Enhanced Recovery in medicine
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Transcript of Enhanced Recovery in medicine
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Enhanced recovery in medicine
Ben BenjaminTorbay Hospital
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Why are you in hospital?
patient doctor nurse notes
20% agreed on reason!
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Hypothesis
If patients are given more information about the expected process of recovery and involved in the decision-making process they will recover more quickly, feel safer, be more satisfied with the care they receive and go home earlier.
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Enhanced recovery elements identified
Referral fromPrimary Care
Pre-Operative
Admission
Intra-Operative
Post-Operative Follow
Up
• optimise health / medical condition
• informed decision making• pre-operative health &
risk assessment• patient information and
expectation managed• discharge planning (EDD)• pre-operative therapy
instruction as appropriate
• minimally invasive surgery• use of transverse incisions
(abdominal)• no NG tube (bowel surgery)• regional / LA with sedation• epidural management (inc
thoracic)• optimise 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• avoid systemic opiate-
based analgesia where possible or administered topically
• admit on day of surgery• optimised fluid
hydration• CHO Loading• reduced starvation• no / reduced oral bowel
preparation ( bowel surgery)
• discharge when criteria met• therapy support (stoma, physio)• 24hr telephone follow up
• optimise pre operative haemoglobin levels
• manage pre existing co morbidities e.g. diabetes
Getting you home; swiftly and safelyGetting you home; swiftly and safely
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What can we learn from enhanced recovery in surgery?
• Unable to influence pre-hospital state• Can give appropriate fluids, nutrition, exercise • Can involve patients in process of recovery
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What is the relevance to medicine?
• acute illness is ‘stress’ just like an operation
• simple adherence to fluid, nutrition & mobilisation plus information are key and could be applied to all inpatients?
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Daily target setting
Mobilisation
Oral fluids
Energy drinkDay clothes,
no PJs
Decision-making between the patient,
medical team and families/carers
Plan transport early
Getting you home; safely and at the right time
Getting you home; safely and at the right time
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Pre-hospital
• Information from GPs, Ambulance crew, carers• Patient’s clothes in bag
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Mobilisation
• Get dressed! (no flappy gowns)• Avoid catheters (consider leg bag)• Is a monitor really necessary?• Is a drip really needed?• Drip-free mornings
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Clothes
• Bring in own clothes• Supply of outdoor clothes (?laundry)
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Fluids
Drip-free mornings
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Energy drinks
• 10 am drinks round – now ER round• Energy drink station for ambulant patients
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Involvement of patients and carers
• Encourage carers and relatives to be involved (problems with visiting times)
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Communication
• Posters• Video• ER motivation sessions – nurses/therapists• Talks to carers
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Insert Pt leaflet
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BenefitsTo improve patient and
carer experience.
To reduce readmission
rates.
To reduce length of
stay.
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Measurement
• Patient experience interviews.• LoS data.• Survival rates.• Beddays used by patients on ER• Readmission rates.
Run charts – • getting dressed by 10am• Drip-free mornings• Number of energy drinks consumed
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Next steps
• Testing the process, approach and methodology continues for patients admitted on MAU.
• Rolling out to other medical wards.• Involving patients and carers in the redesign
plans.• Involving academic partners to help us measure
effect – new PhD student with Exeter Business School!
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Summary
In Torbay hospital we are testing the hypothesis that patient involvement in the recovery process from acute medical illness will result in more rapid recovery, earlier discharge and greater patient satisfaction.
We have developed a multidisciplinary approach, based on enhanced recovery principles, which encourages patients to achieve the goals necessary to get home more quickly and safely
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• Look at video – Torbay Hospital
Thanks to Managers: Jane Dewar, Debbie Honeywill, Andrew FordyceNurses: Erica Dunn, Nicki Joyce, Sue BramwellCarer lead: Stephen BlackOT: Becky Brixton