s202 - day 2 - 1200 - enhanced recovery care pathways
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Health and Care Innovation Expo 2014, Pop-up University S202 - Day 2 - 1200 - Enhanced recovery care pathways Sue Cottle Amy Kerr Neil Betteridge #Expo14NHSTRANSCRIPT
Enhanced Recovery Care Pathway: a better journey for patients seven days a week and better deal for the
NHSSue Cottle
Improvement Manager
Acute care and seven day services
NHS Improving Quality
• National overview
• Enhanced recovery: A patient centred approach
Neil Betteridge, ER Patient and Public advisor
• ER in Thoracic Surgery
Amy Kerr, Heart of England Foundation Trust
• ER in Maternity Care – Sheffield Teaching Hospital experience
• ER in Medicine – Torbay Hospital experience
ER is becoming the norm
Progress and level of ambition• Quality is the driving
principle• Key components – 5 P’s• Good progress made• Extend principles of ER
beyond elective practice• Integrate ER across the
whole system
Designed by patients for patients
• Patient involvement and shared decision making at the heart of ER
• The potency of patient involvement helps to drive spread and adoption of ER
A patient centred approach
“We believe that enhanced recovery should now be considered as standard practice for most patients undergoing major surgery across a range of procedures and specialties”.
ER is becoming the norm
Aligned to the NHS Outcomes Framework
ER is “big cog” in a whole pathway
“Enhanced Recovery is a solid platform to build upon, ER is a strong concept and we have the opportunity to widen this further along the care pathway and continue to generate evidence of its impact”
Professor Keith Willett
The next three to five years improvement programme - dedicated support, dedicated investment
Falling length of stay
170,000 fewer bed days
Increasing day of surgery admissions
No increase in readmissions
Progress: ER reduces length of hospital stay
Progress: ER increases day of surgery admission
Increasing day of surgery admissions
No change in readmissions
We know the Job is not done ………………… But it’s a job worth doing
We know the Job is not done - variation exists Variation in
- spread and adoption to other
elective surgical procedures - momentum of spread in existing procedures
Early testing in- emergency and acute
medical- maternity pathways
Summary and future levels of ambition
• Increase patient engagement to empower patients• Ensure all patients get the same standard of care
seven days a week – spread to non-elective care• Develop systems to optimise patients fitness for
referral and risk stratification to improve patient safety
• Develop internationally comparable outcome measures to further build the evidence
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Enhanced recovery: a patient centred approach
Neil Betteridge
Patient and public advisor
Enhanced Recovery
A better journey for patients…
ER promotes a changing role for patients
• From: ‘You’re sick, or damaged, stay still and we’ll fix you’
• To: ‘We’re going to work together and you need to play an active role in your recovery
It’s the patient’s journey
• Key word is ‘My’• Key concepts are ‘active role’ and ‘responsibility’• It’s a conditional deal: steps you can take to get better sooner• Most people buy that: wouldn’t you?
‘I didn’t know I had a role’ Nick, ER patient
Designed by patients for patients
• Over 1000 leaflets distributed across England
• Positive evaluation from patients and carers and professionals across England
My role and my responsibilities
Key messages: the patient deal
• Prepare: eat well, sort practicalities and think about post-op sooner not later
• Clarify what you can do during admission to get moving sooner – and be sure you know who to ask if unsure
• Recovery doesn’t end on discharge: set daily goals and stay in touch
94% 92% 89%95%
78%
86%
74%
84%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Were you involved as much as you wanted to be about your care and
treatment?
How much information about your condition or treatment was
given to you?
Did you feel you were involved in decisions about your discharge
from hospital?
Did hospital staff tell you who to contact if you were worried about your condition or treatment after
you left hospital?
Patient Experience: Enhanced Recovery compared to National Inpatient Survey
2011-Enhanced Recovery 2010-National Inpatient Survey - elective only
94% 92% 89%95%
78%
86%
74%
84%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Were you involved as much as you wanted to be about your care and
treatment?
How much information about your condition or treatment was
given to you?
Did you feel you were involved in decisions about your discharge
from hospital?
Did hospital staff tell you who to contact if you were worried about your condition or treatment after
you left hospital?
Patient Experience: Enhanced Recovery compared to National Inpatient Survey
2011-Enhanced Recovery 2010-National Inpatient Survey - elective only
Getting there
• ‘If you’re not sure where you are going, you’re liable to end up somewhere else’ - Robert F. Mager
• ‘One important key to success is self-confidence. An important key to self-confidence is preparation’ - Arthur Ashe
…thank you for your attention
Enhanced Recovery Care Pathway: Thoracic Surgery
Amy Kerr
Research nurse
Heart of England Foundation Trust
Enhanced Recovery Care Pathway: Maternity – Elective caesarean
sectionSue Cottle
National perspective
Sheffield Teaching Hospitals NHS Trust Experience
National perspective• ER principles supported by the National Clinical Director for Maternity and
Women’s Health• Engaging with the Royal College of Obstetricians and Anaesthetic
association• Scoping of practice has identified evidence of implementation of ER in
practice • Variation in practice and length of stay• Obstetric Anaesthetic survey in publication
Obstetrics: Elective C - Section
What changes were made?
Pre – operative management• Patient selection• Preadmission counselling• Clear fluids up to 2 hours pre- op: Carbohydrate loading• Analgesia – oromorphine regime• TTO’s prescribed in theatre
New Oramorph regime:C.Meer, B.Kasa, R.Goyal
• Formerly parenteral regime with subcutaneous cannula – service evaluation of 67 patients:– 79% - not used– 63% - Pain or erythema – 39% - taken out as uncomfortable
• Change to hourly oramorph regime – service evaluation of 128 women:– 94% rated pain control good or excellent (as before)– 98% of midwives – less work (oramorph not controlled drug – one
qualified only)
Postoperative management:• Clear fluids up to 1 hour post op
• Postoperative mobilisation– Spinal anaesthesia takes 4 to 9 hours to wear off– 8 hours post op is in the evening for most– Fewer staff then - ?safe to mobilise?– Patients ambivalent about early mobilisation– Elected to mobilise day after surgery as before.
• Removal of urinary catheters on mobilising
• Post operative checklist
What changes were made? The neonate• Breast feeding
– Problems with breast feeding commonly delay discharge– Skin to skin contact at birth between mother and baby improves
breast feeding rates – low rates in theatre– New initiative to encourage this in theatre
• Delayed cord clamping– Increases the amount of blood going to the newborn from the
placenta– Increases blood haemoglobin levels– Should improve neonatal recovery– Obstetricians have instituted a new protocol for this and it is being
used
Telephone service evaluation:• 19 women were followed up by telephone on discharge• 100% reported they were able to do daily activities• 96% reported feeling ‘back to normal’• 82.3% reported no pain. • 76.5% breastfeeding rate; 100% reported no problems at all in
looking after the baby• No readmissions or problems reported in women or neonates
discharged on day 1
Summary• Enhanced recovery successfully introduced for elective caesarean
section• 15 - 20% of patients leave on day one
– Previously around 1%• No increase in readmission rates• No evidence of problems in the community
Testing the pinciples of ER in Medicine
Torbay Hospital Experience
South Devon Healthcare NHS Foundation Trust
Enhanced Recovery – Application of ER principles in medicine
Professor Ben Benjamin
The Torbay Hospital Experience
South Devon Healthcare NHS Foundation Trust
Enhanced recovery care pathway: A better journey for patients seven days
a week and better deal for the NHS
www.nhsiq/enhancedrecovery