Enhanced Recovery Programme: The Whipps  Cross University Hospital Experience

Stefano M. AndreaniConsultant Colorectal Surgeon

Enhanced Recovery Partnership 

• Back ground Hospital• Local population• How we started and how we

carried on• Our Results in view of the

most recent literature

Enhanced Recovery Partnership

• North East London • Covering Waltham Forest and

Redbridge PCT • Population 350,000• Built 1900• 700 Beds

Socially Deprivated Area

• Market Factor• High % advanced stage cancer• Cancer Survival compared to national

average

Income deprivation by London borough

More than 20% 

employees are 

paid less than 

£7.50 per hour

• Social deprivation is an independent risk  factor for increased postoperative hospital 

stay for colorectal patients. 

Trust Average LOS 

–Days‐

Days above 

national Average

Southport and Ormskirk

Hospital NHS 27.94 12.05

Hammersmith Hospitals NHS Trust 22.47 6.58

Stockport NHS Fundation

Trust 22.31 6.41

Royal Free Hampsted

NHS Trust 22.07 6.17

Whipps

Cross University Hospital NHS 

Trust21.43 5.53

Pennine

Acute Hospital NHS Trust 20.8 4.9

The Hillingdon

Hospital NHS Trust 20.71 4.81

Barts

and The London NHS Trust 20.46 4.56

Surrey and Sussex Healthcare NHS Trust 20.05 4.15

City Hospitals Sunderland NHS Fundation

T 19.96 4.06

10 NHS Trusts with longest length of stay for bowel surgery in England 2006/07

www.reducinglengthofstay.org.uk

How we started ERP

Shifting Mentality• Danish surgeon: Henrik Kehlet

Q: Why is the patient still in hospital?Q: What can be done to safely

discharge him?

• within my team– Reg, SHO, FY1– CNS– Stoma Nurse

• Looking for motivated people– Ward– Theatre– Anesthetic department– Dietitian– ………..

Success Factor = Cultural Shift

• Funding• St Mark’s ERP course

> 60 people attended• Anesthetists• Ward nurses• Theatre Nurses• Physiotherapists• CNS• Stoma nurses• ODA• Dietitians

Steering Group Established

• Representative from each single specialties involved

• Creation Pathway for each specialty

• Specialty LEAD responsible to produce their pt care pathway

• Creation multispecialty pathway

• Appointment project manager• Meetings: Once a month• Baseline Study: Retrospective review

using HES• Support from NHS improvement team• Pilot site for ERP

Referral From 

Primary Care

Pre‐Op 

Assessment

Admission

Intra‐Op

Post‐Surgery

Post‐Op Day 

1

Post‐Op Day 

2‐4

Discharge & 

Follow Up

Ideal Patient PathwayIdeal Patient Pathway •

Managing Pre Existing co‐

Morbidities      e.g. 

diabetes/hypertension

• Optimising Haemoglobin levels

• Analgesia Review with Pt• Pre‐Op drinks• Stoma Marked• Continual Pt education on ERP

•Ward Observation• IV fluids –

discontinued• Remove catheter• Recommended Diet –

Build up drinks• Pain team, Surgical team – Review pt• Discharge – Pt informed of plans

•Monitor Catheter• Observe Stoma•Wound Review• Out of bed 6hrs Post‐Op• Pt reminded of ERP requirements• Surgical and Anaesthetic teamreview

• Pt Information – ERP explained• Pt Assessment (Health and Risk)• Referral to relevant specialties•Managing Pts Expectations• Discharge Planning

• Theatre –

Laparoscopic/Open• Epidural, CArdioQ• NGT out before Patient Awake• Pt Stable•

Recovery –encourage pt to drink a     

glass of water• Pt to sit up whilst on the profiling bed• Transfer Pt to ward

•Ward Observation• Out of bed – 8 hours in total•

Recommended Diet –

Build up 

drinks•

Pain team, Surgical team – Review 

pt• Discharge – Pt informed of plans

• Pt Medically fit to go home•Pt information Leaflet•Emergency Contact details•Stoma Care ‐

Community•Follow Up appointment

Prospective Audit

• How much are we implementing ERP?• All colorectal cancer 1st January – 31st

June, 2010– 1st Audit Jan- March– 2nd Audit April-June

• Total number of patient = 38• Number of patients included in ERP Audit

= 29

• Easy to collect data• Prospective data

collection

Since 2008, the LoS

stay has been reduced from an  average of 11.6 days to 7.1 days. 

Since 2008, the LoS

stay has been reduced from an  average of 11.6 days to 7.1 days. 

Expected vs Actual LoS

0 5 10 15 20 25

1

5

9

13

17

21

25

29

Patie

nt id

entif

ier

Length of stay (days)

LoS

11.6

10

7.1

0

2

4

6

8

10

12

14

WX Inpatient Audit (Dec 2008)

National HES Database (2008/09)

ERP Implemented (Jan-Mar 2010)

Aver

age

LoS

Whipps Cross ERP Colorectal Audit 2010

~3 days~6 days

(26 

cases)

(29 

cases)

ERP Audit January – November 2010

(not July)

Length of Stay TotalTotal number of procedures in 10 months 51

Total number of bed days: 344

Mean LoS (days): 6.75

Enhanced RecoveryPartnership Programme

Total number of Surgical patients = 65Number of patients included in ERP Audit = 51

Factors essential for Successful

Implementation ERP

Strong leadership with motivationCore group Project Manager

What about sustain these results?

Implementation and sustainability

• Education• Management of Expectation• Reinforce of ERP concept and practice• Empowering nurses• ERP Nurse

– Keep the things going– Educate– Audit results

LOS

ERP – patients overview

ERP – patients overview

ERP – patients overview

Patients - overview

Patients - overview

Surgery

Quality data collection

Adherence to ERP protocol

Overall adherence to protocolmean 69%median 68%

Adherence to ERP protocol

• Prospective cohort study before and after ERP protocol

• 953 patients with colorectal cancer: – 2002‐2004 Adherence 43.3% in 464 patients – 2005‐2007 Adherence 70.6% in 489 Patients– Postoperative complications and symptoms declined significantly. 

• 30‐day morbidity and readmissions were significantly reduced with 

increasing adherence to the ERP protocol

(>70%, >80%, and >90%) 

compared with low ERP adherence (<50%)

Adherence%

MeanLOSDays

p

50 9.4 < 0.001

70 7.4< 0.001

80 7< 0.001

90 6< 0.001

Overall LOS

daysmean 7.76median 6max 25min 2

7.766

Surgery

Laparoscopy in Combination with Fast Track Multimodal Management is the Best Perioperative Strategy in Patients Undergoing Colonic Surgery: A Randomized Clinical Trial (LAFA-study).

Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF, Gerhards MF, van Wagensveld BA, van der Zaag ES, van Geloven AA, Sprangers MA, Cuesta MA, Bemelman WA; on behalf of the collaborative LAFA study group.

• Multicenter

RCT

• 9 centers in the Netherlands 

• 400 patients eligible for segmental colectomy were randomized to:

‐

laparoscopic or open colectomy

‐

ERP or standard care 

Ann Surg. 2011 May 18. [Epub ahead of print]

Results

Lap/FT Open/FT Lap/standard Open/standard

• Postop

LOS Median 5 6 6 7 days

• Laparoscopy was the only independent predictive factor to reduce hospital stay and morbidity:

Author’s conclusion: “Optimal perioperative treatment for

colonic cancer is laparoscopic resection embedded in a FT program. If open surgery is applied, it is preferentially done in FT care”

ComplicationsTotal 36 39%

Pts

with 1 

complication 30 33%

Pts

with >1 

complication 6 7%

ComplicationsSeverity of complications N°

tot 36grade 1 or 2 27grade 3 or 4 11

death 1 Reoperations 3 Readmissions 5

Reoperations

2 anastomotic leak   ‐ ileostomy

1 perineal wound infection   ‐ wound

debridment

Readmissions

within

30 day

FU2 Acute urinary retention

2 Acute renail

failure

1 Splenic

infarction

2011

• 4 RCTs• 237 patients with colorectal surgery:119 ERP

vs 

118 conventional

2011

ResultsERAS Control RR

(95% CI)

• Mortality 13 per 1000 25 per 1000 0.53(0.12 to 2.38)

• Complications

tot 54 105 0.51(0.39 to 0.67)

minor 29 50 0.57(0.38 to 0.85)

major 14 28 0.50(0.28 to 0.92)

• Readmissions 10 130.79(0.36 to 1.76)

• Length

of stay ‐

2.51 days95% CI ‐3.54 to ‐1.47p < 0.00001

Cochrane

• Quantity and quality of data are low• ERP seems safe

• Lack of sufficient outcome parameters and  poor quality

of trials do not justify 

implementation of ERP as the standard of care

• Role of laparoscopy not clarified• Protocol compliance

not investigated

• 12 Spanish hospitals• 300

patients with elective colorectal surgery for cancer 

following an ERP

Compliance overall

65 %

Results

• LOS Median

6 days(range

3 to 89)

• Complications

tot 89 (29.7 %)

surgical 71 (23.7 %)

• Mortality 3 (1 %)

• Readmissions 8 (2.7%)

• Reoperations 21 (7 %)

Conclusions

• Sustain

ERP is more challanging than its  implementation

• Creation of a single document: paper pathway 

• ERP Nurse is essential and it pays in the long  run

Thank you

• Whipps

Cross Staff

• ERP core group• Colorectal Unit