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

• Enhanced recovery: A patient centred approach

Neil Betteridge, ER Patient and Public advisor

• 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

ER is becoming the norm

Progress and level of ambition• Quality is the driving

principle• Key components – 5 P’s• Good progress made• Extend principles of ER

beyond elective practice• Integrate ER across the

whole system

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

“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”.

ER is becoming the norm

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

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

Progress: ER increases day of surgery admission

Increasing day of surgery admissions

No change in readmissions

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

Summary and 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

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Enhanced recovery: a patient centred approach

Neil Betteridge

Patient and public advisor

Enhanced Recovery

A better journey for patients…

ER promotes a changing role for patients

• From: ‘You’re sick, or damaged, stay still and we’ll fix you’

• To: ‘We’re going to work together and you need to play an active role in your recovery

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

Designed by patients for patients

• Over 1000 leaflets distributed across England

• Positive evaluation from patients and carers and professionals across England

My role and my responsibilities

Key messages: the patient deal

• Prepare: eat well, sort practicalities and think about post-op sooner not later

• Clarify what you can do during admission to get moving sooner – and be sure you know who to ask if unsure

• Recovery doesn’t end on discharge: set daily goals and stay in touch

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

Getting there

• ‘If you’re not sure where you are going, you’re liable to end up somewhere else’ - Robert F. Mager

• ‘One important key to success is self-confidence. An important key to self-confidence is preparation’ - Arthur Ashe

…thank you for your attention

Enhanced Recovery Care Pathway: Thoracic Surgery

Amy Kerr

Research nurse

Heart of England Foundation Trust

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

Summary• Enhanced recovery successfully introduced for elective caesarean

section• 15 - 20% of patients leave on day one

– Previously around 1%• No increase in readmission rates• No evidence of problems in the community

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

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

a week and better deal for the NHS

www.nhsiq/enhancedrecovery