CLINICAL PATHWAY Open Hysterectomy Enhanced Recovery (HER) (For elective benign hysterectomy, myomectomy and ovarian/adnexal surgery) Pre-Admission Unit (PAU) Day of Surgery Pre-op Same Day Admission (SDA) Date: yyaa mm dj Date: yyaa mm dj Assessment and teaching per PAU standards of care and procedure specifi c education material. Pre-operative diagnostic testing as per Medical Directive for Pre-Admission Diagnostic Testing for Elective Surgery. Reinforce pre-operative education Verify and complete all pre-op testing. Tests CBC ECG if over 65 or has cardiac condition PTT/INR for patient on Warfarin (Coumadin) Chest x-ray if signs of lower respiratory infection Urinalysis if signs of urinary tract infection Urine Pregnancy test if pregnancy possible Reinforce pre-operative education: Ensure patient has received Gynecological Surgeries patient education booklet CP 101 B For smokers, encourage patient to stop smoking and to follow-up with primary care provider about smoking cessation aids Prepare patient to expect to: Have a little discomfort, but pain should be well controlled Eat as soon as ready the fi rst evening Mobilize shortly after surgery Have the urinary catheter removed in the evening and need to get up to the bathroom Go home early the next morning Advise patient to have high protein snack at 11 p.m. or bedtime (before midnight), and 2 large glasses (1 to 2 cups) of high calorie clear fl uid (e.g. apple juice or ginger ale) 1.5 hours before arriving at the hospital. More examples are found in the Gynecological Surgeries patient education booklet CP 101 B. Understands pre-op instructions and events Understands usual post-op course, plan for pain management, and usual self-care measures to prevent post-op complications as per patient education booklet. Understands usual length of stay and expected discharge on POD #1 at 6:30 a.m. from Surgical Day Care Overnight Unit (SDON) or 10 a.m. from ward Patients who are booked for surgery later than 12 p.m., will need to be admitted to the ward for overnight monitoring because of the requirements for monitoring after receiving a spinal with intrathecal morphine (18 hours minimum) Understands the need to have transportation and to be accompanied home by a responsible adult at the time of discharge Yes No Signature: Time: NTV circle above, VC Assessment and teaching per Same Day Admission standards of care and procedure specifi c education material. Pre-operative diagnostic testing as per Medical Directive for Pre-Admission Diagnostic Testing for Elective Surgery. Additional testing if required For diabetic patients: Blood glucose by Point of Care Testing (POCT) PTT/INR: for patient normally taking Warfarin (Coumadin) Unless normal result obtained after warfarin discontinued per pre-op instructions Electrolytes: for dialysis dependant patient unless acceptable post-dialysis results obtained within 24 h of surgery CBC if autologous blood donor Additional Orders Antibiotics: As per physician orders Give any pre-operative medications as ordered by the surgeon or anesthesia Adherence with pre-op instructions Understands usual events/expectations of operative day Understands usual post-op course, plan for pain management, and usual self-care measures to prevent post-op complications as per patient information booklet. Patients who are booked for surgery later than 12 p.m., will need to be admitted to the ward for overnight monitoring because of the requirements for monitoring after receiving a spinal with intrathecal morphine (18 hours minimum) Yes No Signature: Time: NTV circle above, VC Variance Codes (VC) 492 Not discharged by end of pathway continued need for acute care 510 Not discharged by end of pathway non-medical reason NTV OFF Non-tracked variance Ordered off clinical pathway CP 101 A (05/2014) CHART DOSSIER THE OTTAWA HOSPITAL L HÔPITAL D OTTAWA
Patient(e) Chart No. N o du dossier Day of Surgery Post-op Post-Anesthetic Care Unit (PACU) Date: yyaa mm dj Vital signs, assessment, treatment, and teaching per PACU standards of care. Anesthesia Handover: Receive handover from anesthesia For anesthesia HER protocol, see page 5 of pathway Additional Orders Indwelling urinary catheter in situ Record vaginal bleeding q 30 min Clear fl uids to DAT as soon as tolerated. Patient should be given a snack within 2 hours of leaving the OR IV fl uids at 5 ml/h only, unless otherwise clinically indicated May transfer to ward or Sugical Day Overnight Unit (SDON) when Post-Anesthetic Care Unit (PACU) discharge criteria are achieved Vaginal bleeding less than 1 soaked pad per hour Urine output 0.5 ml/kg/h when trended over 4 hours Pain Management Indicates adequate pain control achieved per APS guidelines. Pain equal or less than 3 at rest, equal to or less than 5 with activity. Pain not preventing movement. Patient satisfi ed with pain control. Achieves PACU discharge criteria for transfer to overnight unit or ward D : 8-12 h day shift / E : evening shift, if applicable / N : 8-12 h night shift D Yes No Signature: Time: NTV circle above, VC E Yes No Signature: Time: NTV circle above, VC N Yes No Signature: Time: NTV circle above, VC Variance Codes (VC) 492 Not discharged by end of pathway continued need for acute care 510 Not discharged by end of pathway non-medical reason NTV OFF Non-tracked variance Ordered off clinical pathway CP 101 A (2 5) CHART DOSSIER THE OTTAWA HOSPITAL L HÔPITAL D OTTAWA
Patient(e) Chart No. N o du dossier Day of Surgery Post-op SDON or Ward Date: yyaa mm dj Oxygen saturation monitoring (SpO 2 ) and oxygen administration per oxygen titration protocol Vital signs, assessment, treatment and teaching per SDON standards of care Aim for minimized clinical intervention and give positive encouragement to mobilization and self-care Assessments Monitor vaginal bleeding q4h If present, remove vaginal packing as ordered CBC at 20:00 Vital signs as routine for SDON or ward (as per APS protocol) Leave dressing in situ unless more than 30% soiled Nutrition Diet as tolerated or as ordered Activity Activity as tolerated Encourage ambulation as early as possible: Sit in chair when spinal is receded (Bromage score of 0 and sensory level S1), then walk to bathroom, then walk in hallway as tolerated Deep breathing and coughing q1h while awake Ensure urinary catheter has been removed as per orders at 20:00 or once spinal anesthesia has been resolved In and out catheter prn 2 if patient has not voided in 4 hours and bladder scanner shows more than 300 ml urine As per Surgery Discharge Instruction sheet NUR 109 Review discharge plans with patient/family Confi rm ride for 6:30 a.m. (SDON) or 10 a.m. (Ward) If patient is resident of Quebec obtain prescription for staple removal Pain Management Indicates adequate pain control achieved as per APS guidelines. Pain equal or less than 3 at rest, equal to or less than 5 with activity. Pain not preventing movement. Patient satisfi ed with pain control. Physiological Respiratory rate, rhythm and effort are stable (between 14 and 20 at rest) O 2 saturation and oxygen as per titration protocol Vital signs are stable and within normal ranges Level of sedation is minimal Effective deep breathing and coughing Incision Trace oozing on dressing Minimal to small amount of vaginal bleeding (less than half a pad in 8 hours) Activity Performs and tolerates progressively increasing activity Nutrition Tolerates diet Patient voiding well (urine output at least 0.5 ml/kg/h when trended over 4 hours), no evidence of bladder distension, sensation has returned to perineum/buttocks Understands progression of activity Understands progression of diet Knows signs and symptoms of urinary tract infection, excessive vaginal bleeding, and when to call the surgeon s offi ce Understands usual length of stay and expected discharge time of 6:30 a.m. (SDON) or 10 a.m. (Ward) on POD1 Understands the need to have transportation and to be accompanied by a responsible adult at the time of discharge D : 8-12 h day shift / E : evening shift, if applicable / N : 8-12 h night shift D Yes No Signature: Time: NTV circle above, VC E Yes No Signature: Time: NTV circle above, VC N Yes No Signature: Time: NTV circle above, VC Variance Codes (VC) 492 Not discharged by end of pathway continued need for acute care 510 Not discharged by end of pathway non-medical reason NTV OFF Non-tracked variance Ordered off clinical pathway THE OTTAWA HOSPITAL L HÔPITAL D OTTAWA CHART DOSSIER CP 101 A (3 5)
Patient(e) Chart No. N o du dossier Post-op Day 1 SDON or Ward Discharge Day Date: yyaa mm dj Oxygen saturation monitoring (SpO 2 ) and oxygen administration per oxygen titration protocol Assessments Vital signs routine q4h Monitor vaginal bleeding q4h Discharge patient home with original dressing. Only change dressing if soiled more than a trace amount. Nutrition Diet as tolerated or as ordered Activity Activity as tolerated Encourage ambulation as early as possible Ambulate independently to bathroom Monitor output Complete Surgery Discharge Instructions (NUR 109), and provide patient with a copy Inform patient when to call the surgeon s offi ce as per patient education booklet CP 101 B Inform patient that the clinic will call within 3 weeks to provide follow-up appointment Teach patient to continue taking their pain medication q4h as required at home as per their surgeon s instructions Provide take-home prescription for post-operative analgesics, if necessary Provide staple remover if necessary and instructions about staple removal at primary care provider Ensure Quebec patients have prescription for staple removal if required Discharge SDON discharge time is 6:30 a.m. Ward discharge time is 10 a.m. Pain Management Indicates adequate pain control achieved as per APS guidelines. Pain equal or less than 3 at rest, equal to or less than 5 with activity. Pain not preventing movement. Patient satisfi ed with pain control. Physiological Respiratory rate, rhythm and effort are stable (between 14 and 20 at rest) Vital signs and oxygen saturation are stable and within normal ranges Level of sedation is minimal Effective deep breathing and coughing Incision Trace oozing on dressing Minimal to small amount of vaginal bleeding Activity Performs and tolerates progressively increasing activity Able to walk the length of the room with assistance Nutrition Tolerates diet Patient voiding well with no evidence of bladder distension Patient has bowel sounds and passing fl atus Abdomen soft Understands progression of activity Understands progression of diet Knows signs and symptoms of urinary tract infection, excessive vaginal bleeding, and when to call the surgeon s offi ce Discharge Criteria Discharge ready when patient meets SDON or ward discharge criteria. As well: If patient is less than 24 hours post intrathecal morphine, ensure anesthesia has provided an order for discharge from APS Understands follow-up plan as per discharge planning section Stable vital signs, within normal range from Pre-Admission Oxygen saturation above 92% on room air Pain well controlled as per APS protocol Nausea/vomiting well controlled or absent Tolerating oral diet and has managed to eat at least one meal Patient voiding with no retention Able to walk the length of the room with assistance At least one other person at home D : 8-12 h day shift / E : evening shift, if applicable / N : 8-12 h night shift D Yes No Signature: Time: NTV circle above, VC E Yes No Signature: Time: NTV circle above, VC N Yes No Signature: Time: NTV circle above, VC Variance Codes (VC) 492 Not discharged by end of pathway continued need for acute care 510 Not discharged by end of pathway non-medical reason NTV OFF Non-tracked variance Ordered off clinical pathway CP 101 A (4 5) CHART DOSSIER THE OTTAWA HOSPITAL L HÔPITAL D OTTAWA
Patient(e) Chart No. N o du dossier The following are the Anesthetic guidelines of the HER Pathway, to be followed in the Operating Room unless contra-indicated for the patient OR unless another Anesthetic option was more benefi cial or preferred by the patient. Anesthesia Components of the HER Pathway Intraoperative Details PACU and ACUPAM Orders Patients should have received acetaminophen and celecoxib pre-operatively (should be ordered by Gyne, but if not then can be ordered in SDCU if a resident is able to see the patient there before the Operating Room) Avoidance of benzodiazepine/opioid sedation unless clinically necessary SPINAL: Subarachnoid block with suggested 0.75% bupivacaine + 100 mcg PF morphine, to be adjusted to patient need Aim for euvolaemia, close to 1000 ml where possible TIVA: Total intravenous anesthesia (e.g. with Propofol 30 to 250 mcg/kg/h for sedation or general anesthesia) Forced air warmer, with aim for a temperature greater than 36 C Antiemesis prophylaxis and anti-infl ammatory treatment with dexamethasone 8 mg IV PRN antiemetics of ondansetron 4 mg IV, haloperidol 0.5 mg IV TAP BLOCKS: Transversus abdominus plane blocks with 20 ml 0.5% ropivacaine bilaterally under US guidance, performed post-operatively or pre-operatively Analgesia No IV PCA Avoid Tramadol and IV opioids unless necessary Regular acetaminophen 650 mg po q4h Regular celecoxib 200 or 400 mg po q4h Hydromorphone 1 to 2 mg po q4h prn Hydromorphone 0.5 to 1 mg sc q4h prn Anti-emesis and pruritis Ondansetron 4 mg IV q6h prn Haloperidol 0.5 to 1 mg IV q6h prn Dexamethasone 4 mg IV 12 hr after the fi rst dose if nausea is persistent IV Fluids Avoid IV fl uids in PACU unless clinically necessary Saline lock IV when drinking well THE OTTAWA HOSPITAL L HÔPITAL D OTTAWA CHART DOSSIER CP 101 A (5 5)