Enhanced Recovery Programme: Optimizing Surgical Outcomes

1. Enhanced Recovery ProgrammeHelping patients to get better soonerafter surgeryBADS – Portsmouth 18th June 2010Mike SwartClinical Advisor AnaesthesiaEnhanced Recovery Programme

2. The Real Torquay Devon

3. Colorectal Surgery: Length of stayLarge Intestine: Major Procedures days

4. Colorectal procedures

5. Colorectal procedures

6. Primary hip replacement

7. Primary knee replacement

8. ER Programme’s aim ‘And to do this in 2 years not 20!’ Professor Sir Mike Richards, SRO To improve the quality of patients care, through improving their clinical outcomes and experience, and reduce the length of elective care inpatient pathways across the NHS by utilising the good practice principles of enhanced recovery models of care. 8

9. Benefits Early detection of complications Decrease in HAI Patient safety Improved quality of care Empowered patients Harmonisation of care across NHS Knowledge of outcomes Team building Local education Improved focus on use of technology Closer working partnerships (primary care and acute) Improved reputation of Trust International profile of care

10. Example of enhanced recovery elements Referral from Primary Care Pre- Operative Admission Intra- Operative Post- Operative Follow Up 10

11. Example of enhanced recovery elements • Optimising pre operative health state e.g. Hb levels • Managing co morbidities e.g. diabetes • Fit for surgery Referral from Primary Care Pre- Operative Admission Intra- Operative Post- Operative Follow Up 11

12. Example of enhanced recovery elements • Optimised health / medical condition • Informed decision making with companion • Pre operative health & risk assessment e.g. (CPEX) Referral from Primary Care Pre- Operative Admission Intra- Operative • PT information and expectation managed • DX planning (EDD) • No / reduced oral bowel prep (bowel surgery) • Pre-operative therapy instruction where appropriate Post- Operative Follow Up 12

13. Example of enhanced recovery elements • Optimise fluid hydration • Optimise Nutrition • No / reduced oral bowel preparation (where appropriate) Referral from Primary Care Pre- Operative Admission Intra- Operative • Admission on the day of surgery • Carbohydrate loading • No pre med (sedative) Post- Operative Follow Up 13

14. Example of enhanced recovery elements • Minimally invasive surgery where appropriate • Use of transverse incisions (abdominal) if appropriate Referral from Primary Care Pre- Operative Admission Intra- Operative • Use of regional anaesthesia • LA with sedation • Individualised goal directed fluid management Post- Operative Follow Up 14

15. Example of enhanced recovery elements • Planned mobilisation (24hrs post op) • Rapid hydration & nourishment • Appropriate IV therapy • No wound drains • No nasogastric tubes (bowel surgery) Referral from Primary Care Pre- Operative Admission Intra- Operative • Catheters removed early • Regular oral analgesia • Paracetamol and NSAIDS • Avoidance of systemic opiate-based analgesia where possible or administered topically Post- Operative Follow Up 15

16. Example of enhanced recovery elements • DX when criteria met • Therapy input (e.g. stoma / physio / dietician) • 24 hour follow up call Referral from Primary Care Pre- Operative Admission Intra- Operative • Audit & monitor outcomes • Feedback Post- Operative Follow Up 16

17. Example of enhanced recovery elements • Optimising pre operative haemoglobin levels • Managing pre existing co morbidities e.g. diabetes • Admission on day • Optimised Fluid Hydration • CHO Loading • Reduced starvation • No / reduced oral 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 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 Intra- Operative • 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 Post- Operative • DX when criteria met • Therapy support (stoma, physio) • 24hr telephone follow up Follow Up 17

18. Enhanced Recovery Team Nurse specialists Physiotherapy Occupational therapy Social workers Anaesthesia Pain management Pre-assessment Nutrition Team assistant Ward nursing staff Medical staff Management Primary Care Patients

19. Colorectal Surgery: Length of stay (median) days

20. Colorectal Surgery: Length of stay (median) days

21. Readmission rates after a planned hospital stay of 2 versus 3 days after fast-track colonic surgery. Kehlet et al. Br J Surg 2007 Readmission rate % ? Day of discharge

22. Key Milestones 2009 2010 Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Establish steering board Develop messaging – Logo/ tag line 2/6 - ERPP event – confirming benefits & core principles Complete baseline questionnaire 21/7 – ERPP Event – Confirming what support looks like Phase 1 & 2 - Establishing Programme & Scope/ Collecting the Evidence 23/9 – ERIS Programme 27/10 – ERIS Programme 17/12 – ERIS Programme 21/9 – Develop Programme of Support Phase 3 – Raising Awareness Complete ‘How to’ Guide 4/2 – ERIS Programme SHA workshops SHA workshops Phase 4 – Adoption & Spread Evaluation of ERPP

23. Implementation guide

24. Case studies and research articles

25. 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) 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)Winchester & Eastleigh NHS Trust (C,M,G)Royal Berkshire NHS Foundation Trust (C,M,G,U)