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London Feb 21st 2013

Dr Kerri Jones

Consultant Anaesthetist & Associate Medical Director

Adviser Dept Health Enhanced Recovery Programme

Better value, better outcomes

How to deliver quality and value in chronic care:

sharing the learning from the respiratory programme

Content

what is ‘Enhanced Recovery’

what is the proposition?

are the concepts transferable to medical admissions?

the Torbay pilot (S Devon Healthcare NHS

future developments

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What is ‘enhanced recovery’?

Henrik Kehlet, Professor of Surgery, Copenhagen

1980s showed the use of epidurals for major abdominal surgery

improved recovery by

managing pain

reduce stress response

He thought patients still stayed too long in hospital and by 2000

was describing a multimodal approach to care...

Fast-track/Accelerated/Rapid or Enhanced Recovery

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Physiological problem

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His proposition

Looked at factors influencing recovery

Designed a pathway to tackle

each element

What did he do?

created a structured approach

involved the patient

set expectations realistically

held his team to account

is the patient on track with the pathway?

‘why is this patient in hospital today?’

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Colorectal Surgery: Length of stay Large Intestine: Major Procedures

0

2

4

6

8

10

12

14

16

UK Kehlet

days

UK adoption

sporadic

clinicians approached the DH for help to spread

country-wide programme

evidence-based; Kehlet & others

pathway defined

MSK, colorectal, gynae, urology

other specialties

proving to be very successful

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Enhanced recovery elements identified

Referral from

Primary Care

Pre-

Operative

Admission

Intra-

Operative

Post-

Operative Follow

Up

• optimise health / medical

condition

• informed decision making

• pre-operative health & risk

assessment

• patient information and

expectation managed

• discharge planning (EDD)

• pre-operative therapy

instruction as appropriate

• minimally invasive surgery

• use of transverse incisions

(abdominal)

• no NG tube (bowel surgery)

• regional / LA with sedation

• epidural management (inc

thoracic)

• optimise fluid management

• individualised goal directed

fluid therapy

• planned mobilisation

• rapid hydration &

nourishment

• appropriate IV therapy

• no wound drains

• no NG (bowel surgery)

• catheters removed early

• regular oral analgesia

• paracetamol and NSAIDS

• avoid systemic opiate-

based analgesia where

possible or administered

topically

• admit on day of surgery

• optimised fluid

hydration

• CHO Loading

• reduced starvation

• no / reduced oral bowel

preparation ( bowel

surgery)

• discharge when criteria met

• therapy support (stoma, physio)

• 24hr telephone follow up

• optimise pre operative

haemoglobin levels

• manage pre existing co

morbidities e.g. diabetes

Are the principles transferable to medicine?

illness is ‘stress’ just like an operation

simple adherence to fluid, nutrition & mobilisation plus

information are key and could be applied to all inpatients

no evidence base as yet – but from 2010, Kehlet has run a

research study in 2 patient groups

acute pneumonia

‘off legs’

he reports impact is ‘incredible’ though has found it difficult

patient/carer information is relevant to chronic disease

with repeated acute exacerbations

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ENHANCED RECOVERY: MEDICINE

Prof Ben Benjamin

Consultant Acute Medicine and Director of R&D South Devon Healthcare NHS FT

2012 – 2013

Why do it?

Improve

patient

and carer

experience

To reduce

length of

stay

To reduce

readmissions To improve

mobilisation

To gain early

independence

To reduce

deterioration

during

admission

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What is it?

a new approach to caring for patients admitted as a medical emergency to Torbay Hospital

involves patients and families/carers in decisions

patients are partners in their own care

patients, carers, families, nurses, therapists and doctors all work together to agree a plan for Rx and recovery

big focus on nutrition & mobility

What has happened so far??

Core project team

Director of Nursing and Quality – executive sponsor

Prof Ben Benjamin – clinical lead

Emergency Admissions Unit (EAU) manager and test lead

Matron for acute medicine

ER medicine project manager

OT

Carers’ lead

dietician, radiographer, matrons, consultants, ward managers

Wards/Units

EAU (medical assessment unit) – test bed

COTE

respiratory ward

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Which patients?

patients admitted as an emergency, requiring

medical interventions

patients requiring an inpatient stay on the EAUs,

respiratory patients), COTE wards

Getting you home; safely and at the right time

Getting you home; safely and at the right time

What’s happened so far?

current state and future state mapping sessions

baseline measurement – LoS, patient interviews

testing the concepts on patients with sepsis

communications – patient and carer information

pre hospital care – sepsis alert – antibiotic PGD

daily target setting

carers’ lead promoting the message in the community

GP engagement and awareness raising

focus on nutrition, mobility

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Daily target setting

Mobilisation

Oral fluids

Energy

drink Day clothes,

no PJs

Decision-making

between the patient,

medical team and

families/carers

Plan transport

early

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Measures

length of stay will take time as the culture change occurs

bed days

patient experience and satisfaction

oral/iv switch pulling notes and drug charts to capture iv/oral switch is time consuming

time to mobilisation

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Project Reflections so far

executive and clinical leadership – essential for success

baselining – walking the patient journey to identify waste in the system was compelling for the whole team – to get out of their silos

ask the people doing the job how best to change it; improvements have come from a bottom up rather than top down approach

time to carry out improvement – regular weekly huddles, an enthusiast seconded to drive improvements + service improvement project support

work across primary-secondary-social care boundaries

measurement for ER medicine has been challenging

Next steps

testing carried out on other EAU ward

roll out to other wards

CQUIN 2013/14 target

continued involvement of carers and GPs

learning and sharing best practice with colleagues

across the UK through

NHS South workshops

participation in RCP working group

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Further information

http://www.youtube.com/watch?v=pKUfCDQlglw

jane.dewar@nhs.net

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