Enhanced Recovery Programme

Bolarinde Ola FRCOGConsultant Gynaecologist

What is ERP

A new 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

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.

During Consenting for Surgery• 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

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

Those Not Eligible for 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

Pre-operative care by the 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

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

Reducing the physical stress 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

Effects of Starvation

• Increased glucagon• Increased cortisol• Catabolism• Increased Insulin Resistance• Gluconeogenesis• Hyperglycaemia

Effects of Surgery

These are exacerbated by starvation• Inflammatory response • Increased cortisol / cytokines• Catabolism / gluconeogenesis• Insulin resistance• Hyperglycaemia

Sum Effects of Starvation and Surgery

Plan of Carbohydrate DrinksDate 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

Overseas Example of Non-Gas Carbohydrate Drink

Local Non-Gas Alternatives:

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

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

Early nutrition

Aim is to 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

Examples of High Protein Drink

Local High Protein Drinks

Early discharge

• Healthcare professional 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

Early Discharge Targets for ERPProcedure DaysTotal 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 daysLaparoscopic Assisted / Or Vaginal Hyst. 1 daysOther Laparoscopic Surgery 1Anterior and / or posterior repair 1 dayHysteroscopic Surgery 0 day

Benefits to the Hospital

• 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

Conclusions

• Enhanced recovery enables 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