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Audit of the Enhanced Recovery Programme for Hysterectomy at West Middlesex University Hospital

Background and ObjectivesEnhanced recovery is a new approach to the pre-operative, intra-operative and post-operative care of patients undergoing surgery.

Originally pioneered in Denmark it is now being championed in England by a growing number of surgeons, anaesthetists, nurses, allied health professionals and NHS managers.

It has already been shown to benefit patients undergoing gynaecological surgery. It improves quality of care by helping patients to get better sooner after major surgery. It has also been shown to reduce length of stay with obvious benefits to the NHS.

The objective of our audit was to look at the effect of the introduction of the anaesthetic elements of enhanced recovery on patient outcome and recovery.

Methods

72% of the patients had mild pain on the first postoperative day, 28% had moderate pain and none had severe pain. All patients had regular multimodal analgesia. The average morphine requirement on the first post-operative day was 22.6 mg.

Conclusions

References

The adoption of regional techniques, short acting anaesthetics and multimodal analgesia at West Middlesex University Hospital resulted in good pain management which allowed earlier mobilisation, feeding and shorter length of stay.

This has resulted in improving both theatre and hospital efficiency, increasing productivity and also improved patient outcomes and satisfaction.

We are continuously introducing and testing new anaesthetic and analgesic techniques to further improve patients experience.

Department of Health, UK Enhanced Recovery case studies and practical examples, 2011

Enhanced Recovery Gynaecology, NHS Improvement, UK

NHS London, Enhanced Recovery Programme

80% of the patients received general anaesthesia using target controlled anaesthesia with propofol and remifentanil while 20% had either a spinal or epidural anaesthetic.

All patients were mobilised the next morning of surgery and had early oral hydration and nutrition.

Patients were discharged either on the planned day of discharge or if they met the discharge criteria earlier.

The average length of stay was 1.2 days for vaginal hysterectomy, 2.1 days for laparoscopic hysterectomy and 2.64 for open abdominal hysterectomy.

Results

0%

10%

20%

30%

40%

50%

60%

70%

20%15%

65%

Surgical Procedures Done

  No pain mild moderate severe

Abdominal hyst D1 0 74% 26% 0

Abdominal hyst D2 10% 83% 7% 0

Vaginal hyst D1 0 80% 20% 0

Vaginal hys D2 40% 60% 0 0

Lap hyst D1 0 62% 38% 0

Lap hyst D2 0% 100% 0% 0

Pain Score

Vaginal Laparoscopic Abdominal0

0.5

1

1.5

2

2.5

3

1.2 days

2.1 days

2.6 days

Length of Stay

We audited 65 patients who had hysterectomies, age range of 34-77 years. 42 patients had open abdominal hysterectomy, 10 had vaginal hysterectomy and 13 had laparoscopic hysterectomy. All patients were admitted on the day of surgery. None received a sedative pre-medication.

Miriam Kadry, Priyakam Chowdhury, M F Raslan

General anaesthetic80%

Spinal /

epidural20%

Anaesthetic Technique

At West Middlesex University hospital we have adopted the Enhanced Recovery Programme and implemented its elements; pre-operative optimisation of patients, avoidance of dehydration and hypothermia, the use of regional or short acting anaesthetics, early post-operative mobilisation, feeding and avoidance of opioids use. We conducted a prospective audit of patients scheduled for hysterectomy over a period of 9 months period`.Our audit looked at the anaesthetic and surgical techniques, pain scores, morphine requirements and length of stay of patients who had open abdominal, vaginal and laparoscopic hysterectomy.

Transversus abdominis plane block was performed in 92% of the patients who had open abdominal hysterectomy. 10% of the patients received one dose of ketamine prior to surgical incision.

Results