Enhanced Recovery Getting Started Introductions Housekeeping Objectives for
Enhanced Recovery Getting Started
§ Introductions § Housekeeping § Objectives for the session
This Session • Practical activities to get you started • Based on the Implementation Guide • Access to advice, guidance and support • Discuss the key elements of your local implementation plan
Overview This Session: Action Planning: § Principles, elements and § Stakeholder Analysis benefits of ERP § Drivers for Implementation § Current and future pathway § § Testing changes for improvement § Measuring Outcomes
Principles, elements and benefits of Enhanced Recovery
What is it? § Enhanced Recovery is a new way of improving the experience and well-being of patients who need major surgery § It helps people to recover sooner so that life can return to normal as quickly as possible § It gives people a better overall experience due to higher quality care and services § It lets people choose what’s best for them throughout the course of their treatment with help from their GP and the wider healthcare team (“No decision about me without me. ”) § Many people who have experienced Enhanced Recovery say that it makes a hospital stay much less stressful Your Better Sooner!!!
The Principles of ER § Getting the patient in to the best possible condition for surgery § Ensuring the patient has the best possible management during their operation § Ensuring the patient has the best post-operative rehabilitation
Kehlets theory – 1980 s
Example of ER elements Referral from Primary Care • Optimising pre operative haemoglobin levels • Managing pre existing co morbidities e. g. diabetes Pre. Operative • Optimised Fluid Hydration • Reduced starvation • No / reduced bowel preparation ( bowel surgery) Admission • Optimised health / medical condition • Informed decision making • Pre operative health & risk assessment - CPEX • PT information and expectation managed • DX planning (EDD) Intra. Operative • Minimally invasive surgery • Use of transverse incisions • No NG tube (bowel surgery) • Use of LA with sedation • Epidural management (inc thoracic) • Optimised fluid management • Planned mobilisation • Rapid hydration & nourishment • Appropriate IV therapy • No wound drains • No NG (bowel surgery) • Catheters removed early • Regular oral analgesia • Paracetamol and NSAIDS • Avoidance of opiatebased analgesia where possible or administered topically • Audit & outcome measures Post- Operative • DX on planned day • Therapy support (stoma, physio) • 24 hr telephone follow up Follow Up 9
Physical impact
Clinical evidence compelling!
Colorectal Surgery: Length of stay Large Intestine: Major Procedures
Benefits being realised. . .
Multi-Disciplinary Teams? § It give patients a better overall experience through higher quality care and services § It introduces innovative best practices that empower and motivate staff § It accelerates the clinical decision-making process by empowering MDTs § It doesn’t increase MDT workload § It ensures the most-efficient use of healthcare resources § Best-practice is day surgery or an Enhanced Recovery pathway
What does it mean for providers? § It improves patient safety and involvement and meets Care Quality Commission requirements § It reduces demand on resources such as critical care, surgical beds and patient uptake of procedures § It increases job satisfaction of Multi-disciplinary Teams through better ways of working and improved patient outcomes § It improves the reputation of the healthcare provider § Best-practice is day surgery or an Enhanced Recovery pathway
Process & capacity impact
Commissioners? § It enhances the reputation of the healthcare provider § It helps patients recover sooner from surgery § Best-practice is day surgery or an Enhanced Recovery pathway § It improves patient experiences through increased partnership and empowerment (“No decision about me without me. ”) § It motivates medical teams through best practice, empowerment and innovation § It reduces demand on resources such as critical care, surgical beds and patient uptake of procedures
Legend The following denotes a trust is working in this specialty: (M) Musculoskeletal (C) Colorectal (U) Urology (G) Gynaecology Trusts with varying experience of enhanced recovery pathways North East Gateshead NHS Foundation Trust (M) Newcastle Hospitals NHS Trust (C) City Hospitals Sunderland NHS Foundation Trust (U) Scotland Northumbira NHS Trust (MSK) NHS Lothian (M) Gold Jubilee National Hospital (M) South Tees Hospitals NHS Foundation Trust (C, G, U) Yorkshire & The Humber Enhanced Recovery Innovation Sites are shown in red Sheffield Teaching Hospitals NHS Foundation Trust (G) York Hospitals NHS Foundation Trust (C) Scarborough Healthcare NHS Trust (C) North West Leeds Teaching Hospitals NHS Trust (C, G) Calderdale and Huddersfield NHS Foundation Trust (C, G) Aintree University Hospitals NHS Foundation Trust (M) East Lancashire Hospitals NHS Trust (C) Hope Hospital, Salford (C) Wirral University Teaching Hospital NHS Foundation Trust (C)(M) East Midlands Derby Hospitals NHS Foundation Trust (G) Queen’s Medical Centre (C) Sherwood Forest Hospitals NHS Foundation Trust (C) (G) Aintree University Hospitals NHS Foundation Trust (C, M, UPGI, Li) West Midlands City Hospital NHS Trust, Birmingham (C) Good Hope Hospital (C) University Hospitals Birmingham NHS Foundation Trust (C) Birmingham Heartlands NHS Trust The University Hospitals of Leicester NHS Trust (C, M, G, U) East of England (C)University Hospital of North Staffordshire NHS Trust (C, U, G) Colchester Hospital University NHS Foundation Trust (C) West Suffolk Hospital NHS Trust (M) Cambridge University Hospitals NHS Foundation Trust (Addenbrookes Hospital)(G) Robert Jones & Agnes Hunt NHS Trust South West North Devon Healthcare NHS Trust (C) South Devon Healthcare NHS Foundation Trust (C)(M)(G) Royal Devon and Exeter NHS Foundation Trust (U) Royal Bournemouth Hospital (M) North Bristol NHS Trust (Southmead Hospital)(U) Yeovil District Hospital NHS Foundation Trust (C)(M) Salisbury NHS Foundation Trust (C) Dorset County Hospital NHS Foundation Trust (C) Plymouth Hospitals NHS Trust (C) West Dorset NHS Trust (C) South Central South Devon Healthcare NHS Foundation Trust (Torbay Hospital) (C, M, G, U) Isle of Wight Healthcare NHS Trust (C) Milton Keynes Hospital NHS Foundation Trust (C) Royal Berkshire NHS Foundation Trust (C) Portsmouth Hospitals NHS Trust (C) Southampton University Hospitals NHS Trust (C) Oxford Ratcliffe(C) NHHT M)Winchester & Eastleigh NHS Trust (C, M, G) Royal Berkshire NHS Foundation Trust (C, M, G, U) West Hertfordshire Hospitals NHS Trust (C, M, G, U) London South East Coast Brighton and Sussex University Hospital NHS Trust (C) Darent Valley Hospital (Dartford and Gravesham NHS Trust) (M) Royal Surrey County Hospital NHS Trust (C) Worthing Hospital (C) East Kent Hospitals University NHS Foundation Trust (Queen Elizabeth, the Queen Mother Hospitals)(G) Medway NHS Foundation Trust(C) Medway NHS Foundation Trust (C, M, G, U) Brighton and Sussex University Hospitals (C, M, G, U) Barnet & Chase Farm Hospitals NHS Trust (C) Guy’s & St Thomas’ NHS Foundation Trust (C) Hillingdon Hospital NHS Trust (M) Imperial College Healthcare NHS Trust (C) South West London Elective Orthopaedic Centre (M) St George’s Healthcare NHS Trust (C)(U) St Mark’s Hospital (North West London Hospitals NHS Trust) (C) The Whittington NHS Trust (C) (M) UCLH NHS Foundation Trust (C) Whipps Cross University Hospital NHS Trust (C) The Hillingdon Hospital NHS Trust (C, G) North Middlesex University Hospital NHS Trust (C, M, G)
Drivers for Implementation Bella Talwar
Implementation Plan 1. 2. 3. 4. 5. 6. Understanding your current service Team working Action planning Stakeholder analysis Stakeholder engagement Testing and making changes to your pathway Understanding the risks 7. Understanding the investment required 8. Maintaining momentum 9. Sustaining the change
Audience: Patients Enhanced Recovery is a new way of improving the experience and well-being of patients who need major surgery. • It helps people to recover sooner so that life can return to normal as quickly as possible • It gives people a better overall experience due to higher quality care and services • It lets people choose what’s best for them throughout the course of their treatment with help from their GP and the wider healthcare team (“No decision about me without me. ”) • Many people who have experienced Enhanced Recovery say that it makes a hospital stay much less stressful
Audience: Multi-Disciplinary Teams Enhanced Recovery is a new, evidence-based pathway that creates fitter, patients who recover faster from major surgery • It give patients a better overall experience through higher quality care and services • It introduces innovative best practices that empower and motivate staff • It accelerates the clinical decision-making process by empowering MDTs • It doesn’t increase MDT workload • It ensures the most-efficient use of healthcare resources • Best-practice is day surgery or an Enhanced Recovery pathway
Mapping your pathway against the Enhanced Recovery Elements Bella Talwar
Understanding your current service CLINICAL INTERVENTIONS CLINICAL SYSTEM Identify elements in place on enhanced recovery pathway map Process map / Walk the patient journey Track patient journeys Audit of compliance with clinical elements on an individual patient basis OUTCOMES Patient Experience Length of Stay Re-operation rates Readmission rates Complication rates
Understanding your current service Referral from Primary Care • Optimising pre operative haemoglobin levels • Managing pre existing co morbidities e. g. diabetes Pre. Operative • Optimised health / medical condition • Informed decision making • Pre operative health & risk assessment • PT information and expectation managed • DX planning (EDD) • Pre-operative therapy instruction as appropriate • Admission on day • Optimised Fluid Hydration • CHO Loading • Reduced starvation • No / reduced oral bowel preparation ( bowel surgery) Admission • Minimally invasive surgery • Use of transverse incisions (abdominal) • No NG tube (bowel surgery) • Use of regional / LA with sedation • Epidural management (inc thoracic) • Optimised fluid management Individualised goal directed fluid therapy Intra. Operative • Planned mobilisation • Rapid hydration & nourishment • Appropriate IV therapy • No wound drains • No NG (bowel surgery) • Catheters removed early • Regular oral analgesia • Paracetamol and NSAIDS • Avoidance of systemic opiate-based analgesia where possible or administered topically Post. Operative • DX when criteria met • Therapy support (stoma, physio) • 24 hr telephone follow up Follow Up
Care Pathway Project Plan
Short-term investment § Support to change the pathway (e. g. service improvement, change manager, facilitator etc) § Training – new skills e. g. pre-assessment § Equipment – invest to save § Communication/awareness Find out what is already in place & going on Make the connections
What investment may be required? t n Fina no s i ce nly o e th nt e m t ves in Time Focus Commitment. Leadership Financial Engagement & accountability Training Enhanced Recovery Change management Skills Team-working Communication Systematic improvement Approach
What else is ER aligned to? Pre – 11 am Discharge TCAB Top Tips ERP Actual Bed Time Productive Wards Discharge Lounge Ticket Home Nurse Protocol Led Dispensing Discharge
Understanding and improving systems and processes Patient Pathway
Undertake mapping and tracking
Understanding your current service - Exercise § On the map provided: Understanding your current service - Exercise § Mark the interventions you already have in place § You should also consider when, where and how they are provided and whethere is further opportunity for improvement § Identify the interventions you need to establish and start to consider the sequence for implementation
Stakeholder Analysis Janine Roberts
Identifying the team Implementation requires a number of factors: § Changing clinical interventions § Changing care systems and processes § Creating a team to work across the patient pathway § Both require technical and behavioural change management § Lets start with thinking about who to engage and how to structure the project team
Essential Roles Sponsors: • authority to sanction change (organisational alignment / benefit) Change Agents: • facilitate change, require knowledge, skills and credibility Champions: • respected opinion leaders who positively promote work Leaders: • lead by example
Stakeholder Analysis High Influence Satisfy Manage • Opinion formers Key Stakeholders need to be fully engaged through full communication & consultation • Keep satisfied • Review regularly Little / No Influence Inform / Monitor Not crucial to the process but useful to keep informed Little / No Interest Involve • Voices that need to be heard • Need to be proactive High interest
Stakeholder Engagement § Full guide to stakeholder analysis and management: NHS Institute for Innovation and Improvement v‘The Handbook of Quality and Service improvement Tools’ v. Section 3 Stakeholder and User Involvement
Action planning and potential challenges Sophia Mavrommatis
Action Planning Take time to deliberate; but when the time for action arrives, stop thinking and go in’ -Andrew Jackson quoting Napoleon Bonapart
Managing Improvement low Test on a very small scale Agreement amongst the key players Just do it JDI high Certainty that the change will work low
Just Do it! § § Little risk Minimal cost Broad agreement Easy to do
Testing Changes for Improvement Sophia Mavrommatis
Enhanced Recovery Action Plan Action Owner Resources 30 60 90
Action Planning & Challenges § On your table provided start to fill in from the earlier work today which actions need to be completed § Who can deliver these actions § What is the timescale – 30, 60 or 90 days § Resourse – flag up what support you may need here to deliver the action – eg connection into the local PCT, facilitator to deliver a workshop Include in this the top three challenges that you think you will encounter and the actions you will put in place to work through these challenges.
Measuring Outcomes Bella Talwar
Outcomes § Patient / staff § Clinical - elements of the pathway § Financial
Understanding Your Current Service CLINICAL INTERVENTIONS CLINICAL SYSTEM Identify elements in place on enhanced recovery pathway map Process map / Walk the patient journey Track patient journeys Audit of compliance with clinical elements on an individual patient basis OUTCOMES Patient Experience Length of Stay Re-operation rates Readmission rates Complication rates
Making your baseline assessment Referral from Primary Care • Optimising pre operative haemoglobin levels • Managing pre existing co morbidities e. g. diabetes Pre. Operative • Optimised Fluid Hydration • Reduced starvation • No / reduced bowel preparation ( bowel surgery) Admission • Optimised health / medical condition • Informed decision making • Pre operative health & risk assessment - CPEX • PT information and expectation managed • DX planning (EDD) Intra. Operative • Minimally invasive surgery • Use of transverse incisions • No NG tube (bowel surgery) • Use of LA with sedation • Epidural management (inc thoracic) • Optimised fluid management • Planned mobilisation • Rapid hydration & nourishment • Appropriate IV therapy • No wound drains • No NG (bowel surgery) • Catheters removed early • Regular oral analgesia • Paracetamol and NSAIDS • Avoidance of opiatebased analgesia where possible or administered topically • Audit & outcome measures Post- Operative • DX on planned day • Therapy support (stoma, physio) • 24 hr telephone follow up Follow Up 55
Enhanced Recovery Pathway ‘Implementation & Sustainability’ ERP implemented Robotic Surgery CQUINS ERP implemented
Ann’s story to the Deputy Prime Minister “ I had two hip replacements last year. One in June and one in December. The second one was much better, the service is fabulous!”
Benefits Realisation Janine Roberts
Benefits Realisation
Next Steps Janine Roberts
Next steps Making it happen? • What ongoing support can we provide? • Implementation plan • Follow-up session
Next Steps What will be your first change you will test or implement? • Remember the importance of a quick win as well as a plan for sustainability
Next Steps Advice guidance and support – to change § § § § Implementation guide Enhanced Recovery Toolkit SHA support Local Network events UCLH Implementation team E-learning / DVD / Top Tips http: //insight/departments/Projects/QEP/Pages/home. as px § www. improvement. nhs. uk
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