DFOB ENHANCED RECOVERY - Cork University Hospital · Enhanced recovery ‘Enhanced Recovery After...
Transcript of DFOB ENHANCED RECOVERY - Cork University Hospital · Enhanced recovery ‘Enhanced Recovery After...
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ENHANCED
RECOVERY
DFOB
A Standard of care….
RECOVERY
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One of the first comprehensive reviews
2005
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Definition
Components
My experience
Review of the literature
ExamplesExamples
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ERAS groupERAS group
Consensus on the ‘elements’
Summary of core protocol elements
Beginnings of ‘Translational Research
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Definition
Enhanced recovery
‘Enhanced Recovery After Surgery
(ERAS) pathways areFrom expertise silos to patient-
centric outcomes(ERAS) pathways are
multidisciplinary, coordinated,
standardized care plans that
integrate evidence-based
interventions addressing multiple
aspects and phases of the patient’s
perioperative trajectory.’
centric outcomes
Functional recovery both physical
and psychological versus clinical
outcomes
Adherence to pathways and
compliance
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Definition
IHI
Care bundle is
‘a small set of interventions, when ‘a small set of interventions, when
implemented together for a defined
care setting, result in better
outcomes than when implemented
individually’
Resar 2012
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Elements
Defined population
Customization
Multidisciplinary
Compliance
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Definition
Expanded ( Feldman
2015)Based on specifics and outcomes
AVLOS
GI function
Pain and MobilizationBased on specifics and outcomes
‘Postoperative recovery is defined as a multidimensional
construct that follows a particular trajectory.’
Physical
Physiological
Psychological
Social
Economical
Pain and Mobilization
Less than half post discharge functional
measures
¼ measures of HRQOL
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Preoperative assessment
Risk factor identification,
modulation ,
(both long and short term)
Fasting
Fluids
Food
Information ( Patient , Peri-
operative team )
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Anaesthesia
Pain
PONV
Intra-operative management
Communal attention to a common goal
Post-operative Management
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Pharmacology
• Opiates
• PONVPONV
• Thrombophylaxis ( HATS )
• Anti-microbial Prophylaxis
( +/-)
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Regional Anaesthesia
• Stress response
• Functional recovery
Physiologic/Psychological
Stress response
•NeuroendocrinePhysiologic/Psychological
• Mobilisation
• Respiratory Function
•Neuroendocrine
•Catabolic phase
•Sepsis
•GI funciton
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Anaesthesia
Pain
PONV
Intra-operative management
Post-operative Management
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Fluid management
• Goal Directed fluid Therapy (Like the porridge) , just right
• Too much is bad• Too much is bad
• Hypotension and low UOP common but may not predict outcome
• Consider surgery and patient as combined risk
• Vasopressors ?
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Fluid management
Outcome measurement
AVLOS
Functional recovery
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Intra-operative Surgical factors
Minimally invasive*******
Incisions
Avoid hypothermia
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Postoperative NG tubes and catheters
Mobilisation
Discharge planning
Contact informaiton
Preoperative counsellingPreoperative counselling
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Consensus 5 P’s
•Primary care ‘fitness for referral’ for
common conditions e.g. anaemia –
managing the risk
• Patient involvement: shared decision • Patient involvement: shared decision making , information
• Pre-habilitation, assessment and care , planning
• Pain relief, fluid management,
Anaesthetics
• Preparation for and effective discharge.
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AVLOS
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Patient Experience
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Whistlestop
Elements
Defined population
CustomizationCustomization
Multidisciplinary
Compliance
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Literature
Evidence assessmentEvidence assessment
Hypothermia
TEDS
Pneumatic compression
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LiteratureBased upon the unit’s own experience
Components collated from other disciplines
Time to develop the programme
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Programme development3 years
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Whistlestop
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DFOB
Thank You
‘Well being and resilience – civility and work climate’