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Enhanced Recovery Programme

 
What is it and how can it help me?

The enhanced recovery programme is about improving patient outcomes and speeding up a patient's recovery after surgery. It results in benefits to both patients and staff. The programme focuses on making sure that patients are active participants in their own recovery process. It also aims to ensure that patients always receive evidence based care at the right time.

Outcomes of the enhanced recovery programme are:

  • Better outcomes and reduced length of stay
  • Increased numbers of patients being treated (if there is demand) or reduced level of resources necessary
  • Better staffing environment.

There are four elements to the enhanced recovery programme:

  1. Pre-operative assessment, planning and preparation before admission.
  2. Reducing the physical stress of the operation.
  3. A structured approach to immediate post-operative and during (peri-operative) management, including pain relief.
  4. Early mobilisation.

There are also three areas that help the practical management of the enhanced recovery programme:

  1. Staff training and learning
  2. Improved processes and room layout
  3. Procedure specific care plans Enhanced.jpg

Some elements of the enhanced recovery programme are similar to integrated care pathways. In fact, you should build upon an integrated care pathway as your starting point. There are, however some things that are new and specific to this approach: 

  • It brings together two best practices: (1) organisation of care and (2) clinical management, whilst making sure that patients receive evidence based care
  • It uses patients and their families as an appropriate resource in planning and managing their own recovery and care
  • It focuses on less invasive surgical techniques, pain relief and the management of fluids and diet, which help patients to get on their feet quickly post-operatively (much evidence cites this as significant in speeding up recovery)
  • It aims to make events in a hospital as normal as possible. For example, patients eat in a dining area, not in their beds. 

When does it work best?

Improving quality often increases the number of patients you are able to see. This is because you are doing the right things, at the right time, more of the time. Patients get better faster and need less staff and other resources. Making patients active in their own recovery and planning reduces resource needs for staff, and means that the patients are better prepared to manage when they are back at home.

The overall combination allows more patients to be treated within the same staffing resources. This will reduce waiting times and the number of patients waiting.

The introduction of minimally invasive techniques may initially increase theatre time, so this needs to be monitored. Looking at improving systems around theatres and theatre schedules should off-set this, as well as the reduced bed occupancy.

How to use it

Some of the elements are not new and link directly to other areas of work. We have made these links where possible to help answer the questions 'what and how do I do it?'  Where the links don't exist, we have tried to illustrate the 'what?' to help with the 'how?'.

Approach

In the hospitals we visited, clinicians led the development of their enhanced recovery programme. It was a partnership between a respected consultant surgeon and a respected senior nurse or matron which led to the formation of a team, including consultant anaesthetists, surgical trainees and experts in acute pain management. As this was a relatively big change, they also had a strong project management approach to carry it through. 

For example, in Torbay Hospital, an F grade nurse was designated as the facilitator for the project. Clinical engagement and support of all staff (see staff perception) was critical. For example, as the leads had evidence of patient benefits to hand, they put up snippets of evidence in places where staff spent time (staff room, corridors etc.) to gain buy-in.  

The leads also had strength of conviction. They knew the evidence and anticipated the impact. As an example, they managed to persuade 'facilities' to convert one of their wards into a kitchen and dining area when the programme began. Other up-front investments requiring funding included epidural pumps and surgical training which were off-set in the main by a reduction in beds required.

Starting point

Where you already have an agreement about patient care, build on an integrated care pathway. See protocol based care for more information.

' We had a good starting point as we already had an integrated care pathway.' Torbay Hospital    

Elements of the enhanced recovery programme

1. Improve pre-operative care
For complex surgery in particular, it is important to involve family and carers in all pre-operative education and planning processes, as well as the patient's GP. This maximises the chances of the patient understanding and acting on the advice given. 

The aim of pre-operative assessment is to ensure that:        

  • Full assessment, including consultation with an anaesthetist, takes place as soon as the decision to operate has been made
  • The patient has the maximum opportunity to get their bodies as fit as possible for surgery and anaesthetic (for example, they eat the right food, mobilise joints)
  • The patient fully understands the proposed operation and is ready to proceed
  • Staff identify and co-ordinate all essential resources and discharge requirements
  • Dates for the operation and discharge are in everyone's diary.

'There should be anaesthetic input at a pre-op assessment clinic - really important these changes aren't introduced into the old system of admit to ward without prior preparation.'
Kerri Houghton

Further information:

2. Reduce the physical stress of the operation

Apply best practice to reduce the physical stress of the operation as much as possible. 

  • Minimally invasive operation techniques: either smaller incisions or a laparoscopic approach
  • Use of intra-operative fluid management technologies
  • Epidural local anaesthesia
  • Keeping patients warm during the operation

3. Increase comfort post-operatively

The focus is to get patients moving and eating normally as soon as possible after their operation. 

  • 'Vigorously treat' post-operative pain to reduce surgical stress responses
  • Try to get patients moving with a suitable low dose epidural (special pumps are helpful to allow easy mobilisation)
  • Do not use naso-gastric tubes routinely in patients undergoing elective gastrointestinal surgery
  • Help patients to resume a normal diet as soon as possible (include nausea management).

4. Improve post-operative care
The focus is to continue enabling patients to move with a focus on nutrition. 

  • Continue to mange post-operative pain
  • Strong focus on nutrition and mobilisation
  • Clear discharge and post discharge arrangements.

Further information: 

  • 'Management of Patients in Fast Track Surgery'
  • 'Preventing Surgical Site Infection Care Bundle' (includes keeping patients warm enough during the operation)
  • Increase the reliability of performing therapertic interventions through a care bundle approach is one of the 10 High Impact Changes.  This explains what a care bundle is and how the approach makes sure that all patients get the best care (agreed by the team).  

Factors that help the enhanced recovery programme

1. Staff training
There are five areas of focus: 

  • Learning about the evidence around speeding up recovery post-surgery
  • Developing a mindset where patients are active in their recovery whilst aiming to make life in the ward as normal as possible
  • Surgical techniques
  • Adoption of a consistent protocol by anaesthetists
  • Consistent implementation of the programme.

2. Improved processes and room layout

  • Plan or schedule work around what needs to happen to patients and when in order to smooth workflow
  • Use this to plan ahead and know when the next step is ready
  • Focus on the physical environment of the ward and workspace. The focus is to have a logical layout and good organisation to help efficiency.  For example, in Torbay they had a yellow line for patients to follow as part of their post-operative exercise. The method nicknamed sort and shine may also give you ideas
  • Use a spaghetti diagram as a method to identify unnecessary movement of staff, patients and paperwork and see potential areas for improvement.

3. Procedure specific care plans

In addition to developing procedure specific care plans, patients should have their own care plans.  This means that they know what should happen to them each day. It includes things that the staff should do (e.g. remove catheters) and that the patient themselves should do (distances walked). Patients then become a check or reminder for their own care.

Examples

Torbay Hospital: bowel surgery

Advanced care planning in orthopaedics (Hvidovre Hospital, Denmark)
'The patients get this information pack...In the pack there are some instructions that tell them to measure things like the height of the toilet seat and so on. They send this back to us. Using these, with all of the other information we have, means we can get all of their equipment ready. They get this at their discharge. If they aren't able to do the measurement, well then we know we will have problems and need to be thinking about alternative arrangements anyway.'

What next?

Once implemented, your ongoing focus should be on developing measures to indicate how well the programme is working by monitoring the following areas: 

  • Patient readmission rates
  • Patients' length of stay
  • Adherence to plans (one way you can do this is through a care bundle approach that will describe how many patients receive all aspects of best care)
  • Make sure you have ongoing feedback and discussions with staff until the programme has become an everyday part of working practice.

Additional resources

Journals:
'Management of Patients in Fast Track Surgery'  Wilmore, F & Kehlet, H (2001)

'Risks of Interrupting Drug Treatment Before Surgery: The Consequences may be as Serious as those from Drug Errors'  Noble, D & Kehlet H (2000)

Background

'Enhanced recovery programme', originally called the multi-modal approach, was developed by Professor Henrik Kehlet. It is also called fast track surgery. 

Torbay Hospital developed the enhanced recovery programme based on the experience of Robin Kennedy (Yeovil Hospital - North East Somerset Trust) and Polly King's experience of enhanced recovery as Robin Kennedy's Research Specialist Registrar).  He conducted surgical master classes with the surgeons to help them improve their laparoscopic skills.  Torbay were also helped by Polly as someone who had already experienced the benefits of the enhanced recovery programme.

Acknowledgements / sources

Dr Kerri Houghton, Consultant Anaesthetist and Clinical Lead, Centre of Innovation & Training in Elective Care (CITEC) 

Sharon Bone, Matron Gastroenterology, Torbay Hospital, South Devon Healthcare NHS Trust 

Professor Henrik Kehlet, Rigshospitalet, Copenhagen, Denmark 

Henrik Husted and Gitte Holm, Hvidovre Hospital Copenhagen, Denmark (and to the Hope Exchange Programme for helping the NHS Institute make this link).

© Copyright NHS Institute for Innovation and Improvement 2008