Enhanced Recovery Getting Started. Introductions Housekeeping Objectives for the session.
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Transcript of Enhanced Recovery Getting Started. Introductions Housekeeping Objectives for the session.
Enhanced Recovery
Getting Started
Introductions
Housekeeping
Objectives for the session
This Session
• Practical activities to get you started
• Based on the Implementation Guide
• Access to advice, guidance and support
• Discuss the key elements of your local implementation plan
Overview
This Session:
Principles, elements and benefits of ERP
Drivers for Implementation
Current and future pathway
Action Planning:
Stakeholder Analysis
Testing changes for improvement
Measuring Outcomes
Principles, elements and benefits of Enhanced
Recovery
What is it? Enhanced Recovery is a new way of improving the
experience and well-being of patients who need major surgery
It helps people to recover sooner so that life can return to normal as quickly as possible
It gives people a better overall experience due to higher quality care and services
It lets people choose what’s best for them throughout the course of their treatment with help from their GP and the wider healthcare team (“No decision about me without me.”)
Many people who have experienced Enhanced Recovery say that it makes a hospital stay much less stressful
Your Better Sooner!!!
The Principles of ER
Getting the patient in to the best possible condition for surgery
Ensuring the patient has the best possible management during their operation
Ensuring the patient has the best post-operative rehabilitation
Kehlets theory – 1980s
9
Referral fromPrimary Care
Pre-Operative
Admission
Intra-Operative
Post-Operative
FollowUp
• Optimised health / medical condition
• Informed decision making• Pre operative health & risk
assessment - CPEX• PT information and
expectation managed• DX planning (EDD)
• Minimally invasive surgery
• Use of transverse incisions
• No NG tube (bowel surgery)
• Use of LA with sedation• Epidural management (inc thoracic)
• Optimised fluid management
• Planned mobilisation• Rapid hydration & nourishment
• Appropriate IV therapy• No wound drains• No NG (bowel surgery)• Catheters removed early• Regular oral analgesia• Paracetamol and NSAIDS
• Avoidance of opiate-based analgesia where possible or administered topically
• Optimised Fluid Hydration
• Reduced starvation• No / reduced bowel
preparation ( bowel surgery)
• DX on planned day• Therapy support (stoma, physio)
• 24hr telephone follow up
• Optimising pre operative haemoglobin levels
• Managing pre existing co morbidities e.g. diabetes
• Audit & outcome measures
Example of ER elements
Physical impact
Clinical evidence compelling!
Colorectal Surgery: Length of stayLarge Intestine: Major Procedures
0
2
4
6
8
10
12
14
16
UK Kehlet
Benefits being realised...
Multi-Disciplinary Teams? It give patients a better overall experience through higher
quality care and services
It introduces innovative best practices that empower and motivate staff
It accelerates the clinical decision-making process by empowering MDTs
It doesn’t increase MDT workload
It ensures the most-efficient use of healthcare resources
Best-practice is day surgery or an Enhanced Recovery pathway
What does it mean for providers?
It improves patient safety and involvement and meets Care Quality Commission requirements
It reduces demand on resources such as critical care, surgical beds and patient uptake of procedures
It increases job satisfaction of Multi-disciplinary Teams through better ways of working and improved patient outcomes
It improves the reputation of the healthcare provider
Best-practice is day surgery or an Enhanced Recovery pathway
Process & capacity impact
Commissioners? It enhances the reputation of the healthcare provider
It helps patients recover sooner from surgery
Best-practice is day surgery or an Enhanced Recovery pathway
It improves patient experiences through increased partnership and empowerment (“No decision about me without me.”)
It motivates medical teams through best practice, empowerment and innovation
It reduces demand on resources such as critical care, surgical beds and patient uptake of procedures
Trusts with varying experience of enhanced recovery pathways
North East
Gateshead NHS Foundation Trust (M)Newcastle Hospitals NHS Trust (C)City Hospitals Sunderland NHS Foundation Trust (U)
Northumbira NHS Trust (MSK)
South Tees Hospitals NHS Foundation Trust (C,G,U)
North West
Aintree University Hospitals NHS Foundation Trust (M)East Lancashire Hospitals NHS Trust (C)Hope Hospital, Salford (C)Wirral University Teaching Hospital NHS Foundation Trust (C)(M)
Aintree University Hospitals NHS Foundation Trust (C,M,UPGI,Li)
Yorkshire & The Humber
Sheffield Teaching Hospitals NHS Foundation Trust (G)York Hospitals NHS Foundation Trust (C)Scarborough Healthcare NHS Trust (C)
Leeds Teaching Hospitals NHS Trust (C,G)Calderdale and Huddersfield NHS Foundation Trust (C,G)
West Midlands
City Hospital NHS Trust, Birmingham (C)Good Hope Hospital (C)University Hospitals Birmingham NHS Foundation Trust (C) Birmingham Heartlands NHS Trust
(C)University Hospital of North Staffordshire NHS Trust (C,U,G)
Robert Jones & Agnes Hunt NHS Trust
East Midlands
Derby Hospitals NHS Foundation Trust (G)Queen’s Medical Centre (C)Sherwood Forest Hospitals NHS Foundation Trust (C) (G)
The University Hospitals of Leicester NHS Trust (C,M,G,U)
East of England
Colchester Hospital University NHS Foundation Trust (C)West Suffolk Hospital NHS Trust (M)Cambridge University Hospitals NHS Foundation Trust (Addenbrookes Hospital)(G)
West Hertfordshire Hospitals NHS Trust (C,M,G,U)
South East Coast
Brighton and Sussex University Hospital NHS Trust (C)Darent Valley Hospital (Dartford and Gravesham NHS Trust) (M)Royal Surrey County Hospital NHS Trust (C)Worthing Hospital (C)East Kent Hospitals University NHS Foundation Trust (Queen Elizabeth, the Queen Mother Hospitals)(G)Medway NHS Foundation Trust(C)Medway NHS Foundation Trust (C,M,G,U)Brighton and Sussex University Hospitals (C,M,G,U)
London
Barnet & Chase Farm Hospitals NHS Trust (C)Guy’s & St Thomas’ NHS Foundation Trust (C)Hillingdon Hospital NHS Trust (M)Imperial College Healthcare NHS Trust (C)South West London Elective Orthopaedic Centre (M)St George’s Healthcare NHS Trust (C)(U)St Mark’s Hospital (North West London Hospitals NHS Trust) (C)The Whittington NHS Trust (C) (M)UCLH NHS Foundation Trust (C)Whipps Cross University Hospital NHS Trust (C)
The Hillingdon Hospital NHS Trust (C,G)North Middlesex University Hospital NHS Trust (C,M,G)
South West
North Devon Healthcare NHS Trust (C)South Devon Healthcare NHS Foundation Trust (C)(M)(G)Royal Devon and Exeter NHS Foundation Trust (U)Royal Bournemouth Hospital (M)North Bristol NHS Trust (Southmead Hospital)(U)Yeovil District Hospital NHS Foundation Trust (C)(M)Salisbury NHS Foundation Trust (C)Dorset County Hospital NHS Foundation Trust (C)Plymouth Hospitals NHS Trust (C)West Dorset NHS Trust (C)
South Devon Healthcare NHS Foundation Trust (Torbay Hospital) (C,M,G,U)South Central
Isle of Wight Healthcare NHS Trust (C)Milton Keynes Hospital NHS Foundation Trust (C)Royal Berkshire NHS Foundation Trust (C)Portsmouth Hospitals NHS Trust (C)Southampton University Hospitals NHS Trust (C)Oxford Ratcliffe(C)NHHT M)Winchester & Eastleigh NHS Trust (C,M,G)Royal Berkshire NHS Foundation Trust (C,M,G,U)
Legend
The following denotes a trust is working in this specialty:
(M) Musculoskeletal
(C) Colorectal
(U) Urology
(G) Gynaecology
Enhanced Recovery Innovation Sites are shown in red
Scotland
NHS Lothian (M)Gold Jubilee National Hospital (M)
Drivers for Implementation
Bella Talwar
Implementation Plan
1. Understanding your current service2. Team working3. Action planning4. Stakeholder analysis5. Stakeholder engagement6. Testing and making changes to your
pathway Understanding the risks7. Understanding the investment required8. Maintaining momentum9. Sustaining the change
Audience: Patients
Enhanced Recovery is a new way of improving the experience and well-being of patients who need major surgery.
• It helps people to recover sooner so that life can return to normal as quickly as possible
• It gives people a better overall experience due to higher quality care and services
• It lets people choose what’s best for them throughout the course of their treatment with help from their GP and the wider healthcare team (“No decision about me without me.”)
• Many people who have experienced Enhanced Recovery say that it makes a hospital stay much less stressful
Enhanced Recovery is a new, evidence-based pathway that creates fitter, patients who recover faster from major surgery
• It give patients a better overall experience through higher quality care and services
• It introduces innovative best practices that empower and motivate staff
• It accelerates the clinical decision-making process by empowering MDTs • It doesn’t increase MDT workload
• It ensures the most-efficient use of healthcare resources
• Best-practice is day surgery or an Enhanced Recovery pathway
Audience: Multi-Disciplinary Teams
Mapping your pathway against the Enhanced
Recovery Elements
BellaTalwar
Understanding your current service
Identify elements in place on enhanced recovery pathway map
Audit of compliance with clinical elements on an individual patient basis
Process map / Walk the patient journey
Track patient journeys
Patient ExperienceLength of Stay
Re-operation ratesReadmission ratesComplication rates
CLINICAL INTERVENTIONS CLINICAL SYSTEM
OUTCOMES
Understanding your current
serviceReferral
fromPrimary
Care Pre-Operative
Admissio
n
Intra-Operative
Post-Operative
FollowUp
•Optimised health / medical condition
•Informed decision making
•Pre operative health & risk assessment
•PT information and expectation managed
•DX planning (EDD)•Pre-operative therapy instruction as appropriate
•Minimally invasive surgery•Use of transverse incisions (abdominal)
•No NG tube (bowel surgery)
•Use of regional / LA with sedation
•Epidural management (inc thoracic)
•Optimised fluid management Individualised goal directed fluid therapy
•Planned mobilisation•Rapid hydration & nourishment
•Appropriate IV therapy
•No wound drains•No NG (bowel surgery)
•Catheters removed early
•Regular oral analgesia•Paracetamol and NSAIDS
•Avoidance of systemic opiate-based analgesia where possible or administered topically
•Admission on day•Optimised Fluid Hydration
•CHO Loading•Reduced starvation•No / reduced oral bowel preparation ( bowel surgery)
•DX when criteria met
•Therapy support (stoma, physio)
•24hr telephone follow up
•Optimising pre operative haemoglobin levels
•Managing pre existing co morbidities e.g. diabetes
Care Pathway Project Plan
Short-term investment
Support to change the pathway (e.g. service improvement, change manager, facilitator etc)
Training – new skills e.g. pre-assessment
Equipment – invest to save
Communication/awareness
Find out what is already in place & going on Make the connections
What investment may be required?
Financial
Training
CommunicationSystematic
improvement Approach
Team-working
Change management
Skills
LeadershipEngagement & accountability
TimeFocus
Commitment
Enhanced Recovery
Finance is not the only
investment
What else is ER aligned to?
TCAB
Top Tips
Actual Bed Time
Nurse Dispensing
Protocol LedDischarge
Ticket Home
Discharge Lounge
Productive Wards
Pre – 11 am Discharge
ERP
Understanding and improving systems and processes
Patient Pathway
Undertake mapping and tracking
Understanding your current service - Exercise On the map provided: Understanding your
current service - Exercise
Mark the interventions you already have in place You should also consider when, where and how they
are provided and whether there is further opportunity for improvement
Identify the interventions you need to establish and start to consider the sequence for implementation
Stakeholder AnalysisJanine Roberts
Identifying the team
Implementation requires a number of factors: Changing clinical interventions Changing care systems and processes Creating a team to work across the patient
pathway Both require technical and behavioural change
management Lets start with thinking about who to engage and
how to structure the project team
Essential Roles
Sponsors:• authority to sanction change
(organisational alignment / benefit)Change Agents:• facilitate change, require knowledge, skills
and credibilityChampions:• respected opinion leaders who positively
promote workLeaders:• lead by example
Satisfy
•Opinion formers
•Keep satisfied
•Review regularly
Manage
Key Stakeholders need to be fully engaged through full communication & consultation
Inform / Monitor
Not crucial to the process but useful to keep informed
Involve
•Voices that need to be heard
•Need to be proactive
High Influenc
e
Little / No
Influence
Little / No Interest
High interest
Stakeholder Analysis
Stakeholder Engagement
Full guide to stakeholder analysis and management:
NHS Institute for Innovation and Improvement‘The Handbook of Quality and Service
improvement Tools’ Section 3 Stakeholder and User Involvement
Action planning and potential challenges
Sophia Mavrommatis
Action Planning
Take time to deliberate; but when the time for action arrives, stop thinking
and go in’
-Andrew Jackson quoting Napoleon Bonapart
Agreementamongst thekey players
Certaintythat the changewill work
Justdo itJDI
high
low
low
high
Test ona very small scale
Managing Improvement
Just Do it!
Little risk Minimal cost Broad agreement Easy to do
Testing Changes for Improvement
Sophia Mavrommatis
Enhanced Recovery Action PlanAction Owner Resources 30 60 90
Action Planning & Challenges On your table provided start to fill in from the earlier
work today which actions need to be completed
Who can deliver these actions
What is the timescale – 30, 60 or 90 days
Resourse – flag up what support you may need here to deliver the action – eg connection into the local PCT, facilitator to deliver a workshop
Include in this the top three challenges that you think
you will encounter and the actions you will put in place to work through these challenges.
Measuring OutcomesBella Talwar
Outcomes
Patient / staff
Clinical - elements of the pathway
Financial
Understanding Your Current Service
Identify elements in place on enhanced recovery pathway map
Audit of compliance with clinical elements on an individual patient
basis
Process map / Walk the patient journey
Track patient journeys
Patient ExperienceLength of Stay
Re-operation ratesReadmission ratesComplication rates
CLINICAL INTERVENTIONS CLINICAL SYSTEM
OUTCOMES
55
Referral fromPrimary Care
Pre-Operative
Admission
Intra-Operative
Post-Operative
FollowUp
• Optimised health / medical condition
• Informed decision making• Pre operative health & risk
assessment - CPEX• PT information and
expectation managed• DX planning (EDD)
• Minimally invasive surgery
• Use of transverse incisions
• No NG tube (bowel surgery)
• Use of LA with sedation• Epidural management (inc thoracic)
• Optimised fluid management
• Planned mobilisation• Rapid hydration & nourishment
• Appropriate IV therapy• No wound drains• No NG (bowel surgery)• Catheters removed early• Regular oral analgesia• Paracetamol and NSAIDS
• Avoidance of opiate-based analgesia where possible or administered topically
• Optimised Fluid Hydration
• Reduced starvation• No / reduced bowel
preparation ( bowel surgery)
• DX on planned day• Therapy support (stoma, physio)
• 24hr telephone follow up
• Optimising pre operative haemoglobin levels
• Managing pre existing co morbidities e.g. diabetes
• Audit & outcome measures
Making your baseline assessment
Enhanced Recovery Pathway‘Implementation & Sustainability’
Median LOS for Prostectomy
-2
0
2
4
6
8
Apr-0
9
Jun-
09
Aug-
09
Oct
-09
Dec-
09
Feb-
10
Apr-1
0
Jun-
10
Aug-
10
Oct
-10
Dec-
10
Feb-
11
Apr-1
1
Jun-
11
Median LOS for Abdominal Hysterectomy
2
3
4
5
6
7
8
Apr-0
9
Jun-
09
Aug-
09
Oct
-09
Dec
-09
Feb-
10
Apr-1
0
Jun-
10
Aug-
10
Oct
-10
Dec
-10
Feb-
11
Apr-1
1
Jun-
11
Median LOS for Primary Hip Replacement
3456789
10
Apr-0
9
Jun-
09
Aug-
09
Oct
-09
Dec-
09
Feb-
10
Apr-1
0
Jun-
10
Aug-
10
Oct
-10
Dec-
10
Feb-
11
Apr-1
1
Jun-
11
Median LOS for Colectomy
0
5
10
15
20
Apr-0
9
Jun-
09
Aug-
09
Oct
-09
Dec-
09
Feb-
10
Apr-1
0
Jun-
10
Aug-
10
Oct
-10
Dec-
10
Feb-
11
Apr-1
1
Jun-
11
ERP implementedRobotic Surgery
ERP implemented
CQUINS
Ann’s story to the Deputy Prime Minister
“ I had two hip replacements last year. One in June
and one in December.
The second one was much better,
the service is fabulous!”
Benefits RealisationJanine Roberts
Benefits Realisation
Next StepsJanine Roberts
Next steps
Making it happen?
• What ongoing support can we provide?• Implementation plan• Follow-up session
Next Steps
What will be your first change you will test or implement?
• Remember the importance of a quick win as well as a plan for sustainability
Next Steps
Advice guidance and support – to change
Implementation guide Enhanced Recovery Toolkit SHA support Local Network events UCLH Implementation team E-learning / DVD / Top Tips http://insight/departments/Projects/QEP/Pages/
home.aspx www.improvement.nhs.uk