Enhanced Recovery Partnership Programme Programme

Transcription

1 Enhanced Recovery Partnership Programme

2 Overview What is Enhanced Recovery Getting started Project Planning Audit & review What has been achieved at WHHT so far Next steps Questions

3 What is Enhanced Recovery? A new approach to the preoperative, interoperative and postoperative care of patients under going surgery Evidence based approach involving a selected number of individual interventions which when implemented as a group demonstrate a greater impact on outcomes. They are designed to prepare patients for, and reduce the total impact of, surgery, helping them to recover more quickly.

4 Benefits of Enhanced Recovery Empowers patients to be a partner in their own care Improves the patient t experience Improves Quality Clinical outcomes Early detection of complications Quality standards met QUIPP initiative Improves Productivity Reduced length of stay Increased capacity Encourages inter-professional team working Cross organisational working Opportunity for service redesign

5 Getting started Stakeholder analysis and engagement Team working Project Planning Audit and review Sustainability

6 WHHT Projects Colorectal l Surgery Hip & Knee Surgery Major gynaecology surgery Osephagectomy & Gastrectomy Spinal surgery Obstetric Gynaecology Oncology

7 WHHT Stakeholders Clinicians Anaethetists Nurses POA staff Enhanced Recovery Nurse Theatre staff Porters Radiology/Pathology AHPs Social Services Managers Admin staff Patient GPs District Nurses PCT/SHA

8 Stakeholder Engagement Clear project plans SMART objectives People have to want to be involved Peer pressure Managing change Marketing

9 Enhanced Recovery Structure at WHHT Trust Board Delivery Support Group Enhanced Recovery Partnership Programme Board Colorectal Project Group Gynaecology Project Group Orthopaedic Project Group Upper GI Project Group

10 Project Planning Analysis of current services What needs to be changed to enable Enhanced Recovery to work Risk assessment Understanding investment required Objective setting Audit and review

11 Analysis of current services ER Element Preimplementation Post implementation Pre-operative visit? Patient assessed as fit for surgery Patient given verbal and verbal NO explanation of ER pathway Preoperative stoma education until NO considered competent Oral bowel preparation avoided NO NO Patient admitted on day of surgery NO MOSTLY Carbohydrate drinks given NO preoperatively Avoidance of long acting sedative pre-medication Administration of appropriate antibiotics prior to skin incision Epidural or regional analgesia used Individualised goal directed fluid NO therapy Hyperthermia prevention (intraoperative NO warming) Avoidance of post operative crystalloid overload Avoidance of systemic opiates NO NO used postoperatively Early post operative nutrition / solid food intake Targeted individualised nausea NO and vomiting control Early planned mobilisation within NO 24 hours The avoidance of abdominal drains NO NO except following TME NG Tube removed before exit from theatre NO

12 Project Planning st Hertfordshire Hospitals NHS Trust Service Improvement Programme: Enhanced Recovery Partnership Programme - Colorectal is this Project Needed? What Will it Change? ur aim is to improve the quality of patient care through improving The project objectives are to: linical outcomes and experience, and to reduce the length of stay o Improve the quality of patient care LOS) the elective care inpatient pathway Improved clinical outcomes We are implementing the programme in colorectal for the following Improved patient experience o Reduced lengths of stay rocedures Colectomy, hemicolectomy and anterior resection (Full o Sustainable 18weeks delivery st of procedures in Appendix A) o To review with finance the financial benefits resulting from reduced LOS and We will by utilising the good practice principles of enhanced recovery increased productivity. models of care (please see Implementation Plan). Actions & Deadlines Outcome Measures and Baselines n Deadline mplement patient experience questionnaire for local Sept 10 We will be utilising the Department of Health s (DoH) dedicated database. se o Anticipated to be operational October 2009, and the project brief will be udit outcomes of questionnaire Jan 11 updated further to utlisation of the tool and the establishment of the mplement changes to pathway from questionnaire esults as appropriate Jan 11 associated benefits Improved quality of patient care clinical outcomes, improved ment outcomes of audit programme evelop criteria for bowel prep p usage evelop criteria for systemic opiate usage evelop criteria for admitting patients on day of urgery nue to establish Primary Care engagement in the ct Sept 10 Dec 10 Sept 10 Dec 10 o Readmission rates Reduce current readmission rate by 5% o Infection rates These will be monitored using surveillance from March 2010 onwards with the aim of reducing below the National Average during o Reduced Deep Vein Thrombolysis (DVT) Reduce from current rate of 22% to below the National average during o Improved quality of patient care improved patient experience o Reduction in LOS from 16 days to 10 days for AP etc, from 8 days to 5 days for all other procedures o Development and establishment of service specific questionnaires on the ERP experience Adapt Guys & St Thomas questionnaire for local usage

13 st Hertfordshire Hospitals NHS Trust Service Improvement Programme: Enhanced Recovery Partnership Programme - Colorectal & Constraints edding the clinical model Majority of the clinical team are now comfortable with enhanced recovery, but further work required in ensuring all members of the clinical team are comfortable with the improved ways of working Project Management Arrangements Sponsor: Russell Harrison Clinical Lead: Mr Alla Amin, Mr John Meyrick Thomas Project Manager: Helen Broadwell Managerial Support: Kirsty Green Progress to be Reported to: Colorectal Project Group Frequency of Meetings: Bi monthly Project End Date: March 2011 Project Review: Monthly through the Enhanced Recovery Programme Board cial Implications Project Group Membership ONAL FINANCE DIRECTOR TO MODEL PRODUCTIVITY GAIN RESULTING FROM REDUCED LENGTH OF STAY Mr Amin, Mr John Meyrick Thomas, Mr Hallam, Mr Arbuckle, Jill Stokes, Vivienne Robson, Aruna Navapurkar, Laura Liles, Rachel Colgan, Michelle Ashwell, Karen Bowler, Linda Loader, Rekha Shah, Kirsty Green

14 Audit and review ENHANCED RECOVERY PROGRAMME PROFORMA - ORTHOPAEDICS This form only to be filled out for patients identifed for the enhanced recovery trial Attach patient label Section 1 - To be completed at Pre-Operative Assessment ASA Grade (please select one) I - Normal healthy adult II - Mild systemic disease that does not limit activity III - Severe systemic disease that limits activity but is not incapacitating IV - Incapacitating systemic disease wich is constantly life-threatening V - Moribund, not expected to survive 24 hours with or without surgery History of Insulin Dependent Diabetes Melitus? History of Ischaemic Heart Disease (MI, NSTEMI, Angina)? History of CVA or TIA? History of LVF or CCF? History of CPD? Haemoglobin level less than WHO recommendations? Pre Operative anaemia corrected? Did patient receive blood transfusion? Section 4 - Type of procedure Hip replacement right Hip replacement left Bilateral hip replacement Knee replacement right Knee replacement left Bilateral knee replacement Revision hip replacement Section 5 - To be completed by ward post-operation ti Avoiding postoperative crystalloid overload? Avoidance of systemic opiates used post-operatively? Early post-operative nutrition / solid food? Targeted individualised nausea and vomiting control? Early planned mobilisation within 24 hours? Patient experience Is this patient's experience being measured? Which h method are you using? Questionaire Patient/Carer Diary Revision knee replacement Spine fusion Hip and knee replacement Revision hip and knee replacement Shoulder replacement Revision shouder replacement Patient discussion groups Other (please describe below) Preoperative serum Creatinine (mmol) Preoperative haemoglobin level (g/dl) Patient assessed as fit for surgery? Patient given written and verbal explanation of enhanced recovery pathway? Preoperative therapy education e.g. physio/ot? Section 2 - To be completed at Surgical Admissions Lounge Date and time of admission Preoperative assessment completed? Oral bowel preparation avoided? Patient admitted on day of surgery? Carbohydrate drinks given preoperatively? Avoidance of long acting sedative premedication? Section 3 - To be completed by theatres Date and time of surgery The administration of appropriate antibiotics prior to skin incision? Epidural or regional analgesia used? Individualised goal directed fluid therapy? Hypothermia prevention? (intraoperative warning) NG tube removed before exit from theatre? The aviodance of abdominal drains except following total mesoretal excision? Postoperative morbity score (to be completed one week after operation if not discharged) Are any of the following present 7 days after surgery? Pulmonary Neurological Infectious Wound Renal Hematological requirement GI Pain CVS Patient has died If patient dies in hospital - Date of death No. of days on ITU bed No. of days on HDU bed Date and time of discharge Section 6 - For office use only ICD10 code entered Readmission within 42 days? Reoperation within 42 days? Readmission date Discharge date Type of reoperation (choose from supplied list) Date of death (if after discharge)

15 Patient Experience Enhanced Recovery Partnership Programme Your comments about your care with us Please answer the following questions, by circling the word or number, which most accurately reflects your experience. There is also space at the end of the questionnaire for you to write your own comments and suggestions. Your answers will be treated in confidence so please do not write your name anywhere on this paper. 1 Date you went home? 2 Name of the ward you stayed on? Please score your answers using the scale below: Disagree Strongly Agree Type of Surgery you Colorectal Gynaecology Orthopaedic had? 4 Were you informed about Enhanced Recovery during your outpatient consultation? 10 I was given enough privacy when discussing my treatment? I felt reassured by having an Enhanced Recovery Nurse or Link Nurse overseeing my care? I felt involved in decisions about my discharge from hospital? When you were discharged from hospital were you given written/printed information about what you should or should not do? NO NOT SURE 14 Were you told about what medication side effects to watch out for when you went home? NO NOT SURE 15 Were you told who to contact about your condition after you leave hospital? NO NOT SURE 16 Is there anything that we could do to improve your care further? NO NOT SURE 5 Were you informed about Enhanced Recovery during your pre-operative assessment (POA) appointment? NO NOT SURE 6 The information I was given about Enhanced Recovery was helpful and appropriate? I was as involved as I wanted to be in the decisions and care about my treatment? Ifeelthat the staff I saw engaged with me when talking in front of me about my care? Doctors Nurses Others I was able to find somebody to talk to about my worries or fears? Your response is valued and we will use it for developing further improvements to the Enhanced Recovery Programme The Enhanced Recovery Team at West Hertfordshire Hospitals NHS Trust would like to wish you well with your recovery P.T.O

16 Sustainability Regular Project Group meetings Evidence based outcomes Marketing and promotion Audit of areas to improve the patient t pathway Feedback to stakeholders Local and national articles Website

17 What has been achieved so far? Over 2,150 patients have gone through the Enhanced Recovery Pathway to date Length of stay in hospital has reduced by an average of: 2-3 day for orthopaedic patients 2 days for colorectal surgery patients 4 days for Upper GI patients 1 days for gynaecology patients 1 for spinal procedures The number of patients readmitted to hospital has also decreased Patient feedback has been incredibly positive

18 Length of stay Frequency Distribution for non-cancer Hysterectomies at WGH since ER No of patien nts LoS days Pre ER Post ER

19 Length of stay Upper GI Los at WHHT Days Pre ER Q Q Q Q Period Overall Mean 14 Colorectal Los at WHHT Days Pre ER Q Period Overall Mean

20 Re-admission rates 8.0% Readmission rates for non-cancer Hysterectomies 7.0% 60% 6.0% Readmissio on rate within 6 weeks 5.0% 4.0% 3.0% 20% 2.0% 1.0% 0.0% Pre ER Period YTD Re-admis ssion rate 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Colorectal Re-admission rates by period Period

21 Patient Feedback Mr Arbuckle and his team were excellent, I cannot thanks the nurses enough for all their care and attention. I am leaving the hospital today and I will be ever grateful for everything they have done to aid my recovery The service I received ed was excellent. e I was really impressed by the doctors and nurses reception. I can't ask for more. Everyone has been so kind to me in their own special way. Many thanks. Very kind and helpful all round.

22 Patient Feedback Everybody from surgical staff, sisters, nurses, physio and OT were so very kind and understanding. I also think the cleaning staff are exemplary. My stay at St Albans Hospital has been very comfortable. I would be very happy (if I need) to come again. I cannot find anything that could be improved on. The nurses and staff were absolutely top class. Everything was covered as far as I know. I live on my own and have no family near me so was quite anxious about going home but it was all covered and explained to me. Staff on the ward were very helpful a majority of the time.

23 Next steps Continue to increase the number of Colorectal Surgery patients admitted on the day of surgery Expand the Upper GI programme to cover emergency patients Continue to reduce opiate usage post- operatively Expand the Gynaecology programme to cover elective caesarean patients Increase the number of Orthopaedic weekend discharges Expand the orthopaedic programme to the Trust s s Acute site