NG tube insitu and reviewed by consultant, haemoserous fluid / bile

draining. Free Drainage Only

4Ng

Flatus passed 4Fl

Faeces passed. 4Bo



4Pi



PCA / epidural discontinued 4Epi

Pain assessed 6 hourly and well controlled using prescribed

analgesia

4Pa



4Na

Remove catheter if epidural discontinued. Monitor patient is passing urine without difficulties

4Uc

Epidural site satisfactory – no oozing, redness or swelling 4Ep





applicable

Post op day 4 Date:


41



code


1 ☐ ……….…. 2 ☐ ………… 3 ☐ …………… 4 ☐ ……………

5 ☐ ………… 6 ☐ …………

4Sc


1 ☐ ………… 2 ☐ ………………3☐ ……………… 4Wa





4Aesr


4Pr


4Rep






4Dr3




42



Date, Time and

Variance code


Signature and

bleep number


43

Postoperative Morbidity Survey (POMS)

Day 4

postop

Morbidity type Criteria


Infectious Currently on antibiotics and/or has had a temperature of >38°C in the last

24hr.



Use of antiemetic.









Wound Wound dehiscence requiring surgical exploration or drainage of pus from


44

the operation wound with or without isolation of organisms.




45


code

Observations and EWSC completed 8 hourly. Actions taken as per

EWSC: document all actions on variance sheet

5Ob


Sputum clear 5Sp

Oxygen saturations > 94%-97% on room air 5O2



5ivi



5Jejf


5Jejc

Fluid balance chart completed 5Fb



5Ng

Gastrograffin swallow to confirm integrity of anastamosis

(to be carried out on day 6 / 7 if day 5 is a weekend day)

Commence sips of water on Consultant’s instruction and clearly

documented in variance sheet.

5Gs5

Remove NG tube on Consultant’s instruction and clearly

documented on variance sheet.

5Ngr

Faeces passed. 5Bo



5Pi




analgesia

5Pa



5Na

Passing urine without difficulties 5Uo



Drain sites checked 5Ds

Independent of hygiene needs 5Hy

Post op day 5 Date: Insert initials if achieved, a x if


applicable


46


code


1 ☐ ……….…. 2 ☐ ………… 3 ☐ …………… 4 ☐ ……………

5 ☐ ………… 6 ☐ …………7 ☐ ……………8 ☐ ……………

5Sc


1 ☐ ………… 2 ☐ ………………3☐ ……………… 4☐ ………………

5Wa



5Pr




5Aesr

Patient reminded to reposition 2 hourly by day and as required by

night

5Rep






5Dr3




47



Date, Time and

Variance code


Signature and

bleep number


48

Postoperative Morbidity Survey (POMS) Day 5 postop




24hr.



Use of antiemetic.














49


code



6Ob


Sputum clear 6Sp

oxygen saturations > 94%-97% on room air 6O2




6ivi

Continue target feeding regimen via jejunosotmy as devised by

dietician unless contra-indicated


6Jejf



6Jejc

Gastrograffin swallow to confirm integrity of anastamosis ( if not

carried out day 5, to be carried out on day 7 if day 6 is a weekend

day)



6Gs6



6Ngr

Faeces passed. 6Fl




analgesia

6Pa



6Na







applicable

Post op day 6 Date:


50



code


1 ☐ ……….…. 2 ☐ ………… 3 ☐ …………… 4 ☐ ……………

5 ☐ ………… 6 ☐ …………7 ☐ ……………8 ☐ ……………

6sc


1 ☐ ………… 2 ☐ ………………3☐ ……………… 4☐ ………………

6Wa





6Aesr


Pr


6Rep






6Dr3




51



Date, Time and

Variance code


Signature and

bleep number


52

Postoperative Morbidity Survey (POMS) Day 6 post op




24hr.



Use of antiemetic.














53

Plan: Discharge home AM PM Night Variance

code



7Ob


Sputum clear 7Sp

oxygen saturations > 94%-97% on room air 7O2

All venflons removed 7Vr



7Jejf


7Jejc

Gastrograffin swallow to confirm integrity of anastamosis (to be

carried out on day 7 if day 5 is a weekend day)



7Gs7



7Ngr

Continue oral fluids and diet as instructed and documented on

variance sheet.

7Of

Bowels open 7Bo




analgesia

7Pa



7Na







1 ☐ ……….…. 2 ☐ ………… 3 ☐ …………… 4 ☐ ……………

5 ☐ ………… 6 ☐ …………7 ☐ ……………8 ☐ ……………

7Sc

Post op day 7 Date:



applicable


54


code


1 ☐ ………… 2 ☐ ………………3☐ ……………… 4☐ ………………

7wa





7Aesr


7Pr


7Rep






7Dr3




55



Date, Time and

Variance code


Signature and

bleep number


56



present*



24hr.



Use of antiemetic.














57


code



8Ob


Sputum clear 8Sp


Consider changing to overnight feeding, follow feeding regime. 8Jejf



8Jejc


variance sheet.

8Of

Bowels open 8Bo




analgesia

8Pa



8Na







1 ☐ ……….…. 2 ☐ ………… 3 ☐ …………… 4 ☐ ……………

5 ☐ ………… 6 ☐ …………7 ☐ ……………8 ☐ ……………

8sc


1 ☐ ………… 2 ☐ ………………3☐ ……………… 4☐ ………………

8Wa



8Pr




8Aesr

Post op day 8 Date:



applicable


58


code


8rep








59



Date, Time and

Variance code


Signature and

bleep number


60



present*



24hr.



Use of antiemetic.














61


code



9Ob


Sputum clear 9Sp


Overnight feeding, follow feeding regime. 9Jejf



9Jejc


variance sheet.

9Of

Bowels open 9Bo




analgesia

9Pa



9Na







1 ☐ ……….…. 2 ☐ ………… 3 ☐ …………… 4 ☐ ……………

5 ☐ ………… 6 ☐ …………7 ☐ ……………8 ☐ ……………

8sc


1 ☐ ………… 2 ☐ ………………3☐ ……………… 4☐ ………………

8Wa



9Pr

Post op day 9 Date:



applicable


62




code


9Aesr


9Rep







Physiotherapy: Stair assessment if appropriate 9Ph3

Physiotherapy: Discharge advice given if appropriate 9Ph4

Discharge information and teaching given regarding care of

jejunosotomy. Ensure correct amount of syringes are available for

daily flush (single use) until OPA

9DisE

Confirm and complete discharge plan for following day with patient

and relatives

9Disc


63



Date, Time and

Variance code


Signature and

bleep number


64



present*



24hr.



Use of antiemetic.














65


code



10Ob


Sputum clear 10Sp


Discontinue feeds via jejunosotmy 10Jejd



10Jejc


variance sheet.

10Of

Bowels open 10Bo




analgesia

10Pa



10Na







1 ☐ ……….…. 2 ☐ ………… 3 ☐ …………… 4 ☐ ……………

5 ☐ ………… 6 ☐ …………7 ☐ ……………8 ☐ ……………

8sc


1 ☐ ………… 2 ☐ ………………3☐ ……………… 4☐ ………………

8Wa



10Pr



Post op day 10 Date:



applicable


66


10Aesr


10rep


code







Physiotherapy: Stair assessment if appropriate 10Ph3

Physiotherapy: Discharge advice given if appropriate 10Ph4

Discharge information and teaching given regarding care of

jejunosotomy. Ensure correct amount of syringes are available for

daily flush (single use) until OPA

10DisE

Discharged 10Dis


67



Date, Time and

Variance code


Signature and

bleep number


68



present*




24hr.



Use of antiemetic.













69

Start completing from day 1 of pathway

Date

Signature

Written

Dispensed by pharmacy

Explained to patient

Green card completed and explained to the patient

TTH

(NB Ibuprofen for 7 days post

op only)

GP letter

Letter completed

DISTRICT

NURSES Referral phoned out

Supply of products ready for discharge STOMA CARE

Follow up visit arranged: Date: Time:

OPA Cardiff ☐ Glamorgan ☐ Gwent ☐

Follow up phone

call

Follow up phone call arranged: Date :

WARDCONTACT Patient given ward contact number

OT Equipment required for discharge in place

PHYSIO Discharge agreed

Patients own arranged TRANSPORT

Hospital transport booked: Date: Time:

Referral made Hospital

discharge

service Date of discharge confirmed:

Date and time of first visit:

Discharge discussed with Home manager / Matron

Date of discharge confirmed with home

DISCHARGE TO

NURSING /

RESIDENTIAL

HOME Transfer letter completed

Addressograph

Discharge plan

Predicted date of discharge:



70

Discharge needs discussed with social worker

Social worker informed of actual discharge date

SOCIAL:

Package of care Date & time care package will start

DISCHARGE LEAFLET

Given to patient

Patient Diary Completed and put in notes

Medically fit for discharge: Postop day: ……… Actual discharge: Postop day: ………

Hospital Length of Stay (= discharge date minus admission date) = ………. Preop days in hospital:……….

Complications Tick if

present

Acute myocardial infarction — at least two of:

• New onset or worsening of ischaemic symptoms (eg, chest pain, SOB) lasting > 20 min;

• Changes on the ECG consistent with ischaemia, including:

acute ST elevation followed by the appearance of Q waves or loss of R waves

new left bundle branch block

new persistent T wave inversion for at least 24 hours

new ST segment depression which persists for at least 24 hours

• A raised troponin level

Cardiac arrest — documented sudden cessation of cardiac output maintaining effective circulation

Reintubation

Acute pulmonary oedema — respiratory compromise with CXR showing extravascular fluid in lung tissues and alveoli

Pulmonary embolus — high probability of embolism on V/Q scan or pulmonary angiogram

DVT

Stroke — confirmed by CT scan, and clinical symptoms such as paralysis, weakness or speech difficulties, first documented after operation

Sepsis (systemic inflammatory response syndrome) — new finding of at least two of:

temperature, > 38.3°C, or < 36°C

white cell count, > 12x109/L

respiratory rate, > 20 breaths/min

heart rate, > 90 beats/min or

a positive result of a blood culture alone

Wound infection — purulent discharge or redness, or serous discharge and positive result of culture or having antibiotic treatment

Unplanned return to operating room — related to the surgery (eg, surgical bleeding)

Outcomes Record if any complication below is present during hospital stay from day 8 post op onwards.

Record the post op day that the complication occurs


71

Acute renal impairment — increase in serum creatinine level > 20% of preoperative value, or admission to ICU for renal replacement therapy

Unplanned admission — to ICU, CCU or HDU

Death within 30 days

Anastomotic leak

Ileus

Possum-O

Calculate Possum-O on-line - http://www.riskprediction.org.uk/op-index.php

Score = ………………….

Signature ………………… Date ……………..


72

Analgesia Appendix

Pain assessment

Pain must be assessed at rest, on movement and deep breathing using the terms none, mild, moderate or

severe (0-3). Pain should be assessed at least two hourly although in the initial postoperative period or if there

is a pain related problem more frequently.

Analgesia

Epidural analgesia with 2micrograms fentanyl/0.1% bupivacaine

Or

5micrograms fentanyl/0.1% bupivacaine

Or

0.1% bupivacaine only

With

Regular intravenous paracetamol

Intravenous PCA with regular paracetamol + NSAID (if not contraindicated)


73

Once epidural or PCA have been discontinued:

Intravenous step down analgesia day 4-7

Continue regular intravenous paracetamol

Regular intravenous tramadol 50-100mgs

S/C morphine hourly as required (algorithm)

Oral step down analgesia day 9 >

Continue regular intravenous paracetamol

Regular oral tramadol 50-100mgs

Oramorph hourly as required (algorithm)

Anti emetics

1st line Cyclizine 50 mgs as required 8 hourly intravenously

2nd line Ondansetron 4mgs as required 8 hourly intravenously

3rd line Prochloperazine 3-6 mgs twice daily as required via buccal mucosa

Postoperative fluid management:

• Hartmann’s 1.5L over 24 hrs (=62.5 mls/hr)

• Oral intake 800mls on day of surgery.

• IVI down on post op day 1

• Oral intake 2000mls from day 1 (includes 3 nutritional supplement drinks)

• Aim for mean BP ≥60mmHg.

• If poor urine output or hypotension requiring iv fluids, use 250ml boluses of colloid.

• Patients with epidural analgesia may require more postoperative fluids than other

anaesthetic/analgesic techniques due to the vasodilatory effects of the epidural

• Acceptance of a lower average urine output (0.3 mls/kg/hr averaged over 4

hours)in the first 24-48hrs post-operatively helps to avoid fluid overload with no

adverse effect on the patient – as long as other parameters are normal and patient is

euvolaemic with no renal impairment. In the absence of complications, oliguria

occurring soon after operation is usually a normal physiological response to surgery.

• Oliguria soon after surgery does not necessarily reflect hypovolaemia and should be

evaluated in the context of the patient’s volume status. The key question is whether or

not the oliguric patient has significant intravascular hypovolaemia which needs

treatment. Clinical signs reflecting intravascular volume include capillary refill, jugular

(central) venous pressure, and the trend in pulse and blood pressure. Urine output

should be interpreted in the light of these clinical signs, bearing in mind the normal


74

short term physiological effects of surgery on urine output.

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