Enhanced Recovery Programme

E-Learning ‘Helping patients to get better sooner after surgery’

To improve the quality of patients care by improving their experience

and clinical outcomes

This e-learning module will take 20 minutes and there will be a short assessment at the end.

What will I learn

• What is Enhanced Recovery

• What are the core elements

• Why it is important at UCLH and nationally

• What is in it for the patient, MDT, hospital, community and me

• What is my role

• What are the consequences of not doing it

What is Enhanced Recovery

What are the principle of Enhanced Recovery

• Patients have elective surgery with an innovative, high quality care approach

• Patients are in the optimal condition for treatment

• Patients have a better care experience before, during and after their operation

–‘There is a role for everyone’

It makes a difference to patients

“ I had two hip replacements last year. One in June

and one in December.

The second one was much better,

the service is fabulous!”

In June there was no Enhanced Recovery Programme in place but in December there was!

Factors Influencing Patient Recovery

HANNAH - Could this slide be combined in some way with the next one (mountain). Will need to include reference but we can do this later

Kellet’s Theory 1980

What are the core elements

What is the purpose of the different stages of care pathway

– Pre-operatively: Other health problems are identified & managed to enable the patient to be in the best possible condition for surgery

– Intra-operatively: Best possible evidence based management is given to the patient during and after surgery

– Post-operatively: Patients are encouraged with early mobilisation and timely discharge for the best rehabilitation with support

Examples of Enhanced Recovery Elements at key stages of the pathway

9

Referral fromPrimary Care

Pre-Operative

Admission

Intra-Operative

Post-Operative

FollowUp

• Optimised health / medical condition

• Informed decision making• Pre operative health & risk

assessment - CPEX• PT information and

expectation managed• DX planning (EDD)

• Minimally invasive surgery

• Use of transverse incisions

• No NG tube (bowel surgery)

• Use of LA with sedation• Epidural management (inc thoracic)

• Optimised fluid management

• 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 opiate-based analgesia where possible or administered topically

• Optimised Fluid Hydration

• Reduced starvation• No / reduced bowel

preparation ( bowel surgery)

• DX on planned day• Therapy support (stoma, physio)

• 24hr telephone follow up

• Optimising pre operative haemoglobin levels

• Managing pre existing co morbidities e.g. diabetes

• Audit & outcome measures

•10

Factors to consider for Surgery?

Fit for Surgery? Mythen MG. Anesthesia and Analgesia: April and May 2011

Benefits Realised

Success for Sustainability

• What are the key drivers for change within the quality and safety framework: Improve clinical quality, patient safety and clincial experience Incentives with CQUINS and PbR tarrif

How do we measure this: Collect high quality data to support practice change Define what are outcomes

process (compliance with the clinical pathway) clinical (complications) patient experience (satisfaction)

Test, evaluate, refine and embed change based on evidence of own practice. Benefits realisation can take longer

Success for Sustainability Change is Clinically Led with Senior Management Support

Clinical leadership is crucial for successful implementation Leaders are respected role models who can influence peers and other MDT members Involvement and engagement of all members within the MDT is required Project management, Change management, Faciliators, , senior management support and

key stakeholder support and engagement is an ongoing process, and not just at the outset of the implementation process

Ethos of the Clinical Team Celebrate the success of your work and achievements Show mutual respect and value the different and complementary roles of the MDT members Engage in the top tips for patients

Organisational Culture Support the ‘can do’ culture that empowers and enables clinical teams to test new ways of

working, without fear, risk or blame Share the strong relationships between managers and clinicians with quality & safety being

high on the executive agenda

Benefits from Informed (shared) decision making

– Decision aids provide:• support to patients in making the best decision

for their circumstances• information to help them understand whether

to have a diagnostic test• Information of their condition and the

progression of their disease • the treatment options available to them, the

side effects and benefits of each option • Information about the issues that are most

important to them/their preferences

Stakeholder Engagement

Full guide to stakeholder analysis and management:

NHS Institute for Innovation and Improvement‘The Handbook of Quality and Service

improvement Tools’ Section 3 Stakeholder and User Involvement

Why it is important at UCLH and nationally

What else is ER aligned to?

TCAB

Top Tips

Actual Bed Time

Nurse Dispensing

Protocol LedDischarge

Ticket Home

Discharge Lounge

Productive Wards

Pre – 11 am Discharge

ERP

What investment may be required?

Financial

Training

CommunicationSystematic

improvement Approach

Team-working

Change management

Skills

LeadershipEngagement & accountability

TimeFocus

Commitment

Enhanced Recovery

Finance is not the only

investment

National programme

• Support to SHAs to lead a local spread and adoption programme– Objective support and guidance

• Communications and resources– Web site www.dh.gov.uk/enhancedrecovery

• Collating emergent evidence working with opinion leaders

• Stakeholder engagement with national bodies to embed enhanced recovery as the standard model of care

• Policy alignment to support local delivery

• Networking

What is in it for the patient, MDT, hospital, community and me

What’s in it for Patients

Referral from Primary Care Pre-operatively:

Other health problems are identified & managed to enable the patient to be in the best possible condition for surgery

Admission Intra-operatively:

Best possible evidence based management during and after surgery

Follow UP: Post-operatively:

Early mobilisation and timely discharge for the best rehabilitation with support

Top Tips to Enhance Recovery for Patients:

Make them a partner with you in their care Prepare them for the DATE Are all their questions answered Prepare them for treatment and recovery Get them moving soon after surgery They will not gain if their in pain Encourage them to behave as normal Give them confidence to go home and get in

touch if needed‘No decision about me without me’

Audience: Patients

Enhanced Recovery is a new way of improving the experience and well-being of patients who need major surgery.

• It helps people to recover sooner so that life can return to normal as quickly as possible

• It gives people a better overall experience due to higher quality care and services

• It lets people choose what’s best for them throughout the course of their treatment with help from their GP and the wider healthcare team (“No decision about me without me.”)

• Many people who have experienced Enhanced Recovery say that it makes a hospital stay much less stressful

Top Tips to Enhance MDT Working

Multi-Disciplinary Teams? It give patients a better overall experience through higher

quality care and services

It introduces innovative best practices that empower and motivate staff

It accelerates the clinical decision-making process by empowering MDTs

It doesn’t increase MDT workload

It ensures the most-efficient use of healthcare resources

Best-practice is day surgery or an Enhanced Recovery pathway

What does it mean for providers?

It improves patient safety and involvement and meets Care Quality Commission requirements

It reduces demand on resources such as critical care, surgical beds and patient uptake of procedures

It increases job satisfaction of Multi-disciplinary Teams through better ways of working and improved patient outcomes

It improves the reputation of the healthcare provider

Best-practice is day surgery or an Enhanced Recovery pathway

Commissioners? It enhances the reputation of the healthcare provider

It helps patients recover sooner from surgery

Best-practice is day surgery or an Enhanced Recovery pathway

It improves patient experiences through increased partnership and empowerment (“No decision about me without me.”)

It motivates medical teams through best practice, empowerment and innovation

It reduces demand on resources such as critical care, surgical beds and patient uptake of procedures

What’s in it for Primary Care?

• It gives patients a better overall experience through higher quality care and services

• It puts GPs in control of commissioning the right pathways for their patients

• Earlier patient discharge doesn’t create extra workload for primary or social care services

• It improves efficiency and productivity whilst improving quality

• GPs and patients work in partnership through informed decision-making and greater choice

• It is a clinically proven approach to faster patient recovery

ER – Greatest Challenges – Opportunities for Commissioners

• Fitness for referral

• Patient education

• Truly informed consent

• Robust discharge planning

What is my role

Essential Roles

Sponsors:• authority to sanction change

(organisational alignment / benefit)Change Agents:• facilitate change, require knowledge, skills

and credibilityChampions:• respected opinion leaders who positively

promote workLeaders:• lead by example

Understanding your current service

Identify elements in place on enhanced recovery pathway map

Audit of compliance with clinical elements on an individual patient basis

Process map / Walk the patient journey

Track patient journeys

Patient ExperienceLength of Stay

Re-operation ratesReadmission ratesComplication rates

CLINICAL INTERVENTIONS CLINICAL SYSTEM

OUTCOMES

Understanding your current

serviceReferral

fromPrimary

Care Pre-Operative

Admissio

n

Intra-Operative

Post-Operative

FollowUp

•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

•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

•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

•Admission on day•Optimised Fluid Hydration

•CHO Loading•Reduced starvation•No / reduced oral bowel preparation ( bowel surgery)

•DX when criteria met

•Therapy support (stoma, physio)

•24hr telephone follow up

•Optimising pre operative haemoglobin levels

•Managing pre existing co morbidities e.g. diabetes

Short-term investment

Support to change the pathway (e.g. service improvement, change manager, facilitator etc)

Training – new skills e.g. pre-assessment

Equipment – invest to save

Communication/awareness

Find out what is already in place & going on Make the connections

Identifying the team

Implementation requires a number of factors: Changing clinical interventions Changing care systems and processes Creating a team to work across the patient

pathway Both require technical and behavioural change

management Lets start with thinking about who to engage and

how to structure the project team

What are the consequences of not doing it

Support Materials

For copies of the clinical evidence compendium or further information contact http://www.dh.gov.uk/en/Healthcare/Electivecare/Enhancedrecovery/DH_115638

Support materials

Government Vision

Putting patient first

Improving healthcare outcomes

Autonomy and accountability

Cutting bureaucracy and improving efficiency

12th July 2010

The core principles of enhanced recovery are aligned to the Health White Paper:

Just Do it!

Little risk Minimal cost Broad agreement Easy to do

Next Steps

Advice guidance and support – to change

Implementation guide Enhanced Recovery Toolkit SHA support Local Network events UCLH Implementation team E-learning / DVD / Top Tips http://insight/departments/Projects/QEP/Pages/

home.aspx www.improvement.nhs.uk

Overview

This Session:

Principles, elements and benefits of ERP

Drivers for Implementation

Current and future pathway

Action Planning:

Stakeholder Analysis

Testing changes for improvement

Measuring Outcomes

Testing Changes for Improvement

Sophia Mavrommatis

Principles, elements and benefits of Enhanced

Recovery

Drivers for Implementation

Bella Talwar

Mapping your pathway against the Enhanced

Recovery Elements

BellaTalwar

Action planning and potential challenges

Sophia Mavrommatis

Measuring OutcomesBella Talwar

Enhanced Recovery Pathway‘Implementation & Sustainability’

Median LOS for Prostectomy

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0

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10

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Apr-1

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Median LOS for Abdominal Hysterectomy

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Apr-0

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Median LOS for Primary Hip Replacement

3456789

10

Apr-0

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Oct

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Apr-1

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Median LOS for Colectomy

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Jun-

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ERP implementedRobotic Surgery

ERP implemented

CQUINS

Benefits Realised

Potential capacity released

Impact on Patient Pathway

Traditional pathway (£200 per day pp)= £2,200LOS Reduction ER = £1,000