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Enhanced Recovery

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.

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Enhanced Recovery

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  1. Enhanced Recovery Getting Started

  2. Introductions • Housekeeping • Objectives for the session

  3. 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

  4. 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 Overview

  5. Principles, elements and benefits of Enhanced Recovery

  6. 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!!!

  7. 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

  8. Kehlets theory – 1980s

  9. Example of ER elements • Optimising pre operative haemoglobin levels • Managing pre existing co morbidities e.g. diabetes • Optimised Fluid Hydration • Reduced starvation • No / reduced bowel preparation ( bowel surgery) Referral from Primary Care • 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 Pre- Operative Admission • Optimised health / medical condition • Informed decision making • Pre operative health & risk assessment - CPEX • PT information and expectation managed • DX planning (EDD) Intra- Operative • Minimally invasive surgery • Use of transverse incisions • No NG tube (bowel surgery) • Use of LA with sedation • Epidural management (inc thoracic) • Optimised fluid management • Audit & outcome measures Post- Operative • DX on planned day • Therapy support (stoma, physio) • 24hr telephone follow up Follow Up 9

  10. Physical impact

  11. Clinical evidence compelling!

  12. Colorectal Surgery: Length of stayLarge Intestine: Major Procedures

  13. Benefits being realised...

  14. 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

  15. 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

  16. Process & capacity impact

  17. 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

  18. Trusts with varying experience of enhanced recovery pathways 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 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) Scotland NHS Lothian (M)Gold Jubilee National Hospital (M) 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) 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) 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) 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 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 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) 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 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) 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)

  19. Drivers for ImplementationBella Talwar

  20. Implementation Plan • Understanding your current service • Team working • Action planning • Stakeholder analysis • Stakeholder engagement • Testing and making changes to your pathway Understanding the risks • Understanding the investment required • Maintaining momentum • Sustaining the change

  21. 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

  22. Audience: Multi-Disciplinary Teams • 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

  23. Mapping your pathway against the Enhanced Recovery ElementsBellaTalwar

  24. CLINICAL INTERVENTIONS CLINICAL SYSTEM Identify elements in place on enhanced recovery pathway map Process map / Walk the patient journey Track patient journeys Audit of compliance with clinical elements on an individual patient basis OUTCOMES Patient Experience Length of Stay Re-operation rates Readmission rates Complication rates Understanding your current service

  25. Understanding your current service • Admission on day • Optimised Fluid Hydration • CHO Loading • Reduced starvation • No / reduced oral bowel preparation ( bowel surgery) • Optimising pre operative haemoglobin levels • Managing pre existing co morbidities e.g. diabetes Referral from Primary Care • 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 Pre- Operative Admission • 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 Intra- Operative Post- Operative • DX when criteria met • Therapy support (stoma, physio) • 24hr telephone follow up Follow Up

  26. Care Pathway Project Plan

  27. 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

  28. What investment may be required?

  29. What else is ER aligned to?

  30. Understanding and improving systems and processes Patient Pathway

  31. Undertake mapping and tracking

  32. 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

  33. Stakeholder AnalysisJanine Roberts

  34. 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

  35. Essential Roles Sponsors: • authority to sanction change (organisational alignment / benefit) Change Agents: • facilitate change, require knowledge, skills and credibility Champions: • respected opinion leaders who positively promote work Leaders: • lead by example

  36. Stakeholder Analysis Manage Key Stakeholders need to be fully engaged through full communication & consultation • Satisfy • Opinion formers • Keep satisfied • Review regularly High Influence Little / No Influence • Involve • Voices that need to be heard • Need to be proactive Inform / Monitor Not crucial to the process but useful to keep informed Little / No Interest High interest

  37. 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

  38. Action planning and potential challengesSophia Mavrommatis

  39. Action Planning Take time to deliberate; but when the time for action arrives, stop thinking and go in’ -Andrew Jackson quoting Napoleon Bonapart

  40. Managing Improvement low Test on a very small scale Agreement amongst the key players Just do it JDI high high low Certainty that the change will work

  41. Just Do it! • Little risk • Minimal cost • Broad agreement • Easy to do

  42. Testing Changes for ImprovementSophia Mavrommatis

  43. Enhanced Recovery Action Plan

  44. 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.

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