fulfilling the potential - a better journey for patients and a better deal for the nhs

NHSEnhanced Recovery Partnership

A BETTER JOURNEY FORPATIENTS AND A BETTERDEAL FOR THE NHS

FULFILLING THE POTENTIAL

Published on behalf of the EnhancedRecovery Partnership by NHSImprovement

CONTENTS

Enhanced recoverypathways lead tobetter outcomes andimprove the patientexperience.

“”JohnMcGrath

Consultant Urologist, The Royal Devonand Exeter NHS Foundation Trust andEnhanced Recovery PartnershipClinical Lead

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Foreword

Introduction

SECTION 1Are you getting the messagesabout enhanced recovery?

SECTION 2Enhanced recovery pathway asevery day practice

SECTION 3The patient role andresponsibilities in enhancingtheir own recovery

SECTION 4Progress and fulfilling the potential:a measured approach

SECTION 5Why commissioners are importantto enhanced recovery

Summary

Resources

Acknowledgements

CONTENTS

FOREWORD

FULFILLING THE POTENTIAL: A BETTER JOURNEY FOR PATIENTS AND A BETTER DEAL FOR THE NHS

FOREWORDEnhancing recovery:becoming the norm

I am not a surgeon, but I fullyrecognise the central importance ofsurgery both as a treatment forcancer and for many otherconditions. I have also observedover my professional lifetime howmuch the outcomes of surgery haveimproved. These improvementshave resulted from the introductionof new techniques (such aslaparoscopic or minimally invasivesurgery), from better training andfrom greater specialisation especiallyfor complex procedures.

Twenty-five years ago it wasstandard practice for patientsundergoing any form of surgery forbreast cancer to stay in hospital for10 days. For some time now thesimpler breast procedures have beenundertaken as day cases.

More recently still, it has beendemonstrated that almost all breastcancer surgery includingmastectomies (but excluding breastreconstructions) can be done as aday case or with a single overnightstay. This radical change has nowbeen spread across the country withsupport from NHS Improvement –with major benefits for patientsand for the NHS.

We are now witnessing a similarrevolution with regard to othermajor surgical procedures. Forexample, patients undergoingcolorectal cancer surgery would inthe past typically have stayed inhospital for 10-14 days.

Through the introduction ofenhanced recovery patients are nowrecovering much more quickly andcan be as fit and ready for dischargeafter four or five days as theirpredecessors would have been atleast a week later. Implementation ofenhanced recovery across the NHSrepresents an excellent example ofQuality, Productivity, Innovation andPrevention (QIPP) in practice. It is aninnovative approach to clinical carebringing quality benefits for patientsacross a range of specialties andbetter productivity for the NHS. Weknow from work to date thatlengths of stay can be reducedwithout an increase in emergencyreadmissions. The EnhancedRecovery Partnership also providesan excellent means of spreadinggood practice regarding optimisationof fluid management technologiesduring surgery - a key commitmentin Innovation Health and WealthReview (2011).

Our challenge now is to ensure thatall patients who can benefit fromthis approach do so and as soon aspossible. ‘Fulfilling the potential: abetter journey for patients and abetter deal for the NHS’ shows howthis can be achieved.

Professor Sir Mike Richards CBENational Cancer Director and Chair ofthe Enhanced Recovery Partnership

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Professor Sir Mike Richards CBENational Cancer Director

INTRODUCTION


INTRODUCTIONChange is hard. However, theEnhanced Recovery PartnershipProgramme demonstrated ourcapacity in the NHS to change. Injust two years, from May 2009,enhanced recovery pathways havebeen established in the vast majorityof NHS hospitals in England. Now,in 2012, enhanced recovery forsurgery is becoming standardpractice. Length of hospital stay hasdropped to target levels set down atthe launch of the EnhancedRecovery Partnership Programme,without increase in readmissions andwith high levels of patientsatisfaction.

The Enhanced Recovery PartnershipProgramme that ran until May 2011was undoubtedly a great success butthere was still plenty of room forimprovement. There had not beentotal adoption as some groups weretaking a more cautious approach ora ‘wait and see’ stance. This is whythe Enhanced Recovery Partnershipis still actively driving furtherimprovements to support the spreadand adoption of enhanced recoveryas best practice. The energy andenthusiasm of the early adopters isinfectious and their results speak forthemselves.

There is continued support from theDepartment of Health and clearbacking from the Royal Colleges.So can we expect complete adoptionsoon? A better published evidencebase and more effective collectionand reporting of outcomes willundoubtedly help to achieve thisgoal.

We know that commissioners wantto commission pathways thatimprove outcomes and support theirlocal QIPP plans. We hope that thispublication will provide all healthprofessionals and importantlycommissioners with an overview ofthe benefits of enhanced recovery asbest practice. Commissioners arepart of the team and are importantto enhanced recovery for itscontinued implementation andsustainability.

We have seen the spread ofenhanced recovery pathways tomany surgical specialties beyond theoriginal four main areas ofcolorectal, gynaecology,orthopaedics and urology. There isnow a serious move to adoption ofsimilar principles in acute medicineas is already happening in othercountries in Europe

Successful adoption and applicationof enhanced recovery pathways willresult in more empowered patientsand a better functioning team, withincreased bed capacity, fewerpostoperative complications and anoverall reduction in hospital costs.

The future delivery of medical carewill need to focus, not only on thedevelopment of innovativetreatments, but on reducing thelevels of stress associated with thedelivery of in-patient care. Theenhanced recovery pathway providesan evidence-based means ofachieving this within an increasingnumber of surgical and medicalsubspecialties.

Monty Mythen,Professor of Anaesthesia and CriticalCare, University College LondonHospitals and National EnhancedRecovery Partnership Clinical Lead

Alan Horgan,Consultant Colorectal Surgeon, TheNewcastle upon Tyne Hospitals NHSFoundation Trust and NationalEnhanced Recovery PartnershipClinical Lead

DID YOU KNOW?The Enhanced RecoveryPartnership membershipincludes: Department ofHealth, NHS Improvement,National Cancer ActionTeam, Advancing QualityAlliance, NationalEnhanced Recovery ClinicalLeads and Advisors, NHSImprovement Associates,SHA Enhanced RecoveryLeads and Patient Advisors

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ARE YOU GETTING THE MESSAGESABOUT ENHANCED RECOVERY?

The evidence base forenhanced recovery is clearand continues to bestrengthened with theongoing spread andadoption of the pathwayacross the country.

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ENHANCED RECOVERY IS FOUNDED ON FOURWORKING PRINCIPLES

1. All patients should be on a pathway to enhancetheir recovery. This enables patients to recover fromsurgery, treatment, illness and leave hospital soonerby minimising the physical and psychological stressresponses.

2. Patient preparation ensures the patient is in thebest possible condition, identifies the risk andcommences rehabilitation prior to admission or assoon as possible.

3. Pro-active patient management components ofenhanced recovery are embedded across the entirepathway; pre, during and after operation/treatment.

4. Patients have an active role and takeresponsibility for enhancing their recovery.

DID YOU KNOW?• Enhanced recovery (ER) was developed in Copenhagen byProfessor Henrik Kehlet and has been used in the UK since theearly 2000s

• ER can be used with laparoscopic or open surgery• ER is an integrated care pathway that takes a multi-modal,evidence based approach to optimise the patients recovery.


ENHANCEDRECOVERY MAKESA DIFFERENCE

• Enhanced recovery (ER) iscommon sense

• In simple terms, it improves thequality of care, and supportspatients to get better sooner aftermajor surgery

• It improves the delivery of care,reduces complications, improvesthe patient experience, reducesunnecessary lengths of stay andmakes efficiency gains for Trusts

• In addition to the qualityimprovements, enhanced recoverymakes a significant contribution inreducing morbidity translating intoreal cost savings.

ENHANCED RECOVERYIMPROVES THEQUALITY OF CARE.

Enhanced recovery messages are instantly recognisable…

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A best practicecare pathwaywith acompellingevidence base

Patientpartnership atthe heart of thepathway

ER minimises thestress patientsgo through

Patientpreparation isthe key

ER involves a number of components,when implemented as a groupdemonstrates a greater impact thanindividual parts

Access andequity in care...age is not abarrier

Patients get better sooner, fitter soonerand return home sooner, returning tonormal life, work and play

ER supports the spread of innovation asan integral part of the pathway e.g.intra-operative fluid managementtechnologies1,2,3

ER is the right care pathway - fewercomplications, better outcomes, costeffective and better patient experience =key outcomes for commissioners

ER is anexcellentexample of QIPPin practice

ER is onesolution thatsupports manypriorities, locallyand nationally4

The clinical case for ER being standardpractice for all patients and representinggood care is clear

Two choices ofbest practice -day case orenhancedrecovery

¹ CardioQ-ODM oesophageal doppler monitor: Medical Technology guidance 3,National Institute for Health and Clinical Excellence (March 2011)

2 NHS Innovation, Health and Wealth: Accelerating Adoption and Diffusion in the NHS (2011)3 National Confidential Enquiry into Patient Outcomes and Death, Knowing therisk: a review of the peri-operative case of surgical patients (2011)

4 NHS Evidence Oesophageal Doppler-guided fluid management during major surgery:reducing postoperative complications and bed days (2011) www.evidence.nhs.uk/QIPP

Clinicalcommissioninggroups have anopportunity to takeresponsibility forthe improvementof care quality.

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Paul Zollinger-ReadHSJ, 15 March 2012

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THE WIDER APPLICATIONSAND OPPORTUNITIES FORENHANCED RECOVERY

The National Enhanced RecoveryPartnership (ERP) has focused onspecific areas of surgery namelycolorectal, major joint, urological andgynaecological surgery. It is clear thatthe enhanced recovery principles andcomponents are common to allsurgical patients (Figure 1 on page 9).

The ERP is now exploring with clinicalteams the transferability of theprinciples and components into otherareas including; emergency surgery,vascular, AAA, oesophago-gastric,lung, liver, pancreatic and caesareansections. Some teams are alreadytesting in these areas with earlyindications of good results.

Enhanced recovery inoesophagogastric surgeryDr Michael Scott, Consultantin Anaesthesia and IntensiveCare Medicine Department ofAnaesthesia. Royal SurreyCounty Hospital

The whole team (surgeon,anaesthetists, ICU nurse,dietician, physiotherapist andmanager) visited a unit inSeattle known for the bestoutcome for oesophagectomyin world. The Surrey teamadapted the Seattle pathway toinclude the elements ofenhanced recovery such as;early mobilisation, nutrition,exercise and the Seattle teamadapted our goal directed fluidtherapy! Although early days,the first 12 patients has seen areduction in length of stay from18 days to six or seven days.

CASE STUDY

Abdominal aortic aneurysm repairUniversity Hospitals of North Staffordshire NHS Trust

The principles of enhanced recovery are being tested in the field of vascularsurgery. Using the open abdominal aortic aneurysm repair procedure as apilot, the Trust have developed a pathway which aims to reduce the lengthof inpatient stay in hospital as well as improving quality by providingadditional discharge support.

The length of stay for this group of patients was 7 to 11 days. The redesignof the pathway aims to achieve a five day inpatient stay. Patients willreceive a follow up telephone call service, two week open access to thesurgical assessment unit, as well as access to a 24 hour dedicatedenhanced recovery helpline on discharge.

CASE STUDY

Enhanced recovery and breast reconstructionOxford University Hospitals NHS Trust

Oxford University Hospitals NHS Trust undertook a survey of all UK centresperforming breast reconstruction surgery to define current UK practice withrespect to the preferred anaesthetic technique, the peri- and post-operativeapproach to thermoregulation, haemodynamic monitoring, fluid therapy,transfusion practice and analgesic strategy and demonstrated that there ishuge national variation in UK¹.

Oxford as run a pilot modified enhanced recovery (ER) regime to evaluatethe feasibility of introducing an ER protocol into practice for patientsundergoing breast free flap reconstructive surgery. The early preliminaryresults have been encouraging. The current length of stay for these patientsin Oxford is 7 to 10 days. The preliminary results from the pilot have shownthat patients can be safely discharged as early as day five. The Oxfordteam is keen to test this further working closely with the other specialtiesacross the Trust.

¹ Results of the survey were presented earlier this year at the Congress of the InternationalConfederation for Plastic Reconstructive and Aesthetic Surgery in Vancouver.

CASE STUDY

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The term Individualised goal directed fluid therapy used within thecase studies in this publication represents the use of intra-operativefluid management technologies as identified in 2012/13 NHSOperating Framework, Innovation, Health and Wealth Review(2011) and N.I.C.E. Guidance MTG3.


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ROLE OFPRIMARY CARE

PATIENTPREPARATION

ADMISSION

INTRA-OPERATIVE

POST-OPERATIVE

POSTDISCHARGE

CARE

Shared decision makingclarifying the range oftreatment optionsOptimising pre-operativehaemoglobin levelsManaging pre-existingco-morbiditiesDischarge planning andliaising with social care

SDM*Admission onday of surgeryOptimising fluidhydrationCHO loadingReducedstarvationNo/reducedoral bowelpreparation(bowel surgery)

PlannedmobilisationRapid hydrationand nourishmentAppropriate IVtherapyNo wound drainsNo NG (bowelsurgery)Catheters removedearlyRegular oralanalgesiaParacetamol andNSAIDSAvoidance ofsystemic opiate-based analgesiawhere possible oradministeredtopically

Shared decisionmakingOptimised health/medical conditionInformed & shareddecision makingPre-operativehealth and riskassessmentPT informationand expectationmanagedDischarge planning(Expected date ofdischarge)Pre-operativetherapy instructionas appropriate

Minimally invasivesurgeryUse of transverseincisions (abdominal)No NG tube(bowel surgery)Use of regional/LAwith sedationEpidural management(inc thoracic)Optimise fluidmanagementtechnologies to deliverindividualised goaldirected fluid therapy

Discharge when criteria metTherapy support (stoma, physio)24 hour telephone follow up

SDM

SDM

SDM

SDM

SDM

Figure 1: The enhanced recovery surgical pathway

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*Shared decision making (SDM) means involving the patient as an active participant in their care, first clarifyingthe range of clinically acceptable treatment options for them and then the patient working in partnership with theirclinical team in choosing the best treatment for them at the time, the treatment which best meets their individualneeds, values and preferences.

Shared decision making is a journey and runs throughout the pathway from self care through to highly specialistcare. It is not just about whether surgery is right for that patient at that time but how they want to be treated andmanaged and supporting them to be an active partner throughout their health care journey.

Shared decision making is integral to the enhanced recovery pathway.

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CONSIDER THEQUESTION:IF ENHANCEDRECOVERY HASPRODUCED SUCHDRAMATICIMPROVEMENTS INSURGERY... WOULDALL INPATIENTS,INCLUDING ACUTEMEDICINE, BENEFITFROM A SIMILARAPPROACH?

Enhanced recovery inacute medicineSome clinicians have now started toconsider the above question as anyacute illness can trigger a reductionin functional capacity similar to thatfollowing surgery.

Pulmonary rehabilitation support for curative lung cancersurgery: Heart of England NHS Foundation Trust

Babu Naidu, Associate Professor at the University of Warwick andConsultant Thoracic Surgeon at Heart of England NHS FoundationTrust and his team, in conjunction with Pan Birmingham CancerNetwork, have introduced a patient preparation programme forpatients undergoing curative lung surgery.

The rehabilitation programme is a multi-stranded chronic obstructivepulmonary disease (COPD) type programme that optimises health andprepares patients for surgery and continues to support recovery afterpatients return home. The programme has four key elements:

• Pulmonary rehabilitation exercise programme• Smoking cessation advice and support• Nutritional status assessment to identify nutritionally depletedpatients

• Patient self management and education which covers all aspects ofsurgery and recovery.

Impact to date• The post-operative pulmonary complication rate (PPC) has reducedfrom 18.7% to 11.4%

• The hospital re-admission rate has been reduced from16.1% to 5.7%

• The mean hospital length of stay (LOS) has been reduced from 7.2days to 5.7 days

• The ITU admission rate has reduced from 3.2% to 2.9%• In addition, the mean ITU LOS has been reduced from 3.6 daysto two days

• On their return from surgery all patients spend at least one night inward 4 High Dependency Unit (HDU)

• The mean HDU LOS has been reduced from 2.4 days to 1.9 days.• Delivered cost savings in the region of £44,000 over an 11 monthperiod

• £36,700 of this saving has been cash releasing to PCTs. The savingshave been made through reductions in ITU, HDU admissions andhospital readmissions. There have also been savings made throughreduced hospital LOS.

CASE STUDY

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There is currently little researchevidence in this area, but potentiallyuseful strategies which could beimplemented from the moment ofadmission, these could include:

• Prescription of high value nutritionfrom the moment of admission

• Active exercise programmesdesigned to prevent muscle loss

• Better fluid management• Full engagement of patients andcarers

• Provision of information aboutmanaging the acute episode andabout actions that could prevent arepeat admission.

If strategies of this nature were tohave the anticipated effect, bothpatients and the service wouldbenefit and:

• Patients would leave hospital lessdebilitated

• Some patients could avoid the‘tipping point’ into temporary orpermanent dependency

• Primary and social care wouldhave less dependent patients toprovide services for

• Discharge planning could bestarted at the point of admission

• Trusts would benefit fromreduction in length of stay andtherefore be able to reduce beds.

This fits well with the currentemphasis on out of hospital care andmoving care ‘closer to home’.

The potential for active rehabilitationhas already been recognised invarious areas of medical care:

• The emerging role of acutephysicians with an active approachfrom the moment of admission tohospital

• Outreach teams in some healthcommunities prevent unnecessaryadmission and support earlydischarge

• Many stroke services adopt apro-active approach tore-ablement

• NICE¹ guidance published recentlyidentifies the need to reducedebility following episodes incritical care and individual sites arestarting to design appropriatepathways.

These useful strategies may besimple and obvious, but as insurgery, will require a change in theculture and behaviours of care-giversof all disciplines to engage morewith patients and their carers asactive participants as a way toimprove quality of care.

1 http://guidance.nice.org.uk/CG832 Liberating the NHS. Department of Health, (2010)3 The Institute of Healthcare Improvement’s ‘Transforming care at the bedside’ (2004). www.ihi.org4 The King’s Fund ‘Patient-Centred Care Programme (2011). www.kingsfund.org.uk

Enhancing recovery in acutemedicine would support the conceptof ‘No decision about me, withoutme.’2 Involvement of patients hasbeen described in papers suchas the Institute of HealthcareImprovement’s ‘Transforming care atthe bedside3’ and The King’s Fund‘Patient-Centred Care’ Programme.4

Active research is urgently needed toassess the potential for enhancedrecovery strategies to impact on allinpatients.

Kerri Jones, Associate MedicalDirector for Innovation andImprovement, South DevonHealthcare NHS Foundation Trustand advisor to the EnhancedRecovery Partnership.

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ENHANCED RECOVERY INEMERGENCY SURGERY

The Association of Surgeons ofGreat Britain and Ireland (ASGBI)guidelines¹ points out that althoughenhanced recovery pathways havebeen primarily studied in the electivesetting, they should still be appliedto the emergency situation.

Although in emergenciesimplementation of the pre-operativecomponents may not always bepossible, every effort should bemade to implement as manycomponents as possible. The ASGBIare currently updating the guidelinesto include a section on emergencycare.

Emergency Fractured Neck of Femur PathwayThe Royal Liverpool and Broadgreen UniversityHospitals NHS Trust

The Royal Liverpool and Broadgreen University Hospitals NHS Trusthave applied the principles to the unplanned hip fracture pathway.

Patients are:• Fast tracked from the emergency department (ED) to the neck offemur unit within two hours by early notification from theparamedic to emergency department

• Nursed on pressure relieving mattresses• Operated on within 24 hours.

Patients’ health is optimised pre operatively with visits from theconsultant ortho-geriatrician and anaesthetist. Pain is controlledthrough a locally produced, evidence based algorithm. Nutrition statusis optimised with minimal starvation times. Patients are mobilisedearly, either day of surgery or morning after, facilitating earlyrehabilitation. The pathway was facilitated by an advanced nursepractitioner and use of electronic tracker to fully inform the MDT.

Patients operated within 24 hours of admission has increased from 33to 71%. Median LOS has reduced from 27 to 14 days.

CASE STUDY

1 Guide for Implementation of Enhanced Recovery Protocols Association of Surgeons of Great Britainand Ireland guidelines (December 2009)

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Emergency laparotomies: Development of an enhanced recovery care pathwayRoyal Surrey County Hospital NHS Foundation Trust

Emergency laparotomy is a high risk procedure, leading to high mortality rates most notable in the elderlypopulation, requiring high utilisation of critical care and ward bed days.

Local problems with pathway were identified• Poor identification of high risk patients• Less experienced trainees treating patients• Frequent rotation of trainees• Delays in diagnosis and resuscitation of patients• Increasing frequency of out of hours operations• Increasing use of resources.

Care bundle approach supporting enhanced recoveryAnaesthetists at the Royal Surrey County Hospital recognised the need to change their emergency surgical carepathway and implemented care bundles to improve co-ordination of care and consistency of evidence basedcare delivery.

A multidisciplinary team developed a five stage care bundle based on previous experience with colorectal,oesophagetomy and hepatobiliary tract surgery, Goal Directed Fluid Therapy standard and national and localtrials, such as OPTIMISE and local liver resection randomised control trials.

The pathway was also designed to capture the data set required for HQIP National Emergency Network audit.1

ResultsInitial results showed that in the highest risk patients the adoption of the pathway resulted in a dramaticallyreduced length of stay from 20.5 days to 12 days.

1National Institute of Anaesthesia Health Services Research Centre www.niaa-hsrc.org.uk/araticle.php?newsid=299 (accessed 21/02/2012)

CASE STUDY

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ENHANCED RECOVERY INOBSTETRICS

Whilst there is no researchspecifically looking at enhancedrecovery in obstetrics it is reasonableto assume many of the principlesused in gynaecology can be appliedin obstetrics. Elective caesareansections would seem the mostobvious place where these principlescan be used in clinical practice.

Women frequently have theiroperations delayed by emergencyprocedures, meaning they spendlong periods without food or drink.Postnatally, this may delaymobilisation and discharge as well asestablishment of breastfeeding. Byensuring women are in the optimumcondition pre-operatively theseeffects can be minimised.

1 Kadir RA, Khan A, Wilcock F, Chapman L Is inferior dissection of the rectus sheath necessary duringPfannensteil incision for lower segment caesarean section? A randomized controlled trial Eur J ObstetGynecol Reproduct Biol 2006 Sep-Oct;128(1-2):262-6.

2 Hofmeyr GJ, Mathai M, Shah A, Novikova N,Techniques for caesarean section.Cochrane Database Syst Rev 2008 Jan 23;(1):CD004662

3 Attilakos G, Psaroudakis D, Ash J, Buchanan R, Winter C, Donald F, Draycott T Carbetocin versusoxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of adouble blind randomised controlled trial BJOG 2010;117:929-936

PRINCIPLES THAT CAN BE APPLIED

ANTENATAL• Maximise antenatal well-being; ensure Hb optimised, considerprophylactic iron

• Proactive breast-feeding tuition antenatally• Creation of an elective caesarean list with designated times to attend,rather than all coming in at 8am

• Encourage women to eat and drink right up to the cut off times (i.e. sixand two hours before their report time)

• Give energy drinks to have two hours before proposed section time.Give further drinks if procedure delayed

• Appropriate psychological preparation, with an expectation of goinghome after 24 hours and explanation of what to expect with regardsto pain.

PERI-OP• VTE prophylaxis• Prophylactic antibiotics• Careful haemostasis and use of cell salvage where appropriate.• Operative techniques to minimise pain such as not dissecting the sheathposteriorly1 and using Cohen's entry2

• Use of carbitocin instead of syntocinon infusion may allow quickerreturn to the ward and establishment of breast feeding.3

POST-OP• Remove catheter after 12 hours (regardless of time). Women’sdischarge is frequently delayed as they have not completed theappropriate number of voids. Women will be up in the night with anew baby so waking them to perform this will not be necessary

• Regular analgesia and tuition as to how best to administer it• Good breastfeeding support• Home after 24 hours• Good community midwife support.

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ENHANCED RECOVERY:SAFE CARE SEVEN DAYS AWEEK

There is a growing body of evidenceto suggest that where there is a lackof access to clinical services over aseven day period, patients do notalways experience parity of access tothe optimum treatment or diagnostictest. This can result in delays to theirtreatment that can contribute to lessfavourable clinical outcomes.However, some clinical services areresponding very positively to sevenday demand for their services andcan clearly demonstrate the benefitsfor both patients, their carers andoften staff.

The principle of ‘equality oftreatment or clinical outcomeregardless of the day of the week’may be delivered without necessarilyproviding all services at the samelevel. It may be that elective servicesrequire different service deliverymodels than acute services, but thatthe level of service provided shouldensure that the patients continue to‘flow’ through the system and matchcapacity to demand.

More detailed descriptions of sevenday working and case studies canbe found at:www.improvement.nhs.uk/7dayworking

Enhanced recovery: Safe care, seven days a weekRehabilitation seven days per week for elective orthopaedicpatients: Golden Jubilee National Hospital Scotland

The enhanced recovery model has been rolled out for electiveorthopaedic surgery of the hip and knee across Scotland to ensurethat the quality of care is maintained for every patient with an agreedcriteria for elective surgery and bespoke plans in place, leading to nodelays in treatment, therapy or discharge, a reduction in length of staywith fewer hospital acquired infections being contracted as a directresult. The patients experience continuity of care as early discharge isfacilitated by care of community therapists as required. Nine out of 12boards are implementing the enhanced recovery pathways. Theaverage length of stay (LOS) for hip replacement is 3.6 days and kneereplacement 3.8 days.

A one-stop pre-operative assessment clinic has been implementedduring which post operative equipment and social care needs areidentified and arranged across 37 social services departments acrossScotland.

Data shows there was no increase in either complications orreadmissions. Additionally, patient satisfaction improved:• £20,000 can be saved per annum by moving to seven day workingrather than overtime rates for weekends

• Savings of approx £35 per patient on consumables (drugs andwires) identified

• Restricting the choice of prosthesis to two for both hip and kneereplacements has enabled savings of over six figure sums.

Physiotherapists, occupational therapists and rehabilitation assistantswork seven days a week to mobilise patients and discharge across theweek following elective orthopaedic hip and knee replacements. Thesurgeons operate Monday to Friday with a current activity of 60-70joint replacements per week (approximately 3,000 per year).

Further work using lean principles is being undertaken to identify anyoverlap of work and see if time can be released between thephysiotherapists and occupational therapists.

West Scotland are looking to roll this out across heart and lungsurgical transplants.

David McDonald, Caledonian Coordinator, Physiotherapist andEnhanced Recovery Lead, Golden Jubilee National Hospital Scotland

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This initiativehas my fullsupport.Professor Steve FieldsChairman, NHS Future Forum

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WHY CHOOSEENHANCEDRECOVERY... THEBENEFITS• The adoption of enhancedrecovery continues to buildmomentum across the country

• Clinicians, managers,commissioners and patients arerecognising the benefits of ER andits value

• Improvements in the quality ofcare, outcomes, patientexpectations, experience, andefficiency with reductions inunnecessary lengths of stay havebeen highlighted by organisationswho have embedded the pathwayinto day to day practice1.

QUALITY AND OUTCOMES• Improved clinical outcomes• Early detection of risks• Reduction in complications• Earlier interventions/treatmente.g. chemotherapy

• Supporting the achievement ofquality standards andrecommendations 18 weeks, cancerwaits, NCEPOD1

• No increases in re-admissions• Proactive pathway management,improved co-ordination,communication and cooperation

• Supporting integrated care andmultidisciplinary team workingacross the entire pathway.

PATIENT INVOLVEMENT ANDEXPERIENCE• Patients better sooner, returning tonormal activities sooner

• Agreed care partnership withpatients having a clear role andresponsibilities forenhancing their own recovery

• Reduced exposure to risks e.g.hospital acquired infections

• Building the patients confidence andtrust in care delivery, supportingshared decision making

• Improving the access and equity ofcare, a consistent reduction invariation

• Improved satisfaction.

EFFICIENCY• Reductions in unnecessarylengths of stay

• Reductions in duplication of tests• Reduction in cancelled theatre lists• Released bed capacity• Bed days saved in ITI and HDU(where applicable)

• Tariff excess – no gain for two years.Good for commissioners to knowhow providers are utilising thebenefits for the population

• Reduced morbidity translating intoreal cost savings

• QIPP gains.3

INNOVATION• Spread and adoption of enhancedrecovery principles across specialtiesand clinical teams

• New learning and researchopportunities e.g. acute medicine

• intra operative fluid managementtechnologies2

WHERE ENHANCED RECOVERY HAS BEEN EMBEDDED,ORGANISATIONS, CLINICAL TEAMS AND PATIENTS HAVEREPORTED A RANGE OF NATIONAL AND LOCAL BENEFITS.

Sections 2, 3, 4 and 5 continues to provide furtherdetails on the benefits of enhanced recovery.

1 National Confidential Enquiry into Patient Outcome and Death (2011).Knowing the risk: a review of the peri-operative case of surgical patients

2 NHS Innovation, Health and Wealth. Accelerating Adoption and Diffusion in the NHS (2011)

3 Department of Health - Quality, Innovation, Productivity and Prevention (2010)

Enhanced recoveryis great forcancer patientsand for QIPP andfrom an NHSCommissioningBoard point ofview - a proof ofprinciple to beemulated.

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Ciaran Devane, Chief ExecutiveMacmillan Cancer Support andNon Executive Director of the NHSCommissioning Board

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PATIENTS

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BAUS aims to ensure the highest standards of care and encourage contemporary practice with best outcomes,recognising that patients are central to our practice. BAUS is keen to both create new evidence of best practiceas well as promote the adoption of learning from others. The ERPP is a national collaborative approach to tryand improve clinical outcomes for individual patients, which enables them to be fitter, return home sooner andimprove the overall patient experience for those undergoing surgery.

BAUS is keen to see national adoption of such evidence-based programmes with a view to reduction invariation of care across the NHS and supports the integration of national audit to enhance the evidence base.

BAUS wishes to be in the vanguard to deliver a formal SpR education programme integrated into their trainingto ensure that the next generation of Urologists continue to promote enhanced recovery programmes and bestpractice measures to encourage the population of the evidence base for future practice. We also want toensure that the next generation are trained to deliver the sort of care that contemporary modern practicedemands.

Adrian Joyce, President of the British Association of Urology Surgery

British Association of Urology Surgery - keen to adopt

PROFESSIONAL COLLEGES AND ASSOCIATIONSRECOGNISING THE BENEFITS AND SUPPORTING ENHANCEDRECOVERY AS THE SENSIBLE WAY FORWARD

Enhanced recovery continues todemonstrate the benefits of itsevidence-based team approach topractice improvement - with thepatient at the heart of that team.The challenge now is widespreadimplementation of this good practicein a robust and supported way,ensuring all eligible patients haveaccess to the highest standardsof care.Professor Norman Williams,President, The Royal College of Surgeons

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The Royal College of Anaesthetists stronglysupports integrated care pathways; theenhanced recovery programme offers bothmedical and patient engagement in aprocess of identifying needs and tailoringcare from referral to recovery.

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’’Dr Peter Nightingale, Royal College of Anaesthetists

Enhanced recovery of orthopaedic patients, especially thosehaving replacement of painful arthritic joints hasdemonstrated an improvement in several ways. It has madepatients feel better sooner and as a consequence has reducedthe recovery time in those units using it fully. The BritishOrthopaedic Association has supported all elements ofenhanced recovery and outreach support for patients whohave had surgery for their musculoskeletal disorders and areexploring how this can be extended to trauma surgery. Webelieve this will improve the quality of care our patientsreceive and would support evaluation and translation offindings into practice improvements. We have recommendedthe incorporation of enhanced recovery aspects into the BestPractice Tariff for primary hip and knee arthroplasty.

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Professor Joseph Dias, President of theBritish Orthopaedic Association.

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From a BASO point of view, we would whole heartily supportthis. Enhanced recovery is being introduced in other specialtiesand there is much to learn from international practice. BASOwill make sure enhanced recovery becomes a standing itemon the College Cancer Services Committee agenda.Mr Mike Hallisey, BASO - ACS President,BASO - The Association for Cancer Surgery

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The Enhanced RecoveryProgramme is an importantdevelopment in improving the care of patients undergoingsurgery, particularly given increasing patient dependence andcomplexity of healthcare. For those who require intensive careas part of the postoperative pathway, there are threestrategies which improve outcomes: early intervention tooptimise physiology; prevention of complications includinginfection and immobility; and integration of care over timeand across disciplines and locations. These principles arewell-exemplified in the Enhanced Recovery Programme, andit is likely that they are generalisable to other domains ofhealthcare including emergency medical admissions.Reliable delivery of current best practice within the frameworkof enhanced recovery also permits the continued researchevaluation of specific components to ensure that newknowledge can be incorporated and adopted rapidly.Professor Julian Bion, President, Intensive Care Medicine

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ENHANCED RECOVERY: EVERYDAY PRACTICEFOR EVERY PATIENT - FULFILLING THEPOTENTIAL

The Enhanced Recovery Partnershipprogramme 2010 guide: Deliveringenhanced recovery: helping patientsto get better sooner after surgery¹acted as a starting point for clinicalteams and organisations committedto providing the highest quality ofcare.

This section aims to address some ofthe clinical practice aspects that mayhinder the adoption of enhancedrecovery as everyday practice.

Increasing equity of practiceCurrently at least 50% of NHS Trustshave fully implemented enhancedrecovery across one specialty. During2012, the Enhanced RecoveryPartnership aims to maximiseadoption across the original eightprocedures, colectomy, excision ofrectum, prostectomy, cystectomy,hysterectomy (vaginal andabdominal) and hip and knee¹ andencourage lateral adoption intoemergency surgery.

Supporting the patient to be inthe best possible conditionFor patients to achieve the bestresults from enhanced recovery,it is vital that assessment andpreparation starts with the GPassessment2.

PATIENTPREPARATION IS THEKEY TO SUCCESS.

Preparation includes:

1. Provide health screening priorto referral. This helps to identifycauses of increased morbidity –such as anaemia,3,4,5 (Figure 2 onpage 21) sub-optimal diabeticcontrol6, hypertension, reducedrenal function, obesity, smokingand general low levels of physicaland psychological fitness.

2. Review and actively manageexisting long term and mentalhealth conditions. Advise andsupport on diet, smoking, alcoholintake and exercise is ongoing andnot only prior to admission intohospital but at this time changesin life style supports recovery.

3. Discuss treatment options andchoices as part of shareddecision-making², The GP helpsthe patient to understand thetreatment options available andsupports the patient in makingthe right decision to proceed ornot.

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Enhanced recovery requires thebuilding of amultidisciplinaryteam, that crosses organisationaland functional boundaries, it isabout the entire pathway of care,from home to home.

‘Alan Nye, National Primary Care Clinical Lead

‘

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¹ Enhanced Recovery Partnership: delivering enhanced recovery: helping patient to get bettersooner after surgery (2010)

2 Shared decision making NHS Operating framework 2012/13.3 http://hospital.blood.co.uk/library/pdf/INF_PCS_HL_011_01_Iron_leaflet.pdf4 www.transfusionguidelines.org.uk5 www.nhs.uk/Conditions/Anaemia-iron-deficiency-/Pages/MapofMedicinepage.aspx6 UKPDS UK prospective diabetes study, DCCT (Diabetes Control and Complications Trial)

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4. Promote the patients’understanding of their roleand responsibilities inenhancing their own recovery.

5. Bring more aspects ofpreparation care closer tohome.7

6. Identify physical, psychologicaland social risks of recoveryearly. This can lead to earlierreferral to supporting agenciesincluding social care and charitiesfor support. With enhancedrecovery, GPs know that thepatient will not be in hospital forlong and early discussions withthe patient on discharge andsupport can commence,continue to support shareddecision-making.

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Figure 2: Optimising patients with anaemia prior to surgeryDID YOU KNOW?• Shared decision-makingis part of the NHSOperating Framework

• 30 decision aids arebeing developed overthe next 15 months, inaddition to the existingnine aids

For further information goto: www.rightcare.nhs.uk

7 www.dh.gov.uk/en/Healthcare/Primarycare/Practitionerswithspecialinterests/DH_074419

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Pre-operative assessmentThe patient’s pre-operativeassessment appointment isimportant because this is about:

• Good planning• Identifying and managing risk• Continuing to keep patients fullyinformed and involved in theshared decision making

• Offering a date for pre-operativeassessment when appropriate, inmany cases this is on the same daythe decision for surgery/treatmentis made so therefore a date andtime for admission can be agreedwith the patient

• Scheduling pre-operativeassessment clinics carefully. Thiswill enable timely patientassessment of the patient’s ‘fitnessfor surgery.’ This helps to reduceoperation cancellations, repeatedtests,1 unnecessary procedures andprovide timely informed consent

• Giving anaesthetists a key role inpre-operative assessment

• Pre-operative assessment is wheredischarge planning starts, referralsto agencies can also be made atthis point to support dischargewhere required and patients aretherefore prepared for admissionon the day of surgery.

PATIENT PREPARATION IS THE KEY TO SUCCESS

DID YOU KNOW?Anaesthetists supportshared decision-making inpre-op (major surgery)assessment clinics for highrisk patients giving patientsan accurate assessment ofrisk. Patients do notalways realise at this pointthat surgery is not the onlyoption.

Social care referrals made at pre-operative assessmentScarborough Hospital NHS Trust, Yorkshire

Scarborough Hospital NHS Trust involved social services as keymembers of the Enhanced Recovery (ER) Steering Group. Initially, ERwas implemented for patients undergoing hip and knee surgery.

Through the actions of the ER steering group, it was agreed that anypatient requiring a social services assessment would have their‘Section 2’ referral made at the pre-operative assessment clinic by thepre-operative assessment nursing staff. Providing the patient had anagreed date for admission. Once completed the ‘Section 2’ referralwas faxed across to the Social Services Department.

Length of stay for hip and knee surgery as reduced from 4.5 days to2.8 days. This improvement has been achieved by the contribution ofsocial services early assessment and providing earlier dischargesupport.

CASE STUDY

¹ NICE clinical guidelines on routinepreoperative tests for elective surgery.

PLEASE REMEMBER TO CHECKPatients receive a huge amount of information within eachcontact with the hospital during their pre admission phase.Messages and information given to the patient regardingLOS, their role in recovery etc. must be consistent from acrossthe team. This information comes to a pivotal point atpre-operative assessment where best practice would expectthat information and decision making is checked betweenpatient, relative, carer and the hospital team

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Peri-operative riskThe structure of the peri-operativerisk assessment should be designedto provide both a generic andprocedure specific assessment(Figure 3).

Patients should have access to all thenecessary information and continueto be actively involved in decisionmaking and informed consentprocess.

The pre-operative assessment shouldbe carried out by trained andcompetent pre-operative assessmentassessors who should be able toorder and perform basicinvestigations and make referralsaccording to local guidelines agreedby the clinical team¹.

IDENTIFYING THE RISKS

Figure 3: Traffic Light Triage Tool - identifying the risk

Traffic Light Triage Tool at pre-operative assessment (Figure 3)South Devon Healthcare NHS Foundation Trust

South Devon Health Care NHS Foundation Trust uses a traffic light triage tool at pre-assessment (Figure 3)for patients undergoing hip and knee surgery. The tool provides:• The identification of potential risk• Determines who should conduct pre-operative preparation, e.g. nurse, anesthetics.• Identifies the level of risk of mortality and morbidity following surgery• Identified the HDU resources potentially required• Green: risk of mortality less than 1:200, risk of serious mortality less than 1:100 with no need for HDUfacility for elective surgery

• Orange: risk of mortality 1:200 and serious morbidity 1:100• Red: risk of mortality 1:100 and serious morbidity 1:50• Orange and Red potentially need HDU facilities post operatively.

CASE STUDY

¹ BV Murthy (2006). Improving the patients journey: The role of pre-operative assessment team. The Royal College of Anaesthetists,Bulletin May 2006. www.roca.ac.uk/docs/Bulletin37.pdf

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Risk assessment in pre-operative assessment clinic improveoutcomes for patientsSouth Devon Healthcare Foundation NHS Trust

South Devon Healthcare Foundation NHS Trust reviewed the outcomeof 314 patients who had a colorectal resection for an adenocarcinomafollowing introduction of the enhanced recovery pathway. Analysis ofdata revealed there was an association between attending a high riskpre-operative assessment clinic and long term survival.

Attendance of patients at the pre-operative assessment clinic enabledpro-active planning for the postoperative HDU stay compared tothose patients who were not seen in the clinic.

Overall the cost of critical care was greater in those that did not attendthe high risk clinic and had a worse survival.2

2 Carlisle J, Swart M, Dawe E, Chadwick M. Factors associated with survival afterresection of colorectal adenocarcinoma in 314 patients. BJA 20012; 108: 430-5

CASE STUDYImprovements in pre-operativeassessment and preparation,peri-operative care andpost-operative support haveprovided an important reduction inthe mortality rate, which has in turnprovided savings in terms ofICU/HDU bed days per patient, aswell as decreasing the number andseverity of complications suffered bypatients following surgery.

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Cardiopulmonary exercisetesting (CPET)Objective assessment of functional(or exercise) capacity usingcardiopulmonary exercise testing(CPET)1 is increasingly being used toassess peri-operative risk in majorsurgery. Consideration should begiven to performing a CPET in anypre-operative patient who hasincreased risk or is scheduled toundergo a high risk surgicalintervention. CPET benefits patientby helping to stratify them into postoperative care in a ward, highdependency or intensive care setting.

Risk Assessment and PredictionTool (RAPT)This is a simple risk tool thatidentifies those patients who may beat the highest risk of delayeddischarge due to post operativerehabilitation needs. The RAPT2 toolhas been used on hip and kneearthroplasty surgery patients. It isused to measure risk and predictpotential outcome. Risk is based onage, gender and ability to getaround without help

Knowing the potential outcomeahead of time could help familymembers and carers prepare betterfor the patient's care.

Knowing the risk - NationalConfidential Enquiry into PatientOutcome and Death: A review ofthe peri-operative care ofsurgical patients (December2011)

Enhanced recovery pathwayscould provide the solution formeeting the NCEPODrecommendations.

Use of CPET to define level of post-operative care for electivemajor abdominal surgeryFrimley Park Hospital NHS Foundation Trust

Patients for elective major abdominal surgery over the age of 60 yearsattend pre assessment clinic to undergo CPET. Each patient will take10-12 minutes for exercise protocol, however, the total test takesaround 30-45 minutes including preparation. Those with unstableangina, fixed cardiac output states like severe aortic stenosis and thosewho cannot perform cycling are excluded.

For postoperative care, patients are categorised in three groups:i) Ward-based care postoperatively (AT >11, VO2Max >15, Veq O2

<35, Veq CO2 <42, good increase in oxygen pulse from their baseline)

ii) HDU post-operative care -those who may have an AT >11 but withcardiac ischaemia or abnormal ventilatory equivalents of either O2or CO2

iii) ICU post operative care - those who have AT <11, VO2 <15 orwith other significant cardiac or pulmonary abnormality.

CASE STUDY

¹ Smith TB et al. Car diopulmonary exercise testing as a risk assessment method in non cardiopulmonary surgery: a systematic review.Anaesthesia 2009. Aug; 64(8): 883-93.

2 Leonie B. Oldmeadow, MClinEduc, et al. Targeted Postoperative Care Improves Discharge Outcome after Hip or Knee Arthroplasty.In Archives of Physical Medicine and Rehabilitation. September 2004. Vol. 85. No. 10. Pp. 1424-1427.

“1. Identification of thehigh risk groupThe first challenge is to reliably andaccurately identify the patient groupthat is at high risk of mortality andmorbidity. Whilst this might seemobvious, the literature is full ofdiffering descriptions, scoringsystems and tests to meet this aim.They are largely based onassessment of comorbidities alone orcombined with a classification ofsurgical intervention. Tests of organfunction and more recently ofphysiological reserve are also used totry to address this issue.”

“2. Improved pre-operativeassessment, triage andpreparationMeasures to improve fitness forsurgery can be targeted and appliedif the identification of these high riskpatients can be performed in a

suitable timescale. Usually, thisprocess is thought of as havingstarted once the patient has beenaccepted for surgery but morerecent developments identify primarycare as a key partner in identifyingfitness for surgery. As well as specificoptimisation of comorbidities it isimportant to manage volaemicstatus and nutritional status.Recently there has been interest inimproving physiological reserve,using exercise regimens, whereappropriate. There is also theopportunity to consider if surgicalintervention is the best course ofaction due to the risk of adverseoutcomes”.

National Confidential Enquiry intoPatient Outcome and Death (2011):A review of the perioperative care ofsurgical patientswww.ncepod.org.uk

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Patient preparation promotescontinual assessment inmanaging the risk

Joint schoolsJoint schools are becomingcommon practice in a number oforganisations, they are viewed as akey part of the pathway for patientsundergoing total hip and kneereplacements. These schools arewhere patients meet with membersof the clinical team on either a oneto one basis or in groups to receiveinformation, instruction and exerciseaimed at optimising the patientscondition physically andpsychologically, pre and postoperatively.

A variety of models and tools forpatient pre-operative education forpatients are evolving andincreasingly patients undergoingsurgery will receive information viause of DVDs to help themunderstand not only the pathway ofenhanced recovery but their role andresponsibilities in enhancing theirrecovery.

DVD films for patients undergoing hip/kneereplacement surgeryRobert Jones and Agnes Hunt Orthopaedic District Hospital

For patients undergoing enhanced recovery hip and knee replacementsurgery at the RJAH, a DVD has been produced to help patientsunderstand the process.

There are two DVDs; one for patients undergoing total hipreplacement and a further one about knee replacement surgery. Theyhave been produced by NHS Digital Services. The DVD providesreassuring information for patients. The films feature a selection ofpatients talking about their personal experience of rapid recovery jointreplacement, alongside surgeons and a physiotherapist and ananaesthetist, who explain why it is good for patients and the numberof benefits they are likely to experience.

Patient David, 69, from Cheshire was followed by the film crew on theday. The DVD shows him before going to theatre, in the anaestheticroom, awake but sedated in the operating theatres having hisoperation with consultant orthopaedic surgeon Mr Tony Smith andreturning to the ward, eating and then getting out of bed to walk justa few hours after surgery.

CASE STUDY

Preparation for breast surgeryRoyal Marsden NHS Foundation Trust

Patients are taught the basic arm and breathing exercises in group classes at pre-operative assessment. Thephysiotherapists have produced a DVD of exercises which patients can take home with them and use in thecomfort of their own living room. The DVD also contains advice and tips from clinicians on maximising speedof recovery for patients post-surgery.

“It has proved a huge hit with our patient cohort and has ensured that we are giving them the care they needwithout delaying their discharge home,” says Kate Jones, Clinical Specialist Physiotherapist at the RoyalMarsden.

CASE STUDY

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Delivering major breast surgery safely as a day case or one night stay. www.improvement.nhs.uk


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Proactive care of older peoplegoing to have surgery (POPS)teamThe Guys and St Thomas’ POPSservice works closely with thesurgical teams along the enhancedrecovery pathway, providing ward-based education that focuses onelderly care and surgical issues. Themulti-disciplinary team providespre-operative assessment forpatients aged over 65 years withmultiple complex comorbidities orfunctional problems. Patients areoptimised for anaesthetic andsurgery.

The team then follows the patientthrough the surgical admission,addressing medical, functional anddischarge planning concerns. ThePOPS team provides structuredsupport for the following surgicalspecialties: orthopaedics urologyvascular upper and lowergastrointestinal surgery ear, noseand throat surgery head and neck,and maxilo-facial surgery.

Focused pre-operative patient stoma education, prior toileostomy formation after anterior resection, contributes to areduction in delayed discharge within enhanced recoveryAshford and St. Peter’s NHS Foundation Trust

Stoma formation is a well-known cause for delayed dischargefollowing colorectal surgery. This has been addressed by the enhancedrecovery programme (ERP) pre-operatively through stoma counsellingsessions. These aim to promote independent stoma managementpost-operatively, thus expediting hospital discharge. We compared thenumbers of patients with prolonged hospital stay secondary todelayed independent stoma management prior to and following theintroduction of an enhanced recovery programme with pre-operativestoma education.

MethodsA retrospective data collection on 240 patients undergoing anteriorresection with the formation of a loop ileostomy (September 2008 toOctober 2010) of which120 patients were pre enhanced recovery and120 patients post introduction of ER. Comparisons were made inpatients with prolonged hospital stay (defined as hospital stay of morethan five days) secondary to stoma management.

Results17.5% of patients in the pre-ERP group experienced postponedhospital discharge due to a delay in independent stoma management,compared to 0.8% of patients experiencing such a delay after theintroduction of ERP.

ConclusionsDelayed discharge secondary to independent stoma management canbe significantly reduced with pre-operative stoma managementteaching as part of an enhanced recovery programme.

Younis J, Salerno G, Fanto D, Hadjipavlou M, Chellar D, Trickett JP.International Journal of Colorectal Disease, 2012, 2012 Jan;27(1):43-7.

CASE STUDY

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SPOTLIGHT ONANAESTHETICS

Minimising the risk of postoperative nausea and vomiting• Avoid use of nitrous oxide• Consider the use of intra-operativeanti-emetics and prescribe first-lineand rescue anti-emetics routinely.

Anaesthetics a key role inenabling early mobilisation• Analgesia must be effective toallow early mobilisations

• Where possible regionalanaesthetic techniques or nerveblocks should be used and longacting opiates usage should beavoided or minimised wherepossible

• Regular paracetamol and a non-steroidal anti-inflammatory agent(INSAID) will reduce opiaterequirements

• Where regional analgesia cannotbe used, patient controlledanalgesia (PCA) using intravenousmorphine with a combination ofanalgesic regime e.g. paracetamoland ibuprofen (if not contra-indicated) can be very effectiveat reducing morphine usage.Mobile delivery systems arehelpful

• The advantages of using of spinalanalgesia include lower insertionfailure rate, lower rate ofcomplications and patients canmobilise sooner

• Traditionally, epidurals can provideexcellent analgesia. However, theydo not always maximisemobilisation. Other approachesinclude local anaesthetic injectiontechniques, rectus sheaths or TAPblock, with or without in dwellingcatheter.

Effective analgesia in abdominalsurgery• In open abdominal surgery avariety of epidural analgesia canprovide optimal post-operativeanalgesia. Sited in the thoracicregion of the spine maximisingpain relief to the abdominal area

• The use of Transversus AddominusPlane (TAP) blocks are popularwith laparoscopic surgery.

Maintain normothermia pre andpost operatively• This reduces the risk of bleedingand wound infection.

• Hypothermia can be prevented byroutinely monitoring the patient’stemperature in theatre andutilising an air-warming system,along with intravenous fluidwarmers, as per NICE guidance1.

ENSURING THE PATIENT HAS THE BEST POSSIBLE CARE,MANAGEMENT AND REHABILITATION: PUTTING THESPOTLIGHT ON THE FREQUENTLY ASKED QUESTIONS

1 National Institute for Health and Clinical Excellence, Inadvertent perioperative hypothermia,The management if inadvertent perioperative hypothermia in adults: guidance 2008

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Predictors of poor outcome2 include:greater age, higher ASA status, highblood loss, longer than expectedsurgery, evidence of hypovolaemiaand/or hypoperfusion (e.g. metabolicacidosis, blood lactate > 2mmol/litre, central venous O2 <70%), greater use of vasopressors,high volumes of i.v. fluids (> 3.5litres total), positive fluid balance (>2 litres positive on day of surgery).

Failure to achieve these aimssuggests quality of care should bereviewed, and/ or the need forongoing care in a higher careenvironment (e.g. extended recovery,HDU or ITU).

Intra-operative fluidmanagement

Indicators of central hypovolaemiainclude:• Blood and/or fluid loss• Tachycardia• Hypotension• Cool peripheries• Low CVP• Low cardiac output• Reduced stroke volume• Pulse pressure variation (duringIPPV)

• Pre-load responsiveness• Low central venous O2 saturation.

Central hypovolaemia shouldrespond to volume therapy (i.e. afluid bolus).

The Enhanced RecoveryPartnership recommends thedevelopment of localguidelines and algorithmsfor fluid management andregular audit of compliance,in line with nationalguidelines, NICErecommendations and theInnovation, Health andWealth Review (2011).

The Enhanced RecoveryPartnership recommends theuse of intra-operative fluidmanagement technologiesto enhance treatment withthe aim of avoiding bothhypovolaemia and fluidexcess. This should bedecided on a case-by-casebasis adhering to localguidelines in the context ofNICE recommendations,national guidelines and theInnovation, Health andWealth Review.

The Enhanced RecoveryPartnership recommendsthat all anaesthetists caringfor patients undergoingintermediate or majorsurgery should have cardiacoutput measuringtechnologies immediatelyavailable and be trained touse them.

GENERAL PRINCIPLES OFENHANCED RECOVERY FLUIDMANAGEMENT• Maintain good pre-operativehydration

• Give CHO drinks pre-op• Use intra operative fluidmanagement technologies todeliver individualised goal directedfluid therapy

• Avoid crystalloid excess (salt andwater overload)

• Avoid post-operative i.v. fluids• Encourage early post-operativedrinking and eating.

Aims of enhanced recovery fluidmanagement (by the end ofsurgery)• Patient is warm and well perfusedwith no evidence of hypovolaemiaand/or tissue hypoperfusion/hypoxia

• Hb > 7g/dl• No clinically significantcoagulopathy

• ‘Zero balance’ (i.e. less that 1litre positive fluid balance)

• Minimise use of vasopressors.

The Enhanced Recovery Partnership fully supports the use ofintra-operative fluid management technologies to deliverindividualised goal directed fluid therapy. This is recommended inthe 2012-13 NHS Operating Framework1, in the Innovation, Healthand Wealth Review2 and in NICE Guideline MTG33.

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The use of intra-operative fluidmanagement technologies isrecommended from the outset byNICE guidelines in high risk surgeryand in high risk patients undergoingintermediate risk surgery. Thisincludes the following types ofcases:• Major surgery with a mortality rateof > 1%

• Major surgery with andanticipated blood loss of greaterthan 500mls

• Major intra-abdominal surgery• Intermediate surgery in high riskpatients (including patients aged> 80 years)

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The Enhanced RecoveryPartnership recommends theregular audit of practice andoutcomes benchmarkedagainst national data forsurgical procedures.

The GIFTASUP4 guidelines said:“In patients undergoing some formsof orthopaedic and abdominalsurgery, intra-operative treatmentwith intravenous fluid to achieve anoptimal value of stroke volumeshould be used where possible asthis may reduce postoperativecomplication rates and duration ofhospital stay.”

What the 2010 EnhancedRecovery ImplementationGuide5: Delivering enhancedrecovery3 said:“Individualised goal-directed fluidtherapy…

When intravenous fluid is given, thebenefits of maintaining circulatoryfilling and organ perfusion must beweighed against the risk of excessfluid accumulation in the lungscausing hypoxia, and, in the gut,causing nausea and delayed returnof gut motility (ileus).”

• Unexpected blood loss and / orfluid loss requiring > 2 litres offluid replacement

• Patients with ongoing evidence ofhypovolaemia and or tissuehypoperfusion (e.g. persistentlactic acidosis).

Perceived lack of resources is not aviable excuse in the NHS. NICE haveconcluded that we can’t afford NOTto have cardiac output measuringtechnologies available2. Thechallenge is using the resources in atargeted fashion and being able toescalate level of monitoring asdeemed appropriate. Practitionersshould not be constrained by lack ofavailability of such monitors.

What NICE3 said aboutCardio-Q Doppler:“…The case for adopting theCardioQ-ODM in the NHS,…issupported by the evidence.

1.1 The CardioQ-ODM1 should beconsidered for use in patientsundergoing major or high-risksurgery or other surgical patients inwhom a clinician would considerusing invasive cardiovascularmonitoring. This will include patientsundergoing major or high-risksurgery or high-risk patientsundergoing intermediate-risksurgery.”

This should ideally include:• 30 and 90 day mortality rate(ideally risk adjusted)

• Length of hospital stay• Same day admission rate• Readmission rate• Patient reported outcomes.

We propose that any NHS Trusts thatwish to opt out of applying theprinciples of enhanced recoveryshould be able to demonstrate that:• Their mortality rates are betterthan national average

• Their lengths of stay arecomparable with the best 20% ofNHS Trusts in England

• Readmission rates are better thanaverage

• Patient satisfaction is high.

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1 NHS Operating Framework 2012-13

2 DH Innovation, Health and Wealth Review (2011)

3 NICE (2011) CardioQ-ODM oesophageal doppler monitor: Medical Technology guidance 3.National Institute for Health and Clinical Excellent, March 2011.

4 British Consensus guidelines on intravenous fluid therapy for adult surgical patients, March 2011

5 DH (2010) Delivering enhanced recovery: Helping patients to get better after surgery,Department of Health, March 2010.


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SPOTLIGHT ONUROLOGY

Blood conservationNICE guidance recommends routineuse of intra-operative cell salvage incystectomy and radicalprostatectomy1. It has been shownto reduce the need for allogeneicblood transfusion and, in otherspecialties, has been associated witha reduced length of stay. It alsoavoids transfusion reactions/wrongblood etc.

Effective opiate sparinganalgesiaBilateral rectus sheath catheters havebeen used successfully in open pelvicsurgery to minimise epidural andopiate usage.

New surgical techniquesIn cystectomy, incision length isminimised and exenterative steps areperformed with an extra-peritonealapproach.

A laparoscopic or robotically-assistedapproach can also be used forsuitable cases. In the case of radicalprostatectomy, a minimally-invasiveapproach is the preferred option.

Minimise the use of drainsSpecific urological operations mayrequire the use of drains forexample, cystectomy – the drain canusually be removed in the early post-operative period (between 24 and48 hours). Placement of a drainfollowing radical prostatectomy isnot required in all cases and shouldbe reserved for situations where aurine leak is deemed more likely.

Minimise the use of nasogastrictubes in abdominal surgeryRoutine placement of a nasogastrictube is not required peri-operativelyin patients undergoing radicalcystectomy though it may berequired in the later post-operativeperiod if an ileus develops.

Early rehabilitation in urologyTo enable mobilisation, adequateanalgesia is necessary. The regimechosen will be proportionate to themagnitude of the surgery and mayinclude epidural, spinal, PCAS orlocal anaesthetic infusion catheters.In suitable cases, spinal anaesthesiaand mobile infusion techniques(PCAS or anesthetic catheters) mayoffer improved mobility and areduced failure rate compared toepidural.

1 National Institute for Health and Clinical Excellence intra operative red blood cell salvageduring radical prostatectomy or radical cystectomy: guidance 2008

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Discharge• Discharge should be criteria based:patients are discharged when theyare mobilising, can control theirpain by oral analgesia, are able toeat and drink. Occasionally,patients are sent home with aurinary catheter which is removedat an outpatient visit days later

• Patients should be provided withwritten information on dischargethat includes emergency contactinformation, practical advice to aidrecovery and expected length oftime until they return to normalfunction. Typically, there is noincrease in readmissions or post-operative work for primary care.

SPOTLIGHT ONGYNAECOLOGY

Standardised approach• Procedure specific pathwaysshould be agreed by thegynaecology department for allpatients undergoing inpatientgynaecological procedures

• Standardisation of peri- and post-operative pathways gives theopportunity to embed safety andquality measures such as antibioticand VTE prophylaxis, andpostoperative management asoutlined in the following sections.

Pre-operative assessment• Information needs to be providedto patients about their procedurespecific pathway to enable activeparticipation in their recovery byreinforcing the rationale for earlymobilisation, feeding, and howtheir pain will be managed

• Bowel preparation andpre-operative sedation are seldomindicated, and it has been shownto be safe to allow patients todrink clear fluids up to two hoursprior to surgery

• The use of complex carbohydratedrinks has been shown to reducethe effects of the physiologicalstress response to surgery and aidrecovery.

Operative techniqueStandardisation of the pathway foroperative procedures within adepartment is very important toensure the provision of safe,reproducible and high quality care:• Use of minimal access surgicaltechniques are associated withdecreased length of stay. Ifappropriate, open surgery shouldbe performed through a transverseincision

• There is no evidence to supportthe routine use of nasogastrictubes and drains.

Post-operative care• Standardise the post-operativecare for patients on the ward.

• Gain departmental agreement one.g. the timing of catheter removalto allow the application of aconsistent approach to managingpost-operative recovery.

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This is an excellent initiative withsignificant benefits for patients and theBritish Gynaecological Cancer Societywishes to lend its support.

‘Professor Sean Kehoe, President of theBritish Gynaecological Cancer Society.

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DID YOU KNOW?NHS South East Coast Orthopaedic Enhanced RecoveryProgramme is recommended as best practice by NHS Evidence.The savings delivered were a result of reducing the length ofstay in hospital. There was a range of length of stay savingsacross the 11 different Trusts. The gross savings at £275 per bedare £247,500 or £5893 per 100,000 population.

The savings delivered were a result of reducing the length ofstay in hospital. There was a range of length of stay savingsacross the 11 different Trusts. The gross savings at £275 per bedare £247,500 or £5893 per 100,000 population.

SPOTLIGHT ONMUSCULOSKELETAL

Applying enhanced recoveryto trauma procedures inmusculoskeletal surgery leads tohighly significant improvementsto quality of care andproductivity

To date, the focus withinorthopaedics has been onimplementing enhanced recovery tohip and knee joint replacementpathways. The Enhanced RecoveryPartnership helped to; raise theprofile of enhanced recovery withinorthopaedics, increase the evidencebase for it’s implementation, engagemulti-disciplinary teams and keystakeholders, and create someimportant drivers for change1.Consequently, the results achievedby pioneering sites2 have beenreplicated widely across the country,and a national reduction to averageLOS with high levels of patientexperience has been achieved3.

However, whilst the results for hipand knee replacement patients areencouraging, two key challengesremain if we are to further improvepatient outcomes and significantlyincrease hospital productivitythroughout the country. The firstchallenge is that more work isrequired to support the adoption ofenhanced recovery as the standardpractice for all hip and knee

replacement patients across all units.This is because there remainsevidence of considerable variation inoutcomes, such as case-mix adjustedlength of stay across units, and alsovariations in pathway content, withnon-adoption of recognisedenhanced recovery steps in someunits4.

Secondly, the challenge for hospitalsthat have successfully implementedenhanced recovery for hip and kneereplacement patients is for them toapply the same principles to otherorthopaedic procedures. Importantly,this work should not be limited toelective surgery, especially given thatexemplar units are now reportingexcellent results when implementingenhanced recovery pathways fortheir fractured neck of femurpatients.

For example, at Poole Hospital, LOShas reduced and the number ofpatients discharged home hasincreased following the introductionof enhanced recovery principles. Theaverage LOS at Poole for fracturedneck of femur patients is now 12days which is 9.3 days lower thanexpected for their case-mix and 8days less than the national averageof 20 days5 (Figure 4 on page 34).They are further applying theprinciples of enhanced recovery inorthopaedic trauma, and havesignificantly increased the number oftrauma procedures completed as daysurgery over the last two years6. Thishas improved both patientexperience and improved efficiency.This success is not in isolation; othersites such as Torbay are alsoreporting reduced LOS for fracturedneck of femur patients following theimplementation of enhancedrecovery7.

1 Department of Health (2011) Enhanced Recovery Partnership Programme Report - March 2011. Accessed on 12th April 2012 fromwww.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_128707.pdf

2 Wainwright T, Middleton R (2010) An orthopaedic enhanced recovery. Current Anaesthesia and Critical Care. 21: 114-120

3 Gordan et al. (2011) Implementing the Rapid Recovery Program in primary hip and knee arthroplasty in a UK state run hospital. European Journal ofOrthopaedic Surgery and Traumatology 21 (3): 151-158

4 Dr Foster (2011) Inside your hospital. Dr Foster Good Hospital guide 2001-2011. Accessed on 12th April 2012 fromwww.drfosterintelligence.co.uk/wp-content/uploads/2011/11/Hospital_Guide_2011.pdf

5 Data from Dr Foster Practice and Provider Monitor Tool. Accessed on 12th April 2012.

6 Lloyd et al. (2012) How to cut overnight stays and improve trauma pathways. Health Service Journal. 23rd February 2012.

7 Swart M (2011) Enhanced Recovery for Patients with a Fractured Neck of Femur. Presented at the AAGBI Annual Conference 2011, Edinburgh.Accessed on 12th April 2012 from http://videoplatform.aagbi.org/videoPlayer/?vid=53&class=videoThumb

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The potential impact, if this work infractured neck of femur is replicatedacross the country is highlysignificant. This is because of thehigh volumes of fractured neck offemurs that occur annually (therewere 62,453 inpatient spells in2011) and the current variations inLOS and mortality rates. Whilstimplementing enhanced recoverywithin trauma surgery will presentdifferent challenges, the factors thathave underpinned success in hip andknee replacement such as strongclinical and managerial leadership, amultidisciplinary team approach, astandardised pathway, and a highlyorganised logistical framework,remain the same.

We therefore propose that theimmediate focus of our effortsshould be not only to ensure thespread of enhanced recoverythrough elective care, but moreimportantly to improve clinicaloutcomes and patient experience forour most vulnerable patients such asthose with a fractured neck offemur. It is here that we will have thebiggest impact on improving thequality of care for patients, and thepotential for productivity gainsacross the country is highlysignificant.

Robert MiddletonDirector of Trauma and ConsultantOrthopaedic Surgeon at PooleHospital NHS Foundation Trust andThe Royal Bournemouth andChristchurch Hospitals NHSFoundation Trust.

Tom WainwrightClinical Researcher at The RoyalBournemouth and ChristchurchHospitals NHS Foundation Trust, andVisiting Associate at BournemouthUniversity.

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Expected LoS

LoS

Figure 4 – Actual length of stay (LOS) against case-mix adjusted LOSfor fractured neck of femur patients at Poole Hospital. Theintroduction of enhanced recovery principles has resulted in adramatic reduction to LOS

5 Data from Dr Foster Practice and Provider Monitor Tool. Accessed on 12th April 2012.


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Carbohydrate drinking (COloading) is safe, humane andpatient’s feedback indicates theylike it.

Pre-operativePatients are encouraged to eat up tosix hours before and can drink clearfluids until two hours before. Asuitable carbohydrate drink isadministered to the patient theevening before surgery and on themorning of surgery (two hoursbefore going to the operatingtheatre). This ensures completegastric emptying is achieved prior toanaesthesia and removes the risk ofaspiration.

Post-operativePatients are encouraged tocommence drinking as soon aspossible after surgery and build upto a full diet progressively as soon astolerated. Post-operatively a lowvolume, high calorie supplement canbe prescribed on a daily basis tosupplement postoperative calorieintake.

GENERAL QUESTIONS

Pre-operative assessment clinic carbohydrate drinksRoyal Devon and Exeter NHS Foundation Trust

All patients at the Royal Devon and Exeter Hospital receive carbohydratedrinks as part of their pre-operative assessment clinic visit. The patientswhen seen at the assessment clinic are given a bag containing twocarbohydrate drinks with instructions on when and how to consume them.Also contained in the bag is an information leaflet on what is ER and whatis expected of them, a leaflet on anaesthetics and if they have not had aninformation leaflet on their operation.

They also get a ‘ticket to go’ which is a summary of all the salient pointswe want them to adhere to, i.e. starving times and pre-op instructions andthen on the reverse the discharge instructions and expectations.

Patient instructionsPatients are advised to take drinks before 06.30 hours, if on the morningoperating list and before 11.30 hours if on the afternoon operating list.Patients are advised to consume the drinks over a period of 20 minutes.

Patients with diabetes also get two carbohydrate drink. Blood sugars aremonitored on admission and all patients who have major surgery havesliding scale insulin regimes, if necessary. Guidelines for management ofpatients with diabetes are agreed and reviewed regularly.

CostThe cost of the bags are £12.34 for 250 bags and the drinks are 1 tray of20 drinks = £36.00. Each patient gets two drinks.

CASE STUDY

DID YOU KNOW?At Torbay Hospital, everysurgical patient gets a‘doggy bag’ atpre-operative assessmentcontaining theircarbohydrate drink.

Staggered admission times and nolate changes to the theatre list willsupport this.

Admitted on the day of admissionshould be standard practice ratherthan the exception.

Minimise complicationsTo help prevent wound infection,antibiotics should be given 60minutes or less before ‘knife to skin’as per the WHO Safer SurgeryChecklist1.

Avoid bowel preparationEvidence is now accepted that theuse of bowel preparation prior tocolorectal surgical procedures has noeffect on the rate of anastomoticdehiscence and carries the risk offluid and electrolyte imbalance priorto surgery.

Admitting on the day of surgerySame day admissions are safe if youhave a good pre-operativeassessment service. Many patientsdo not need a bed when they arrive,they can walk to theatre or wait inan admissions lounge.

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1 National Patient Safety Agency, WHO SafetySurgical Checklist (2009)

How to stop implementationof carbohydrate loadingbeing difficult? - Adopt forevery patient at pre-op andtake the barriers away!

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Preparing for rehabilitation andre-ablement commences with theGP and continues throughout thepathway. Encouraging patients tohave a role and understanding theirresponsibility for enhancing theirown health and recovery is a vitalcomponent.

Goal settingIndividual patient ‘goal setting’ isanother important element ofenhanced recovery. Goal settingencourages and motivates thepatient. It helps patients to dailyself-assess and gain confidence withtheir progress, as well as provideclinical teams with an assessment ofprogress and risk.

Anecdotal evidence has highlightedthat family and friends have becomeactively involved in encouraging thepatient to achieve their goals dailyand weekly.

ENSURING THE PATIENT HAS THE BEST REHABILITATION

Integrated care pathwaysimprove goal setting forprofessionalsEast Kent HospitalsUniversity NHS FoundationTrust

Introduced an integrated carepathway (ICP) documentationfor gynaecological oncologypatients. The ICP is goal-defined and time specific. It isbeing used by the surgical andnursing team, guided bytarget parameters to beachieved by certain pre-andpost operative days. The ICPhas encouraged much clearerdocumentation andchronological information,which has improvedcommunication and thereview of care.

CASE STUDYPro-active discharge planning –Avoiding unnecessary delaysBest practice is to create a dischargeplan at pre-operative assessmentclinic, in collaboration with thepatient and relatives/carer. Earlydischarge planning can identify andaddress any specific discharge needs.

It is important to consider whoneeds to be informed prior todischarge of patients, including theGP, district and community nurses.The patient also needs to be awareof their responsibilities.

The patient should be aware of theexpected length of stay, andproposed discharge date. Settingthis expectation and encouragingpatients to actively participate intheir care helps with motivatingpatients to achieve their goalstowards the planned discharge date.

PATIENT GOALS

•Self wash•Eat•Walk

•Sit out•Eat•Walk

•Sit out•Drink•Eat

•Shower•Dress•Home

•Walk•Shower•Dress

I checked how myhusband was doingat every visit. Ithelped me knowwhat he would beable to do when hecomes home - canhe still do thewashing up?

Patient diary entry

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Timely patient discharge can beaided by professional teams agreeingdischarge criteria guidelines. Suchguidelines aid staff to take sharedresponsibility for the decision todischarge. They also ensuredecisions are not reliant on oneindividual, which may delaydischarge.

Delays in ordering of patientmedications for discharge may alsocontribute delays in patientdischarge. Implementation of nurseled prescription pharmacyprescriptions can avoid this, thepre-ordering of medications in thepre-operative assessment clinic canmake a significant difference as canwards having pre-packed routinemedication.

Clinical teams are testing patientself-medication with ‘over thecounter’ simple analgesics providedby pharmacy. This is to promotepatient self-management of theirpain control and build patientconfidence to avoid delays indischarge due to concerns aboutpain control.

Patients better and home soonerEnhanced recovery promotes thatthe patient is better sooner, but as asafety precaution all patients,should be made aware of who andwhere to contact for advice andguidance if needed.

Primary care colleagues should alsobe informed of the patientdischarge, who to contact and howto fast track patients into hospital, ifnecessary. They should also knowwhat information the patient hasbeen given.

Patient follow-upAvoid unnecessary follow-ups forpatients and where follow-ups arenecessary a range of differentapproaches are being applied to theER pathway such as:

• Patients triggered follow up, self-managed follow-up wherepatients ring a number to discussany concerns or have access to anopen access follow-up clinic

• For example, a 24-hour contacttelephone number staffed by wardnurses may be used.

Nurse-led prescriptions ordering system speeds up dischargeplanningTaunton and Somerset NHS Foundation Trust

This nurse-led prescriptions ordering system, in combination withfrequent and sustainable clinical pharmacy visits and a improvedservice dispensary, have maintained low levels of dispensing errors andallowed rapid prescription turnaround, with the majority of workbeing completed earlier in the day rather than much later. It affectsmissed doses and timely discharge, both of which are importantquality factors.

Nurse-led prescription ordering avoids the need for additionalpharmacy staff, and allows clinical pharmacists to focus on complexclinical issues rather than transcribing prescriptions. Required work ispresented to the dispensary more quickly, making better use ofstaffing resources earlier in the day and avoiding the need for overtimelater in the day.

NHS Evidence www.evidence.nhs.uk/QIPPPharmacy management and nurse-led medicines ordering: To improveefficiency and aid patient discharge.

CASE STUDY

Patient activated telephonefollow upUniversity Hospital ofNorth Staffordshire NHSTrust

University Hospital of NorthStaffordshire NHS Trustprovide not only a nurseactivated follow up call servicebut also patient activatedfollow up. This means patientshave open access to thesurgical assessment unit aswell as a 24 hour dedicatedhelpline run by nurses duringoffice hours and the surgicalnurse practitioners out ofhours.

CASE STUDY

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Figure 5: Cancer risk stratified follow up pathway model being tested

Cancer risk stratified follow uppathways (Figure 5) are currentlybeing testedAs best practice, healthcareprofessionals should discuss thepurpose, duration, frequency andlocation of follow-up with patientsand carers.

The current development of cancerrisk stratified pathways and an ITbased remote monitoring systemaims to lead to safe, convenient andcost effective follow-up for patients.This initiative supports patients toreceive care closer to home as wellas providing commissioners with amore efficient pathway of care.

Why is this relevant to enhancedrecovery pathway?• Enhanced recovery is about theentire pathway

Nurse activated telephonefollow-upEast Lancashire TeachingHospital, Salford Royal andWirral University TeachingHospital

Patients described their phonecalls from the nursing staff tobe really helpful in continuingto rehabilitate at home.Patients feedback hasindicated the calls providereassurance and support totheir family and carers.

Videos of these patientsdescribing their enhancedrecovery experience areavailable on the North WestSHAs DVD-rom EnhancedRecovery Training Resource.

Email:[email protected]@nhs.netWeb:www.advancingqualityalliance.nhs.uk

CASE STUDY

• There are various late effectsassociated with cancer wheresurgery may be required e.g.obstruction, hormone therapyincreasing the risk of osteoporosisleading to a raised fracture riskelevated cardiovascular risk,increase risk of other cancerrequiring surgery/treatment.Awareness and monitoring therisk could reduce emergencyadmissions

• For many patients this is thecontinuation of their care plan,building on the principle‘optimisation for life’.

• For some patients surgery may bethe only treatment they choose oroption available. Post-treatmentpatients are assessed and put ontothe appropriate pathway• Self management• Shared care• Complex care• Transition to end of life care.

www.improvement.nhs.uk/survivorship

Professionally led follow-upPatients are contacted by telephone,at a specified time post discharge,for example day one, three or sevendays post-discharge. This telephoneconsultation with patients not onlyenables continuity of care, educationand support for patients, whereneeded, but also promotes patientconfidence and self management. Italso avoids unnecessary visits to thehospital.

No decisionmade aboutme, withoutme.

‘Liberating the NHS:Department of Health: 2010


THE PATIENT ROLE AND RESPONSIBILITIESIN ENHANCING THEIR OWN RECOVERY...

Patients are the reason thehealth service exists and currenthealth policy explicitly recognisesthat we should be at the heart ofthe services we use.

Service redesign and improvement ofthe sort provided by taking forwardenhanced recovery generatesopportunities to involve service usersin a number of ways whichcontribute to its effective delivery.

Patients have an active role inenhanced recoveryThe most important involvement isalong the care pathway itself. Theenhanced recovery pathway askspatients to play an active role in theircare before, during and afterhospital admission. Given that thismodel differs markedly from themore ‘traditional’ approach tosurgery, where patients in the pasthave been ascribed a more passiverole, the ‘sick role’. Aligning patient

expectations with those whoare delivering the service isclearly critical to success.

Enhanced recovery is notjust patient-focused, it ispatient-centredThat is to say, its approachgoes beyond just delivering thebest possible clinical outcomefor the patient, cruciallyimportant though that is. Itexceeds this aspiration by alsorecognising that for the personexperiencing the surgery, theclinical aspects of the wholeprocess are just some of themeans to an optimum recoveryin the shortest possible time.

What does patientempowerment mean forenhanced recovery?To achieve optimal recovery inthe shortest possible time, aspatients we will need to draw

on a number of resources to help usalong the different stages of thepathway.

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MY ROLE AND MYRESPONSIBILITIESIN HELPING TOIMPROVE MYRECOVERY

Steps to a successfulrecovery start beforemy operation

GETTING BETTER SOONER

NHS

The Enhancing PatientExperience Working Grouphave produced informationsupporting the patients’ role.www.improvement.nhs.uk/enhancedrecovery

BY THE ENHANCING PATIENT EXPERIENCE WORKING GROUP

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THE BARRIERS AND ENABLERS TOAN OPTIMUM RECOVERY

1. Having ownership of thedecision to opt for surgery:If the patient has made an activedecision in electing for surgery,rather than having ‘been referred’,then this sets the tone for an activerole along the rest of the carepathway (see case study: SharedDecision Making in Urology onpage 42).

2. Good communication fromthe GP at the time of referralabout what to expect fromenhanced recovery:If expectations are aligned at theearliest stage, the whole journey isless stressful for the patient, who inturn feels more in control andbetter able to play their part intheir recovery.

3. Quality assured informationsoon after referral:This might be provided by the localservice, with a view to a face toface follow up (e.g with a specialistnurse) to ensure that the personunderstands what will be involvedand, most importantly of all, iscomfortable with what will beexpected of them. If patients ‘own’the process at this stage, they willdrive it more strongly later.

4. Practical support in advanceto make post-operativerecovery less difficult:Many providers of enhancedrecovery invite pre-operativepatients to the hospital to meetstaff and learn coping and recoverytechniques such as physiotherapybefore post-operative pain anddistress make absorbing this newinformation more challenging.

EIGHT TOP TIPS FOR PATIENT EMPOWERMENT5. Peer and/or family support:Relevant patient groups play animportant part in reinforcingpositive messages of supportaround self-management, via ahelpline service, written informationor by putting people in touch withothers who have benefited fromself-management. Involving carers,partners, other family or closefriends can also help provide anetwork which gives the personconfidence to feel they will havesupport even when not in directcontact with their healthprofessional team.

6. Positive reinforcement fromthe anaesthetist and surgeon:It is extremely reassuring for thepatient, before and duringadmission, to hear their specialisthealth professionals describeenhanced recovery techniques asnormal in getting the best outcomefor patients.

7. Knowing who to ask:Whether the patient be at thepre, peri or post-operative stagethey will have questions arisingor anxieties forming which, if leftunattended, could jeopardisetheir recovery process. It is oneof the most empowering thingsof all to feel confident that atsuch times you know where youcan turn to for answers, adviceor support.

8. Anticipating a rapidrecovery positively:Whether it is early post-operativemobilisation in the ward ormaking the journey home, thepatient will be more able to getbetter sooner if they havepreviously considered all that willbe involved and know that theycan access support to deal withthe unexpected.

• Patient’s level of confidence• Getting the right information at the right time• Getting easy access to support along their journey; or for socialand practical issues when at home

• Knowing how to cope at home whilstcontinuing to recover

• Social care arrangements being made inthe first part of the pathway is not onlyreassuring for the individual, but addressesan issue which unattended can significantlyincrease the risk of delay in discharge orunplanned readmission

• Empowering people to help themselvesthroughout the pathway becomes a keydeterminant in the overall quality of careultimately experienced as a result ofenhanced recovery.


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Learning from patients: Using thepast to improve the futurePatients’ experience of the servicecan be very different from what wasintended and it would run contraryto the principles of continuousimprovement merely to assume ahigh quality experience. Only byproviding structured consultationusing a variety of methods can theytell us what works, what doesn’t andwhat could be done better.

SHAPING THE FUTURE

The Wirral Hospital Enhanced Recovery Team run ‘patient parties’ to seekfeedback: so much more inviting and engaging than just sending a coldcontact questionnaire or running something which might otherwise betermed a focus group.

In February 2012 for instance, around 100 patients were invited to anevent, informal in tone but highly structured, to provide feedback from theirexperience of enhanced recovery. Senior clinicians from relevant specialtieswere also present, as were members of the national advisory board forenhanced recovery. Their views were therefore used to review servicedelivery not only in the region, but also contributed to developing enhancedrecovery information nationally through the ‘My role and my responsibilitiesin helping to improve my recovery’ leaflet.

ARE WE GETTING IT RIGHT?PATIENT FEEDBACK

Danny felt that the enhanced recovery admission letter wasexcellent and informed him what to expect during his stay in simplelaymen’s terms.

Sam thought that the pre-load drinks gave him an extra boost andhe wasn’t kept starving for 12 hours prior to surgery like in the past.Being able to have a drink of 400mls of clear fluid 90 minutes beforesurgery was great as he usually drinks plenty of water in a day - “Itfelt like normal.”

Tom said the ‘big plus’ was having no pain following surgery. Hewas surprised at this.

FIVE ELEMENTS OFSHARED DECISIONMAKING

• Inform patients when thereis a choice about theirtreatment

• Explain what options areavailable to them

• Explain the possible benefitsand risks of each option

• Find out what isimportant to the patient -what are their values?

• Engage with the patient toreach a decision that is right(and safe) for them.

DID YOU KNOW?The enhanced recoverypartnership supports theimplementation of the 14NICE Quality Statements.

Patient Experience in AdultServices, NICE, February2012.

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Derek felt that his daily goals were a great incentive to his recovery.He felt this gave him greater involvement in getting better.

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Sue thought the pro-cal shots were a very good idea. She felt thatthe daily goals inspired her to get ‘up and around’ and get ready forhome.

Paul stated he would have preferred to come into hospital on themorning of surgery as he ‘would have had a better night’s sleep athome.’ He felt he was hanging around on the ward waiting forsomething to happen.

The above are taken from real patient feedback on the enhancedrecovery pathway

The role of the patient and thequality of their outcome andtheir experience from start tofinish is at the heart of enhancedrecoveryHowever, this section stands alonebecause all of the components ofenhanced recovery describedelsewhere ultimately converge in oneplace only: the life of the patientwho, as a result of thosecomponents, is better sooner.

1 The MAGIC shared decision making programme is testing how best to implement shared decision making in routine clinical practice.The programme is supported by The Health Foundation. www.health.org.uk/areas-of-work/programmes/shared-decision-making

Arthritis Care is delighted to see enhanced recovery becoming ever more widelyused for people with arthritis undergoing joint surgery. We believe service usersshould always be informed of their choices and given clear information aboutwhat will happen before, during and after their hospital stay. This allows themto support themselves and makes for a better experience during a stressfulperiod in their lives. The person-centred approach taken by enhanced recoveryis one we wholeheartedly commend.

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Arthritis Care

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Shared decision making (SDM) in urology - helping patients to make the right decision for them¹

The SDM consultation looks at the treatment options for male lower urinary tract symptoms. This is supportedusing the NHS enlarged prostate booklet for patients.

The patient is not expected to make a decision between possible treatment options at a first face to faceconsultation, and takes the booklet and DVD home for further deliberation – specifically, he is encouraged towrite in the booklet what is important to him in regard to the options and possible benefits and risks. At afollow-up telephone consultation the clinician supports the patient to make a decision based on his knowledgeand understanding of the options, referring to his notes on personal values. Through implementing SDM,supported by a patient decision aid, a routine second face to face appointment has in many cases beenreplaced by the telephone follow-up. If the patient is finding it difficult to make a decision and needs furthersupport, a further face to face appointment is made.

The urology team have found, following implementation of SDM:• Patient pathways and the consultation itself have been streamlined• Patients value the decision aid tool and share it with friends and family – it prompts them to ask questions toa degree and depth not previously experienced by clinical staff

• Imparting a full understanding of the implications of treatment choices helps manage patient expectationsand reduces the possibility of regret, following irreversible treatment choices as surgery

• Fewer men have opted for surgery as a first treatment choice.

CASE STUDY


PROGRESS AND FULFILLING THEPOTENTIAL: A MEASURED APPROACHThe Enhanced Recovery Partnershiptook a measured approach, as oneway of assessing the impact andspread:

• Good progress has been made,but there is further to go

• Variation in practice still existsacross the country in the fourspecialties; colorectal,gynaecology, urology andmuscular skeletal

• We still need to focus on reducingvariation in practice.

Data was captured relating topatient experience, lengths of stay,day of surgery admissions,re-admissions and compliance withelements of enhanced recovery.

This information in this section wasdrawn from a variety of sourcesincluding Hospital Episode Statistics(HES), the national patient surveyand audit data submitted by trustsonto the Enhanced Recovery Toolkit.www.natcansatmicrocsite.net/enhancedrecovery

THE NEWS IS GOOD

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• NHS Trusts implementing enhanced recovery scoresignificantly better than the general experience ofinpatients captured in the national patient survey

• Lengths of stay for the eight procedures in the EnhancedRecovery Programme have been falling since the 2008-09baseline

• Readmission rates for organisations known to haveimplemented enhanced recovery for the eight procedures arenot significantly higher or lower than the national average

• Trusts implementing enhanced recovery are able to achievehigh levels of compliance with most elements of the ERpathway (13 of 19 elements show at least 80% compliance)

• Good progress has been made in reducing lengths of stay.Despite rises in activity for almost all these procedures, therewere nearly 70,000 fewer bed days for these procedures in2010-11 than in 2008-09.

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wanted to be aboutyour care and

treatment

How much informationabout your condition

or treatment wasgiven to you?

Did you feel you wereinvolved in decisionsabout your discharge

from hospital?

Did hospital stafftell you who to contact

if you were worriedabout your condition

or treatment afteryou left hospital?

2011 - Enhanced Recovery 2010 - National Inpatient Survey (elective)

Patient experienceFigure 6 shows the levels of patientsexperience reported in trusts whoare implementing enhancedrecovery. The questions used weretaken from the national inpatientsurvey and so are well validated.These questions have all been usedin the national survey since 2007and show similar levelsof achievement each year to thepercentages shown for 2010.

Figure 6: Patient experience: Enhanced Recovery compared to National Inpatient Survey

As can be seen from figure 6, trustsimplementing enhanced recoveryscore significantly better than thegeneral experience of inpatients.The sample size is 2,600 for theenhanced recovery and 24,000 forthe National Inpatient Survey.

Figure 7: Trend in HES mean length ofstay and day of surgery admission

Lengths of stayLengths of stay (Figure 7) for theeight procedures1 in the EnhancedRecovery Programme have beenfalling since the 2008-09 HospitalEpisodes Statistics (HES) baseline.

Contributing to this is an increase inthe percentage of patients admittedon the day of their surgery ratherthan in advance. However, most ofthe reduction is accounted for byshorter lengths of stay after surgery.

Sites known to have implementedenhanced recovery for theseprocedures tend to have lowerlengths of stay and higher rates ofday of surgery admission than thenational average.


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1 Source: Hospital Episodes Statistics, The Information Centre for Health and Social Care. Trends areshown for elective single episode spells with a main operation of Primary hip replacement (the primarypart of each OPCS 4.3 code W37 to W39, W46 to W48 and W93 to W95 plus W46.0, W47.0 orW48.0), Primary knee replacement (W40.1, W41.1 or W42.1), Colectomy (H05 to H10), Excision ofrectum (H33 except H33.7). Hysterectomy abdominal (Q07), Hysterectomy vaginal (Q08), Bladderresection (M34) and Prostatectomy (M61). 2011-12 data are provisional.

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Musculoskeletal - primary replacement

Gynaecology - hysterectomy

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Figure 7 (continued): Trend in HES mean length ofstay and day of surgery admission

Colorectal

Urology


ReadmissionsFigure 8 shows changes inreadmissions over the period January2009 to June 2011 in the proceduresthe enhanced recovery partnershiphas focussed on over the past twoyears.

The percentage of patientsreadmitted as an emergencyfollowing a hip replacement hasreduced in recent years, withvariation in the trend for otheroperations. The readmission, withinsix weeks of discharge for hip andknee replacements or 28 days forthe other operations, may be for anyreason and not necessarily related tothe surgery.

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January to June 2009 July to December 2009

July to December 2010 January to June 2011

January to June 2010

Figure 8: Trend in HES emergency readmissions following surgery

Readmission rates for organisationsknown to have implementedenhanced recovery for theseprocedures are not significantlyhigher or lower than the nationalaverage.

This demonstrates that as enhancedrecovery becomes more widespread,there is no increase inreadmissions but there is a netbenefit to trusts and patients with areduction in length of stay.

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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Pre Op VisitPatient Assesses for Surgery

Patient Explanation on ERTherapy Education Given (MSK)

Stoma Education Given (Col)Oral Bowel Prep Avoided (Col)

Patient Admitted on Day of SurgeryCarbohydrates Given

Avoidance of SedativesAntibiotics Priced

Epiduaral or Regional AnalgesiaIndividual Fluid TherapyHypothermia Prevention

Avoid Abdominal Drains (Col)NG Tube Removed

Avoid Crystalloid OverloadAvoid Ststemic Opiates

Post-Op NutritionNausea and Vomiting Control

Early Mobilisation

Figure 9: Percentage compliance with enhanced recovery components: October to December 2011

Compliance with elements ofenhanced recoveryFigure 9 shows the complianceagainst the elements of enhancedrecovery as recorded on the nationalER toolkit for patients admittedfrom October to December 2011.This is shown for colorectal,musculoskeletal, gynaecology andurology patients except whereindicated.

The graph shows that sitesimplementing enhanced recovery areable to achieve high levels ofcompliance with most elements ofthe pathway (13 of 19 elementsabove show at least 80%compliance).

Of the other six elements only oneelement, carbohydrate given prior tosurgery, showed compliance of lessthan half of patients (46%).

Clearly this is still an area wherethere is a modest cost involved andsome variation in its adoption(outside colorectal) and so is an areawhich may benefit from furtherevidence.


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Dr Foster findingsDr Foster carried out someindependent research on the linksbetween a rapid recovery pathway,length of stay, emergencyreadmissions and re-operation ratesin providers of hip and kneereplacements. Trusts were asked toidentify which elements of a rapidrecovery pathway they hadimplemented locally. The surveyshowed that hospitals that followedthe rapid recovery pathway havesignificantly lower numbers ofpatients spending a long time inhospital (Ref: Dr Foster HospitalGuide 2011).

Bed day savingsNational implementation ofenhanced recovery in colorectal,gynaecology, urology andmusculoskeletal surgical specialtieswas estimated to offer bed daysavings of 140,000 to 200,000 peryear. This potential impact wasbased on improvement in electivelengths of stay across most providersto a target level already achieved orexceeded by one in ten providers inthe baseline year 2008-09.

Table 1: Impact of potential improvements in length of stayassessed using 2010-11 HES data

Progress has been made inimplementing enhanced recoveryand in reducing lengths of stay sincethe baseline. Despite rises in activityfor almost all these procedures, therewere nearly 70,000 fewer bed daysfor these procedures in 2010-11than in 2008-09. However,estimated annual savings stillpossible for these specialties, fromfurther implementation of enhancedrecovery, amount to 120,000 beddays per year.

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Procedure groupPrimary hip replacementPrimary knee replacementColectomyExcision of rectumAbdominal hysterectomyVaginal hysterectomyBladder resectionProstatectomy

2010-11meanLOS5.55.59.211.14.02.615.63.5

2010-11median

LOS557832133

No.major

providers1561561471461561465464

No.patients60,60067,30010,40010,00029,8007,0001,3003,900

TargetLOS (frombaseline

5.15.07.99.13.12.012.53.1

Potentialbed dayssaved (1)31,30038,20010,20015,80019,7003,4003,4002,300

124,300

(1) Based on improvements of the majority of providers to the target (LOS)

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Table 2: Annual impact of potential improvements in mean LOS assessed using 2010-11 HES dataMean LOS improves to best decile or quintile (using 2010-11 as a baseline)

FUTURE POTENTIAL

Further specialtiesEnhanced recovery may be appliedto a range of specialties. Areaswhere further potential estimatedbed day savings have been identifiedare shown in table above. Thisexcludes operations largelyperformed as day cases, which maybring other benefits.

As discussed earlier, applying theprinciples to some emergencyadmissions, caesarean sections andmedical admissions could save morehospital bed days.

This potential impact was based onimprovement in lengths of stayacross most providers to a targetlevel already achieved or exceededby between one in five and one inten providers in the baseline year2010-11. As before, the potentialbed day saving excludes a minorityof providers with the longest lengthsof stay, which may not be able toachieve such reductions due to localfactors such as high underlying levelsof co-morbidities or socio-economicfactors.

Beyond this, enhanced recoverycould come to be applied asstandard across a range of surgeryand, where appropriate, acutemedical healthcare, to improve thepatient experience and supportearlier discharge home.

Procedure group

ElectiveOesophagogastrectomyGastrectomy for cancerPancreaticoduodenectomyPartial excision of liverExcision of lungBreast excision and reconstructionBreast reconstruction no excisionVascular AAA

EmergencyPrimary hip replacementClosed reduction bone fracturePrimary open reduction bone fractureReplacement head of femurColectomyExcision of rectumExcision of adnexa of uterusTherapeutic endoscopic ops on ureterExcision of appendix

DeliveryEmergency C-sectionElective C-section

17.214.017.610.28.65.12.87.0

16.79.26.617.115.218.22.44.53.3

4.23.1

2010-11meanLOS

14111487525

1353131114233

32

2010-11median

LOS

363820203110611082

13914515012712784144115142

143143

No.major

providersNo.

patients

1,100900700

1,6005,7004,0007,7004,700

17,60030,20046,60015,0003,1001,7007,1004,60030,300

99,50066,800

5.010.413.46.76.42.61.24.4

11.75.04.012.610.213.41.83.12.7

3.52.5

TargetLOS (1)(decile)

14.111.314.08.17.73.31.75.4

13.06.44.913.511.414.31.93.52.9

3.72.6

TargetLOS (2)

(quintile)

10,7002,4002,5004,40010,3006,9009,3008,400

68,40096,80091,60052,80011,8004,5003,6005,20014,000

47,00029,000

479,600

Potentialbed dayssaved (1)

3,4001,8002,2002,6004,8004,8006,4005,000

50,80064,50060,20042,9008,9003,5002,8003,80010,500

34,10024,000

337,600

Potentialbed dayssaved (2)


SECTION5

WHY COMMISSIONERS ARE IMPORTANTTO ENHANCED RECOVERY

Commissionershave a strongdesire to do theright thing.

Commissioner

SECTION 5

CQUIN payments to supportproviders in the establishment ofenhanced recoveryNHS London developed the CQUINshown on page 52, which has beenimplemented across the capital.

Other CQUINs have been developedfrom the North West, South East andSouth West of the country. These areshown on pages 53, 54 and 55.

Commissioners have a key roleand responsibility• To ensure that the healthcare theyprocure for their patients improvesoutcomes and patient experience.

• To co-ordinate and ensurecollaboration across partners.

• Commissioners have a lead role inensuring that the contractualagreements with providers supportthe delivery of services.

Enhanced recovery contractualarrangements and useful leversThere are a number of contractuallevers that commissioners may wishto support providers in establishingenhanced recovery as everydaypractice these include the use oftransformational monies, CQUINs1

and service specifications.

Incentivising commissioners throughthe Commissioning OutcomesFramework as it is developed wouldshow a clear commitment to qualityimprovement and patient experienceacross the pathway.

1 Department of Health (2010), Using Commissioning for Quality and Innovation (CQUIN) payment framework

2 NHS Outcomes Framework, Liberating the NHS: Transparency in Outcomes- a framework for the NHS (2010)

51

‘‘’’

DID YOU KNOW?Implementation ofenhanced recovery willimprove outcomes, patientexperience and safety andsupports the delivery of theNHS Outcomes FrameworkDomains 3, 4 and 52.

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52

Enhanced recovery and highimpact innovations

Innovation, Health and Wealth¹ says:

It is not ourintention, nor is itappropriate, tomake judgementsabout compliancefrom the centre,but we will requirecommissioners tosatisfy themselvesthat all eligibleorganisations aredelivering the highimpact innovationsset out in thisreport in order topre-qualify forCQUIN payments.This will take effectin 2013/14.

Enhanced recovery supports theadoption of one of the high impactinnovations, individualised goaldirected fluid therapy using fluidmanagement technologies (seesection 2).

The London CQUINIn 2011 CQUINs were worth 1.5% of out-turn, rising to 2.5% in2012/13

In 2011, London introduced a CQUIN payment to incentivise theadoption of enhanced recovery surgical pathways. The CQUIN coveredeight elective operations in four specialities:

• In urology, cystectomy and prostatectomy• In gastrointestinal surgery, colectomy and rectal resection• In gynaecology, abdominal and vaginal hysterectomy• In orthopaedics, hip and knee replacement.

The CQUIN had four components, each worth 25% of the total value.

1. Recording of comprehensive information about enhancedrecovery patients on the national database, to allow Trusts tobetter understand enhanced recovery implementation. The reportingrequirement applied to all patients who are treated on a planned basis(i.e. excluding urgent/emergency admissions) undergoing the relevantoperations.

2. To ensure that the majority of patients admitted for colorectalsurgery receive goal directed fluid therapy, the Trust qualified forfull payment if ≥ 80% of patients undergoing planned colorectalsurgery performed receive goal directed fluid therapy.

3. Targeted day of surgery admission, to drive rational peri-operative pathways, the Trust qualified for full payment only if ≥ 80%of eligible patients were admitted on the day of surgery.

4. Targeted length of stay for patients undergoing the eightspecified operations. The target for each procedure was to equal thenational median from the previous year. Since average length of stay islonger in London than nationally, for many London Trusts these werechallenging stretch targets.

DID YOU KNOW?The National Technology Adoption Centre is preparing an‘Adoption pack for intra-operative fluid managementtechnologies’. This should be available by the spring 2012. Forfurther information go to: www.ntac.nhs.uk

1 NHS Innovation, Health and Wealth.Accelerating Adoption and Diffusion inthe NHS (2011)

‘‘

’’


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Kent, Surrey and Sussex approach to CQUIN incentives: 2012/13

CQUIN payments to incentivise improvements in the quality of care have been used by the Enhancing QualityProgramme (EQ) across Kent, Surrey and Sussex since 2010. They have proved successful in encouraging clinicalengagement and have driven real improvements in the care received across many different clinical pathways.

Enhanced Recovery (ER) formally joined with EQ in 2011, and due to the measurable benefits seen by EQ, thereare plans to introduce CQUIN payments for improvements made in 3 of the 4 ER pathways (Colorectal,Orthopaedic and Gynaecology) for 2012/13.

In order to incentivise improvement a baseline minimum data set was agreed with nominated clinical and trustleads, which is completed on a monthly basis. Currently seven out of the ten trusts in the region are collectingdata for at least two of the pathways, with the other three looking into ways they can start collecting dataimminently. Two months of data have currently been collected.

A process of identifying the areas for improvement has been underway, as there are too many data points toincentivise them all. These areas have been determined clinically, with the input of consultants, nurses,physiotherapists, occupational therapists, other allied health professionals, and with the trust nominated leads.There will be two areas for improvement for each pathway, and although discussions are still ongoing it is likelythat these areas will include:• Patient education of ER and their role in their recovery• Early mobilisation• Carbohydrate loading• The use of a post operative fluid policy• Peri-operative cardiac output monitoring.

CQUIN components• Each trust will be required to submit data, on an agreed spreadsheet, each month• Weightings for each pathway were agreed to incentivise data collection prior to the beginning of thefinancial year 2012/13. Three consecutive month’s data must be received in order to establish a baseline.

• CQUIN weighting adjusted according to baseline start date.

The following weightings apply November, December 2011 and January 2012:• Orthopaedics – 9% of EQ&R CQUIN• Colorectal – 8%• Gynaecology – 8%

For trusts establishing their baseline during April, May and June 2012 reduced weightings will apply as follows:• Orthopaedics – 5% of EQ&R CQUIN• Colorectal – 4%• Gynaecology – 4%• The total EQ&R CQUIN will be worth 0.5% of a trusts SLA (or 20% of the total CQUIN money available,which will be 2.5% of SLA)

• Orthopaedics was weighted slightly higher to reflect the larger volumes of patients going through thispathway (and thus larger amounts of data to be collected).

53

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54

Wirral University Teaching Hospital NHS Foundation Trust CQUIN Example 2011/12

The CQUIN, at the Wirral University Teaching Hospital NHS Trust was developed in a collaborative way with tencontractual ERP specialty pathways agreed through a series of meetings between GPs, commissioners and leadclinicians from the acute trust.

• Colorectal: All resection surgery and reversal/ closure of stoma• Orthopaedics: Elective primary hip and knee surgery• Urology: - cystectomy and prostatectomy• Gynaecology: Endometrial cancer and anterior/posterior repair prolapse surgery• Vascular: Aortic surgery and amputations.

The CQUIN identified key milestones for providing evidence of implementation of ERP elements within allpathways and achieving agreed targets of length of stay. (Milestones for every pathway = Patient and carereducated pre op, oral bowel prep avoided, DOSA, early feeding, mobilisation within 24 hours and team leddischarge). Each pathway had a % of CQUIN scheme available.

A minimum data set (https://www.natcansatmicrosite.net/enhancedrecovery) was reported monthly using thenational reporting tool and local patient experience measures. Rules for partial achievement of milestone wereagreed.

An ERP project board chaired by the Director of Nursing met regularly to monitor progress (against agreedmilestones) and support roll out, ironing out any issues and maintaining support for delivery.

Milestones

Rules for achievement of milestones(including evidence to be supplied tocommissioner)

Identify individual(s) responsible for reportingand analysing ERP data in line with nationalreporting tool by end of June 2011

Implement colorectal and gynaecologypathways by the end of Q1

Implement orthopaedic, urology and vascularpathways by the end of Q2

Identify baselines for length of stay (LOS)from 2010/11 and agree targets withcommissioners for each ERP pathway byend of Q2 2011/12

Achieve agreed LOS targets for each pathwayby end of Q4

Date milestoneto be reported

July 2011

July 2011

October 2011

September 2011

April 2012

Total

Milestone weighting(% of CQUIN schemeavailable)

1.00%

4.00%

4.00%

1.00%

2.00%

12.00%

Date/periodmilestone relatesto

Q1 2011/12

Q1 2011/12

Q2 2011/12

Q2 2011/12

Q4 2011/12


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Exeter CQUIN

In the first year (2011), payments were seen as an encouragement to develop pathways in the four surgicalareas. Over the next 12 months, enhanced recovery pathways will be rolled out across most elective surgicalprocedures. NHS Devon would like to incentivise a greater pace of change for benefit across the health systemas a whole. Fitness for Surgery measures are included in this CQUIN to help evaluate the impact of measuresbeing taken in primary care to better prepare patients ahead of surgery.

Rules for CQUIN specify elective procedures in those specialties not specify specific procedures but those belowreflect actual activity.

Urology: Cystectomy and radical prostatectomy Colorectal: all elective bowel resections

Gynaecology : abdominal hysterectomy Orthopaedics: all TKR and THR

The content of the baseline and progress assessments must be at individual patient level. This is supported byinternal audit of the components of ER pathways, including surgical risk assessment, Fitness for Surgeryassessment tool, procedure, surgeon, anesthetist, HDU bed days, ITU bed days and length of stay.

Numerator• No. of elective inpatients in the above specialties having a documented enhanced recovery pathway• %, median and aggregate reduction in length of stay in the above patient groups compared to 2009/10 and2010/11for the given procedures

• %, median and aggregate reduction in HDU and ITU length of stay in the above patient groups compared to2009/10 and 2010/11 for the given procedures.

Denominator• Total number of patients undergoing elective inpatient surgery in each of the specialties identified in thisCQUIN incentive scheme.

The following milestones were also linked to CQUIN payments:

Rules for achievement of milestones (includingevidence to be supplied to commissioner)

Baseline assessment for orthopaedics

Baseline assessment for urology, gynaecology, colorectaland one further agreed specialty.Action plan for orthopaedics.

Action plan for gynae, colorectal, urology and the onefurther agreed specialty (November).Progress assessment for orthopaedics (December).

Progress assessments for orthopaedics, colorectal, urology,gynaecology and the one further agreed specialty.

Achievement of the milestones described in the agreedQ3 action plans.

Date/periopmilestonerelates to

Q2 (Sept)

Q3 (Oct)

Q3

Q4

Q4

Date milestoneto be reported

Sept 30th 2011

Oct 30th 2011

Nov 30th 2011

Dec 31st 2011

15th Mar 2012

15th Mar 2012

Total

Milestone weighting(% of CQUIN schemeavailable)

10%

30%

20%

20%

20%

100%

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SECTION5


56

Midlands & East SHA Regional Commissioning Framework Service Specification for Enhanced Recovery

Regional Commissioning FrameworksNHS Midlands & East has required through their Regional Commissioning Framework 2012/13, that by March2013 all commissioners have included enhanced recovery in contractual agreements with providers so that allproviders implement enhanced recovery for the four clinical specialities identified by the national programme.Suggested key markers for each of the four specialities have been listed as follows:

ORTHOPAEDICS• More than 95% of patients admitted on the day ofsurgery

• All elective patients seen in a pre-admission clinic and preoperatively receive• Pre-operative physiotherapy education and occupationaltherapy assessment is carried out (hip and knee school)• High risk patients are seen in an anaesthetic pre-operative assessment clinic

• A formal written discharge plan is made• Anaesthetic protocols are in place• All patients participate in protocol driven activemobilisation programme available seven days a week

• The hospital has an acceptable median length of stay(calculated according to the national median LOS)

• Patient satisfaction scores are documented and aredemonstrably favourable e.g. more than 85% of patientsagree or strongly agree that their post-operative pain wasmanaged well

• Re-admission data is acceptable and comparable with thenational average

• A discharge protocol is in place which involves a post-operative phone-call and written instructions for thepatient on how to contact the team in the event ofproblems.

UROLOGY• More than 95% of patients admitted on the day of surgery• All elective patients seen in a pre-admission clinic andpre-operatively receive• A formal written discharge plan is produced.• High risk patients are seen in an anaesthetic clinic• If applicable, stoma therapy education should be givenpre-operatively

• Anaesthetic protocols are in place• All patients participate in protocol driven activemobilisation programme available seven days a week





GYNAECOLOGY• More than 95% of patients admitted on the day of surgery• All elective patients seen in a pre-admission clinic andpre-operatively receive• A formal written discharge plan is produced• High risk patients are seen in an anaesthetic clinic• If applicable, stoma therapy education should be givenpre-operatively

• Anaesthetic protocols are in place• All patients participate in protocol driven activemobilisation programme available seven days a week




• A discharge protocol is in place which involves a post-operative phone-call and written instructions for the patienton how to contact the team in the event of problems.

COLORECTAL• Minimum 75% of patients admitted on the day of surgery• All elective patients seen in a pre-admission clinic andpre-operatively• Patients receive pre-op stoma therapy education• High risk patients are seen by an anaesthetist• Formal, written discharge plans are made pre-operatively

• All patients receive carbohydrate loading pre-operatively• All patients receive goal-directed fluid therapy using fluidmanagement technologies

• Minimally invasive surgery is offered to all suitable patients(according to criteria defined in the Cancer Manual)

• All patients participate in protocol driven activemobilisation programme available seven days a week






SECTION5

Positioning enhanced recoverywithin the integrated systemoperational plans

Commissioners should identify howthe system will collaborativelyestablish enhanced recovery,ensuring that providers aresupported through theimplementation phases withinitiatives such as use of CQUINs ortransformation funds to enablechanges in staffing or equipmentrequirements.

As a part of the plans for theimplementation of enhancedrecovery, the PCT clusters, as thesystem managers, will ensure thatcapacity i.e. bed availability isadjusted to reflect changes in lengthof stay.

As local health economies review thecapacity required in the acute settingthe impact of Enhanced Recoveryshould be factored into any futurechanges in the bed requirements ofacute providers.

Best Practice Tariffs (BPT)BPTs are prices set as part of thenational tariff list to financiallyincentivise providers to adhere toevidence based best practice. Suchincentives can be useful but thereneeds to be careful considerationabout plans in place to ensuresustainability of good practice postincentive. There are BPTs for hip andknee surgery supporting enhancedrecovery Commissioners need toensure the sustainability of goodpractice post incentive.

BENEFITS FOR COMMISSIONERSCost savings:Commissioners can make cost savings from fewer complications,reduced length of stay and lower conversion rates. Providers will releasecapacity as length of stay will fall as part of the implementation of ERcommissioners will want to work closely with providers to plan for howthis capacity should be used for their population.

Collaboration and partnership working:Clinically led commissioning requires joint working across public health,social, primary and secondary care. Enhanced recovery encouragesclinically led service redesign across all the partners.

Benefits to patients:Faster recovery is of enormous benefit to patients. However, there arealso less obvious benefits such as a greater degree of informed andshared decision making by patients.

Delivering equity for the population:The clinical case for enhanced recovery being standard practice of goodcare for all patients is clear. Taking this as the starting pointcommissioners will want to commission enhanced recovery for theirpopulation to ensure all their patients benefit.

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58

1. Commissioners and GPs deal with the totality of the patienteveryday. How can this way of working and thinking becomeroutine cross primary and secondary care for every patient?

Commissioning enhanced recovery pathways as every day practice continues to support thetotality of patient care.

2. As clinical commissioning groups go through an authorisation process to become anindependent commissioner, they will need to demonstrate; clinical focus, added value, engagementwith patients, clear and credible plans to deliver quality improvements within agreed financialresources, collaborative working arrangements and strong leadership capability.

Enhanced recovery pathways are clinically focused, cost effective, patient driven pathways. Withan evidence base, in improving quality outcomes, team working across functional, organisationaland professional boundaries. ER is part of the solution.

3. Commissioning aims to promote the spread and adoption of innovation, evidence basedpathways and good quality care.

Enhanced recovery supports a wide range of improvements and innovations integrated within thepathway rather than a stand alone ideas, technologies and clinical practices. The success ofenhanced recovery is in its entirety.

4. In order to meet the commissioning governance challenge. Commissioners will need tocollaborative with other organisations engaging across professional and functional boundaries.

Enhanced recovery promotes the integration of services and team working across professionalboundaries, involving health and social care, primary and secondary.

5. Patients trust their GPs and trust that they would contract the best for them.

Enhanced recovery continues to support the patients trust by supporting patient and carerinvolvement and strengthening the patient’s confidence in the pathway and the NHS.

6. Commissioning is ultimately about good outcomes for patients.

Most importantly, enhanced recovery is the right care pathway – fewer complications, betteroutcomes, more cost effective and better patient experience – these are key outcomes forcommissioners.

THE SIX MINUTE BRIEFING

CLINICAL COMMISSIONING GROUPS MAY NEED TO INVEST ALITTLE TIME TO UNDERSTAND WHY COMMISSIONERS AREIMPORTANT TO ENHANCED RECOVERY.


SECTION5

COMMISSIONING THOUGHTSFROM THE FRONTLINE

Involve commissioners and primary carefrom the startFrom the outset (Autumn 2009) we wanted inExeter to involve commissioning colleagues at thePrimary Care Trust to achieve recognition of theenhanced recovery pathway benefits for patientsbut also in terms of wider NHS resource efficiency.

A commissioning team member attended ourclinical meetings to see first hand evidence-basedsolutions from enhanced recovery for issues whichpurchasers and providers have to overcome. Theevolution of CQUIN payments for enhancedrecovery patients has further involvedcommissioners seeking more efficient ways ofworking across the healthcare landscape.

Enhanced recovery pathways has been adopted inurology, colorectal, gynaecology, andorthopaedics, though remaining ‘procedurespecific’ to some degree. We now want to rollenhanced recovery out for all inpatient electivesurgery and explore further applicationopportunities in emergency surgery and medicine.

A limited range of original Department of Healthdataset indicators is used to measure enhancedrecovery. Success is measured (attendance at pre-op clinic, carbohydrate drinks, early mobilisation,reduced length of stay etc). Quarterly reports willbecome more detailed as the programme evolvesbeyond initial roll out.

Dr. Colin Berry, Enhanced Recovery Clinical Lead,Exeter and Devon NHS Foundation Trust

How do commissioners support improvement?As enhanced recovery includes pre and postadmission, understanding and supporting thequality of care commissioned at these stages fromproviders, including community, primary andsocial care is something only commissioners canfully deliver.

Including enhanced recovery in servicespecifications, as these are added into thecontracts with all providers, will increase thefocus. In addition, measurement of the deliveryof the enhanced recovery elements of pathwayscould also be introduced.

Further contractual means to influence providersto improve can be through CQUIN in the earlystages of adoption or, as the expectation ofenhanced recovery delivery becomes morestandard through contractual penalties.

Commissioners can help providers to change bycreating these and other contractual incentivesthat are defined at a level which can be used toovercome internal lack of motivation to changewhere this exists.

John Harrison, Director, Peninsula Cancer Network

What’s really in it for commissionersFor enhanced recovery to deliver the maximal benefits it needs to be across an integrated care pathway and notjust delivered from one step in the pathway – i.e the acute trust. Key steps of the pathway lie outside of the acutetrust setting – Primary care – screening for fits prior to referral (Hb, BP), optimising Long Term Conditions e.g.Diabetes and shared decision making on elective care pathways prior to referral, also social care with dischargeplanning of high risk patients prior to admission. The only way this can be achieved is by commissioning anintegrated care pathway and not allowing it to be driven as a purely acute trust initiate. There are risks to thecommissioner if they allow the implementation of Enhanced Recovery to be purely driven by a provider in that, ifsuccessful, capacity will increase and there maybe a rise in activity.

Primary Care – may be a LES for pre-referral screening or optimising long term conditions, most of enhancedrecovery is core general practice and implementing ER should be part of improving quality and outcomes inprimary care – a role of the clinical commissioning groups.

Dr Alan Nye, GP and Primary Care Advisor

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60

Starting to build a track record of capability to commissionClinical commissioning groups (CCGs), as part of their authorisation processneed to build up a track record of their capability to commission. This includesbeing able to interpret data and use information to prioritise, redesignpathways that deliver improved outcomes and measure that improvement inQIPP terms i.e. Quality, Innovation, Productivity and Prevention.

CCGs are very keen to use evidence to validate what they have put in theircommissioning intentions and QIPP plans as there is sometimes a disconnectbetween what seems like a good idea and what will deliver the outcomesCommissioners have used in their planning assumptions.

Case studies of where enhanced recovery has delivered will provide theevidence they are looking for particularly if it correlates with comparativeLOS/readmission/spend data e.g. Atlas of Variation.

Enhanced recovery is about whole system pathway redesign in order to get tothe bigger impact -extending enhanced recovery pathways into primary careand using QP indicators (Quality and Productivity – part of QOF) as thefinancial incentive. There are plenty of points linked to three planned andthree unplanned care pathways.

Alison Shead, Commissioning Lead

Integrated health and social care commissioning is the way forward: Asocial care perspectiveThere are some key interfaces with social care. Improving the patientexperience does to some degree depend on social care, especially if there areplans to reduce lengths of stay, move care closer to home and support earlydischarge. Taking this together with funding pressures, it will require wholesystems solutions involving social care.

Data on hospital admissions, readmissions and delays in discharge canunderlie to commissioners the value of social care services, specialist housing,installing aids and adaptations etc. Enhanced recovery may be one of theconnections between health and social care where services can be aligned asa cohesive approach. Fitting a hand rail for £100 to speed up a patientsdischarge, frees up a hospital bed saving at least £200.

However, enhanced recovery alone will not make the NHS wealthy.Integrated health and social care commissioning will effectively improvehealth outcomes and ensure efficiency.

Simon Williams, Director of Community and Housing andNational Lead for Urgent Care


SECTION5

GOOD COMMISSIONINGEnhanced recovery is about goodpractice, good teamwork, goodoutcomes, good clinicalgovernance and the good use ofresources, which underpin thebuilding blocks for goodcommissioning.

=

+ +

++

�61

SUMMARYThe NHS Enhanced RecoveryPartnership Programme commencedin 2009 and its first publication in2010 ‘Delivering enhanced recovery– helping patients to get bettersooner after surgery’ was producedto act as a starting point forindividuals, teams and organisationswanting to implement enhancedrecovery. Initially focusing on specificprocedures in colorectal surgery,urology, gynaecology andorthopaedics, by 2011 enhancedrecovery pathways had beenintroduced in over 180 NHS Trusts inEngland.

Clear evidence shows that enhancedrecovery pathways are associatedwith better clinical outcomes andpatient experience, fewercomplications and are cost effective– supporting the case to makeenhanced recovery ‘standardpractice’.

During the implementation acrossEngland it became evident thatenhanced recovery principles andcomponents could be applied to allin-patients – emergency or elective,medical or surgical.

The Enhanced Recovery Partnershipcontinues as part of NHSImprovement to support thecontinued spread of enhancedrecovery throughout the NHS, inexisting and new specialties. Thisupdated publication: ‘Fulfilling thepotential – a better journey forpatients and a better deal for theNHS’ provides the updated evidence,information and shares the learningfrom across the country, in order tosupport the implementation anddevelopment of enhanced recoverypathways that continues to buildupon the founding principles:

• All hospital in-patients should beon enhanced recovery pathways –these contain a number ofinterventions which have a greaterimpact when combined to helppatients recover from episodes ofinpatient hospital care

• Patients participate as partners intheir care from informed decisionmaking right through treatment torecovery and discharge.

Enhanced recovery as a standardapproach has been supported by theRoyal Colleges and Associations,which is evident in this publication.Successful implementation andsustainability of enhanced recoverypathways involves thecommissioners as they are importantto ensuring best practice is providedfor their patients. The publicationalso gives emphasis to the role andresponsibility of patients inenhancing their own recovery andkeeps the patient at the heart ofenhanced recovery.

Whilst the publication provides anoverview it contains many examplesof good practice, which will pointyou in the right direction. Furtherresources to support implementationcan be found on the NHSImprovement website:www.improvement.nhs.uk/enhancedrecovery

Mr Nigel AchesonMedical Director, Peninsula CancerNetwork, Consultant GynaecologistOncologist, Royal Devon and ExeterNHS Foundation Trust and NationalEnhanced Recovery Advisor

SUMMARY


62

RESO

URCES


RESOURCESAdvancing Quality Alliance (Aqua)www.advancingqualityalliance.nhs.uk

Association of Surgeons of GreatBritain and Irelandwww.aagbi.org

British Orthopedic Associationwww.boa.ac.uk

British Association of UrologySurgeonswww.baus.org.uk

British Association of Day Surgerywww.bads.org.uk

British Association BreastSurgeonswww.baso.org.uk

Department of Healthwww.dh.gov.uk

Enhanced Recovery Toolkitwww.natcansatmicrocsite.net/enhancedrecovery

National Technology andAdoption Centrewww.ntac.nhs.uk

Kings Fundwww.kingsfund.org.uk

NHS Choiceswww.nhs.uk

NHS Improvementwww.nhs.improvement.uk

National Institute for ClinicalExcellence (NICE)www.nice.org.uk

NHS Evidencewww.evidence.nhs.uk/QIPP

National Confidential Enquiry intoPatient Outcomes and Deathwww.ncepod.org.uk

National Cancer Action Teamwww.ncat.org.uk

Right Carewww.rightcare.nhs.uk

Royal College of Anaesthetistswww.rcoa.ac.uk

Royal College of ObstetriciansAnd Gynaecologistswww.rcog.org.uk

Royal College of Surgeonswww.rcseng.ac.uk

The Health Foundationwww.health.org.uk

The Institute of HealthcareImprovementwww.ihi.org

The NHS Institute for Innovationand Improvementwww.institute.nhs.uk

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64

ACKNOWLEDGEMENTS

ACKNOWLEDGEMENTSAcknowledgements and thanks go out to all of themany individuals, clinical teams, organisations, patientgroups, Royal Colleges and Associations for theircontinued advice and valuable contribution to thispublication and for supporting the National EnhancedRecovery Summit (April 2012) and importantly for theircontinued support in taking forward enhanced recoveryand building the momentum for enhanced recoverybecoming the standard pathway of care:

• Professor Sir Mike Richards• Professor Monty Mythen• Mr Alan Hogan• Department of Health• NHS Improvement• National Cancer Action Team• Advancing Quality Alliance (Aqua)• National Enhanced Recovery Clinical Leads andAdvisors

• SHA Enhanced Recovery Leads• NHS Improvement Associates• The Enhanced Recovery Partnership Advisory Board• Operational and Working Groups• The Enhancing Patient Experience Working Group• Royal College of Surgeons• Royal College of Anaesthetists• Royal College of Nursing• Association of Surgeons of Great Britain and Ireland• British Association of Urological Surgeons• Royal College of Obstetricians and Gynaecologists• British Orthopaedic Association• Royal Society of Medicine• British Gynaecological Cancer Society• Association of Coloproctology of Great Britainand Ireland

• BASO ~ The Association for Cancer Surgery• British Association of Day Surgery• Royal College of Physicians• Royal College of Radiologists• Faculty of Clinical Oncology• Future Forum

• Royal College of General Practitioners• Faculty of Intensive Care Medicine• The Allied Health Professional Federation• Royal Surrey County Hospital• Scarborough and North East Yorkshire HealthcareNHS Trust

• Pan Birmingham Cancer Network• Heart of England NHS Foundation Trust• East Kent Hospitals University NHS Foundation Trust• South Devon Healthcare NHS Foundation Trust• Royal Devon and Exeter NHS Foundation Trust• Peninsula Cancer Network• Golden Jubilee National Hospital Scotland• East Lancashire Teaching PCT• Wirral University Teaching Hospital NHSFoundation Trust

• Royal Marsden NHS Foundation Trust• University Hospital of North Staffordshire NHS Trust• The Royal Liverpool and Broadgreen UniversityHospitals NHS Trust

• Frimley Park Hospital• Robert Jones and Agnes Hunt Orthopeadic HospitalNHS Foundation Trust

• Ashford and St Peter’s NHS Foundation Trust• Taunton and Somerset NHS Foundation Trust• Oxford University Hospitals NHS Trust• NHS London• NHS South Central• NHS North East• NHS Midlands and East• NHS South East Coast• National Technology Adoption Centre• Robert Middleton, Director of Trauma and ConsultantOrthopaedic Surgeon at Poole Hospital NHSFoundation Trust and The Royal Bournemouth andChristchurch Hospitals NHS Foundation Trust

• Tom Wainwright, Clinical Researcher at The RoyalBournemouth and Christchurch Hospitals NHSFoundation Trust, and Visiting Associate atBournemouth University


65

• Dr Steven Laitner, General Practitioner and AssociateMedical Director National Clinical Lead for SharedDecision Making (Quality and Productivity,Department of Health)

• Arthritis Care• Macmillan Cancer Support• The Chronic Pain Coalition• The Wirral Patient Party Group• London Borough of Merton Community andHousing

• Nick Cooper• Kate Llewelyn.

A special thanks to the Enhanced RecoveryPartnership Publication Working Group:• Mr Nigel Acheson (Chair)• Mr John McGrath• Dr Martin Kuper• Neil Betteridge (patient representative)• Shelia Dixon• Sue Cottle• Andy McMeeking• Vicki Dodds• Dr Alan Nye• Pamela Hayward-Sampson• Jan Yeates• Wendy Lewis• Dr Michael Swart• Dr Kerri Jones• Dr Ann Driver.

ACKNOWLED

GEMENTS


66

MY ROLE AND MYRESPONSIBILITIESIN HELPING TOIMPROVE MYRECOVERY

Steps to a successfulrecovery start beforemy operation

GETTING BETTER SOONER

NHS

For further copies of ‘Fulfilling the potential: a better journey for patients and a better dealfor the NHS’, and ‘My role and my responsibilities in helping to improve my recovery’,visit www.improvement.nhs.uk, email: [email protected] or call 0116 222 5184

NHSNHS Improvement

NHS Improvement3rd Floor | St John’s House | East Street | Leicester | LE1 6NB

Telephone: 0116 222 5184 | Fax: 0116 222 5101

www.improvement.nhs.uk

NHS Improvement

NHS Improvement’s strength and expertise lies in practical service improvement. It has over adecade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lung andstroke and demonstrates some of the most leading edge improvement work in England whichsupports improved patient experience and outcomes.

Working closely with the Department of Health, trusts, clinical networks, other health sector

partners, professional bodies and charities, over the past year it has tested, implemented, sustained

and spread quantifiable improvements with over 250 sites across the country as well as providing

an improvement tool to over 1,500 GP practices.

Delivering tomorrow’simprovement agendafor the NHS

fulfilling the potential - a better journey for patients and a better deal for the nhs

Health & Medicine

benefits of enhanced

better productivity

better training

patientsall patients

breast cancer

form of surgery

nhs improvement

patients innovative