Post on 24-May-2015
description
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%
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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
• Informed decision making
1. Pulmonary Rehabilitation
2. Smoking Cessation
3. Patient self-management and education
4. Nutritional Intervention
Referral
• Managing pre-existing medical conditions
• Informed decision making
Referral
• Managing pre-existing medical conditions
• Informed decision making
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
• Health & risk assessment
• Good quality patient information
• Shared decision making
• Managed expectations
• Discharge planning
• Pre-operative assessment clinic
• Maximising hydration
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
• Minimally invasive surgery
• Pain minimising surgical approach
• Avoidance of fluid overload
• Use of regional anaesthetic
• Hypothermia prevention
• 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
• IV fluids stopped early
• 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• Active, planned
mobilisation• Early oral
hydration & nourishment
• Drain management protocol
• IV fluids stopped early
• Routine catheters avoided or removed early
• Regular & breakthrough multi-modal oral analgesia
• Minimise use of systemic opiate-based analgesia
Post-operative prescription bundlePost-operative
• Active, planned mobilisation
• Early oral hydration & nourishment
• Drain management protocol
• IV fluids stopped early
• Routine catheters avoided or removed early
• Regular & breakthrough multi-modal oral analgesia
• Minimise use of systemic opiate-based analgesia
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
Post-operative• Active, planned
mobilisation• Early oral
hydration & nourishment
• Drain management protocol
• IV fluids stopped early
• Routine catheters avoided or removed early
• Regular & breakthrough multi-modal oral analgesia
• Minimise use of systemic opiate-based analgesia
Follow up• Discharge criteria
– Nurses/physiotherapist
• Telephone follow up
• Drain clinic – Weekly nurse led clinic– Facilitates earlier discharge
Follow up
• Discharge when criteria met
• Telephone follow up
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
• Good quality patient information
• POAC
• DOSA
• Minimally invasive surgery
• Avoid fluid overload
• Digital drains
• Standardised analgesia guideline
• Early physiotherapy
• Early oral fluids and nutrition
• Drain clinic
Referral
• Managing pre-existing medical conditions
• Informed decision making
• Pulmonary rehabilitation
Pre-operative
• Health & risk assessment
• Good quality patient information
• Shared decision making
• Managed expectations
• Discharge planning
• Pre-operative assessment clinic
• Maximising hydration
Admission
• Admit on day of surgery
• Optimise fluid hydration
• Reduced starvation
• Avoidance of sedative medication
Intra-operative
• Minimally invasive surgery
• Pain minimising surgical approach
• Avoidance of fluid overload
• Use of regional anaesthetic
• Hypothermia prevention
• VTE prophylaxis
Post-operative• Active,
planned mobilisation
• Early oral hydration & nourishment
• Drain management protocol
• IV fluids stopped early
• Routine catheters avoided or removed early
• Regular & breakthrough multi-modal oral analgesia
• Minimise use of systemic opiate-based analgesia
Follow up
• Discharge when criteria met
• Telephone follow up
• 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
To what extent is your organisation delivering Enhanced Recovery Care Pathways to ensure consistent standards of care delivery seven days a week?