Enhanced Recovery The Efficient Way to Help Patients Get Better Sooner After Surgery

Transcription

1 Enhanced Recovery The Efficient Way to Help Patients Get Better Sooner After Surgery November 2012

2 Overview Background Patients journey Aim of the program How have we performed? Can we do more? Questions?

3 Length of Stay Why? Historical reasons Patient expectations Patient worries No help/ continuity at home Pain Wound healing Anaemia Slower rehabilitation

4 What is Enhanced Recovery? A growing movement within surgery which aims, through a variety of methods, to help patients to get better sooner after major surgery

5 Key principles Patient education / communication Anaesthetic factors Surgical factors Nutrition Rehabilitation Process

6 Benefits Improved patient experience Patients fitter sooner Reduced length of stay Improved clinical outcomes Cost efficiency savings Increased bed capacity for trusts Helps to meet quality and operational standards Team building

7 Legend The following denotes a trust is working in this specialty: (M) Musculoskeletal (C) Colorectal (U) Urology (G) Gynaecology Enhanced Recovery Innovation Sites Scotland NHS Lothian (M) Gold Jubilee National Hospital (M) North East South Tees Hospitals NHS Foundation Trust (C,G,U) Yorkshire & The Humber Leeds Teaching Hospitals NHS Trust (C,G) Calderdale and Huddersfield NHS Foundation Trust (C,G) North West Aintree University Hospitals NHS Foundation Trust (C,M,UPGI,Li) East Midlands The University Hospitals of Leicester NHS Trust (C,M,G,U) West Midlands University Hospital of North Staffordshire NHS Trust (C,U,G) South West South Devon Healthcare NHS Foundation Trust (Torbay Hospital) (C,M,G,U) East of England West Hertfordshire Hospitals NHS Trust (C,M,G,U) South East Coast London The Hillingdon Hospital NHS Trust (C,G) North Middlesex University Hospital NHS Trust (C,M,G) South Central Winchester & Eastleigh NHS Trust (C,M,G) Royal Berkshire NHS Foundation Trust (C,M,G,U) Medway NHS Foundation Trust (C,M,G,U) Brighton and Sussex University Hospitals (C,M,G,U)

8 Areas Orthopaedics Hips & Knees Gynaecology Hysterectomy Colorectal Upper and Lower GI Back Surgery. Shoulder Procedures ENT Procedures

9 Multi-Disciplinary Team Enhanced Recovery Nurse Consultant Orthopaedic Surgeon Consultant Anaesthetists Junior Doctors Matron Ward Sisters Ward Clerks Theatre Staff Pain Nurse Pre-op Assessment Staff Physiotherapists Occupational Therapists Allied Health Professionals Pharmacists Porters Discharge facilitator

10 Enhanced Recovery Nurses Co-ordinate running of ER Point of contact Advice & information Post-discharge Runs weekly school Audit & Research

11 Patient Education Starts at the out-patient appointment Continues at Pre-operative assessment Comprehensive coverage at weekly educational sessions

12 Hip and Knee School Better educated patients are better recovering patients What to expect Pain relief Physiotherapy Occupational therapy Attendance up from 17% to 98%

13 Alleviating patient worries Know what to expect Sleep well before op Already will have met ward staff

14 Anaesthetic factors Avoidance of pre-medication Individualised, goal-directed fluid therapy (carbohydrate-loading) Regional anaesthesia Short acting anaesthetic agents Prevention of hypothermia Effective opiate-sparing analgesia Minimise post-op nausea and vomiting

15 Surgical factors Minimally traumatic vs. minimally invasive Laparoscopic surgery Reduced tourniquet time Careful Haemostasis; Floseal, Tranexamic acid Careful tissue handling Local anaesthetic infiltration Leave the dressing 48 hrs Training

16 Nutrition Maximising patients pre-operative hydration Individualised and targeted prevention of nausea and vomiting Early post-operative oral hydration

17 Rehabilitation Front-loading Same day mobilisation 365 day service Encouragement of patient self-care Own clothes (and make-up!)

18 Process Admit patients on day of surgery Planned discharge criteria Telephone and follow up support immediately post-discharge Auditing and monitoring the outcomes

19 What have we achieved?

20 Over 2600 patients have gone through the Enhanced Recovery Pathway to date Length of stay in hospital has reduced by an average of: 2-3 days for orthopaedic patients 2 days for colorectal surgery patients 4 days for upper GI patients 2 days for gynaecology patients 1 day for back procedures- discectomies and decompressions The number of patients readmitted to hospital has also decreased Patient feedback has been incredibly positive

21 Results - Orthopaedics patients March 2010 October 2012 Median length of stay for Total Hip Replacement is 3 days Median length of stay for Total Knee Replacement is 4 days

22 Readmission rate Admission for any reason within 28 days of surgery (42 for orthopaedics) Ortho - Unchanged at 5.5% Gynae reduced from 7.6% to 1.9% Colorectal reduced from 27.3% to 15.5% Over 50% of readmissions unrelated to original surgery

23 ENHANCED RECOVERY PROGRAMME PROFORMA - ORTHOPAEDICS This form only to be filled out for patients identifed for the enhanced recovery trial 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? Attach patient label 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 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 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 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 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? Section 6 - For office use only ICD10 code entered Readmission within 42 days? Readmission date Type of reoperation (choose from supplied list) Date of death (if after discharge) Reoperation within 42 days? Discharge date

24 Audit ER Pathway attendance at pre-op education programmes anaesthetic safety individualised fluid management hypothermia prevention avoidance of sedatives targeted treatment of post-operative nausea early nutrition early mobilisation early post-discharge telephone follow-up

25 Patient Experience 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? YES NO NOT SURE 14 Were you told about what medication side effects to watch out for when you went home? YES NO NOT SURE 15 Were you told who to contact about your condition after you leave hospital? YES NO NOT SURE 16 Is there anything that we could do to improve your care further? 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

26 Patient Satisfaction All the staff were so caring and attentive. Such detail is made and given to me re my discharge. Thank you so much for your care and kindness. All was very good. Everyone was very helpful and very caring. 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.

27 Patient satisfaction Patients returning to hip & knee school Patient ownership

28 Sustainability Regular Project Group meetings Flexibility to adapt to Emerging and evidence based treatment Patient feedback Audit results Marketing and promotion Feedback to stakeholders Local and national articles Website

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30 Next steps Continue to increase the number of Colorectal Surgery patients admitted on the day of surgery Continue to reduce opiate usage postoperatively Expansion of the ER Orthopaedic Programme other procedures- Back and Shoulder Surgery Expand to Breast Surgery, and ENT procedures.

31 Summary We have been very successful in achieving our initial aims LOS dramatically reduced safely with no increase in morbidity Reduced readmissions Minimal cost huge savings Bed days saved Happy and safe patients

32 Questions