Enhanced recovery care pathways

Enhanced Recovery Care Pathway: a better journey for patients seven days a week and better deal for the

NHSSue Cottle

Improvement Manager

Acute care and seven day services

NHS Improving Quality

• 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

Enhanced Recovery is becoming the norm

“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”.

Endorsed by Royal Colleges and Associations

Designed by patients for patients

• Patient involvement and shared decision making at the heart of ER

• The potency of patient involvement helps to drive spread and adoption of ER

A patient centred approach

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

The next three to five years improvement programme - dedicated support, dedicated investment

Progress and level of ambition• Good progress made• Extend principles of

ER beyond elective practice

• Integrate ER across the whole system

Progress: Improved patient experience

94% 92% 89%95%

78%

86%

74%

84%

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Were you involved as much as you wanted to be about your care and

treatment?

How much information about your condition or treatment was

given to you?

Did you feel you were involved in decisions about your discharge

from hospital?

Did hospital staff tell you who to contact if you were worried about your condition or treatment after

you left hospital?

Patient Experience: Enhanced Recovery compared to National Inpatient Survey

2011-Enhanced Recovery 2010-National Inpatient Survey - elective only

94% 92% 89%95%

78%

86%

74%

84%

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Were you involved as much as you wanted to be about your care and

treatment?

How much information about your condition or treatment was

given to you?

Did you feel you were involved in decisions about your discharge

from hospital?

Did hospital staff tell you who to contact if you were worried about your condition or treatment after

you left hospital?

Patient Experience: Enhanced Recovery compared to National Inpatient Survey

2011-Enhanced Recovery 2010-National Inpatient Survey - elective only

Steps to getting better sooner

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

Progress: ER increases day of surgery admission

Increasing day of surgery admissions

No change in readmissions

Falling length of stay

170,000 fewer bed days

Increasing day of surgery admissions

No increase in readmissions

Progress: ER reduces length of hospital stay

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

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

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

Enhanced Recovery Care Pathway: Thoracic Surgery

Amy Kerr

Research nurse

Heart of England NHS Foundation Trust

Regional Thoracic Surgery Unit

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

Lung Cancer Surgery Guidelines

Patients are older and less fit

Referral Pre-operative Admission Intra-operative Post-operative Follow up

Whole team involvement

Active patient involvement

So, what are the components of an enhanced recovery pathway in thoracic surgery?

Referral• Managing pre-existing conditions

• Informed decision making

Referral

• Managing pre-existing medical conditions


1. Pulmonary Rehabilitation

2. Smoking Cessation

3. Patient self-management and education

4. Nutritional Intervention

Referral



Referral



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%

Pre-operative• Pre-operative assessment clinic

– Assess risk and identify co-morbidities– EDD and expectations

• Informed decision making– Patient information– DVD

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…

Pre-operative








1. Brady M, Kinn S, Stuart P. Perioperative fasting for adults to prevent peri-operative complications. Cochrane Database of Systemic Reviews 2003; 4: CD0044232. 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

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.org2. Brady M, Kinn S, Stuart P. Perioperative fasting for adults to prevent peri-operative complications. Cochrane Database of Systemic Reviews 2003; 4: CD0044233. 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

Admission

• Admit on day of surgery

• Optimise fluid hydration

• Reduced starvation

• Avoidance of sedative medication

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

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

Intra-operative






• VTE prophylaxis

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: 130-1352. 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

Post-operative• Active, planned

mobilisation• Early oral

hydration & nourishment

• Drain management protocol


• Routine catheters avoided or removed early

• Regular & breakthrough multi-modal oral analgesia

• Minimise use of systemic opiate-based 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, multi-centre, observational cohort study of analgesia and outcome after pneumonectomy. BJA 2011; 106(3): 364-3702. 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: 418-4263. 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









Post-operative prescription bundlePost-operative

• Active, planned mobilisation

• Early oral hydration & nourishment






Post-operativeExtra 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









Follow up• Discharge criteria

– Nurses/physiotherapist

• Telephone follow up

• Drain clinic – Weekly nurse led clinic– Facilitates earlier discharge

Follow up

• Discharge when criteria met


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

Thoracic Core Components

• Rehabilitation

• Patient optimisation


• POAC

• DOSA


• Avoid fluid overload

• Digital drains

• Standardised analgesia guideline

• Early physiotherapy

• Early oral fluids and nutrition

• Drain clinic

Referral



• Pulmonary rehabilitation

Pre-operative








Admission

• Admit on day of surgery

• Optimise fluid hydration

• Reduced starvation

• Avoidance of sedative medication

Intra-operative






• VTE prophylaxis

Post-operative• Active,

planned mobilisation

• Early oral hydration & nourishment






Follow up

• Discharge when criteria met


• Pulmonary rehabilitation post surgery

Whole team involvement

Active patient involvement

Getting the patient in best possible condition for surgery…best possible management

during surgery

...experiences the best possible post-operative rehabilitation

National Implementation Plan

• National Survey • Beacon units • Dissemination • Areas of research• Guidance Document

National Survey UK – 2013Areas for development

• Pre-Operative Assessment Clinic 1/4

• Dehydration NPO > 6hrs 1/4

• Patient information needs improving 1/3

• Thoracic specific Analgesia 1/3

• Thoracic specific Physiotherapy 1/3

• Post discharge follow up 3/4

Clinical Guidelines: Evidence based or Consensus

Other Beacon Units

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

SCTS 2013 10:45 ERAS in the NHS

M. Mythen; London/UK

11:00 Components of a Thoracic ProgrammeT. Batchelor; Bristol/UK

11:10 The Patient Pathway: Information and Discharge. A. Kerr National Lung

Cancer Nurse Forum

11:20 Patient ExperienceR. Kyle

11:25 Patient ExperienceM. Marston

11:30 Barriers to Starting a ProgrammeM. Shackcloth; Liverpool/UK

11:40 Key to a Successful ProgrammeN. Rasburn; Bristol/UK

11:50 State of Play Nationally for Thoracic Surgery

R. Wotton; Birmingham/UK 12:00 A Danish Perspective

R. Petersen; Copenhagen/DK

12:15 DiscussionPanel

Where do we go from here?

Research • Epidural – Paravertebral RfPB funded• Minimally invasive surgery 2nd stage HTA• Rehabilitation 1st stage HTA• Carbohydrate loading in preparation

National Implementation Plan• National Survey • Beacon units • Dissemination • Areas of research• Guidance Document

ConclusionsImproved 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

Thank you for your attention

Any Questions?

Enhanced Recovery Care Pathway: Maternity – Elective caesarean

sectionSue Cottle

National perspective

Sheffield Teaching Hospitals NHS Trust Experience

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

Obstetrics: Elective C - Section

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

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)

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

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

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

Testing the pinciples of ER in Medicine

Torbay Hospital Experience

South Devon Healthcare NHS Foundation Trust

Enhanced Recovery – Application of ER principles in medicine

Professor Ben Benjamin

The Torbay Hospital Experience

South Devon Healthcare NHS Foundation Trust

http://www.sdhct.nhs.uk/patientcare/patientinformation/enhancedrecoveryinmedicine/



Enhanced recovery care pathway: A better journey for patients seven days

a week and better deal for the NHS

www.nhsiq/enhancedrecovery

http://www.nhsiq/enhancedrecovery

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Enhanced recovery care pathways

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