Enhanced Recovery Partnership Program Enhanced Recovery Programme Helping patients to get better sooner after surgery 1

Enhanced Recovery Partnership Program What is enhanced recovery? Is a novel approach to elective surgery, ensuring that patients are in the optimal condition for treatment, have the best possible care during their operation, and experience optimal post-operative rehabilitation Patients on enhanced recovery pathways recover more quickly following surgery Enhanced Recovery Programmes (ERPs) are often referred to as Rapid, Accelerated Recovery or Fast Track surgery They should involve the whole health community 2

Enhanced Recovery Partnership Program History –Early 2000: Prof Henrik Kehlet, Copenhagen –Orthopaedic models such as Accelerated or Rapid Recovery have been in existence in England also since early 2000 –Clinician-driven programme –UK has piecemeal approach not maximising benefit for patients –Why has it not spread across the NHS when benefits are clearly reported? 3

Enhanced Recovery Partnership Program Colorectal Surgery: Length of stay Large Intestine: Major Procedures days

Enhanced Recovery Partnership Program Factors Influencing Patient Recovery

Enhanced Recovery Partnership Program Elective time spent in hospital Source: Hospital Episodes Statistics

Enhanced Recovery Partnership Program Colorectal procedures (2)

Enhanced Recovery Partnership Program Colorectal procedures (3)

Enhanced Recovery Partnership Program Hysterectomy (3)

Enhanced Recovery Partnership Program Bladder resection (3)

Enhanced Recovery Partnership Program Prostatectomy (3)

Enhanced Recovery Partnership Program Primary hip replacement (3)

Enhanced Recovery Partnership Program Primary knee replacement (3)

Enhanced Recovery Partnership Program 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) Northumbira NHS Trust (MSK) South Tees Hospitals NHS Foundation Trust (C,G,U) North West 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) Aintree University Hospitals NHS Foundation Trust (C,M,UPGI,Li) Yorkshire & The Humber Sheffield Teaching Hospitals NHS Foundation Trust (G) York Hospitals NHS Foundation Trust (C) Scarborough Healthcare NHS Trust (C) Leeds Teaching Hospitals NHS Trust (C,G) Calderdale and Huddersfield NHS Foundation Trust (C,G) West Midlands City Hospital NHS Trust, Birmingham (C) Good Hope Hospital (C) University Hospitals Birmingham NHS Foundation Trust (C) Birmingham Heartlands NHS Trust (C)University Hospital of North Staffordshire NHS Trust (C,U,G) Robert Jones & Agnes Hunt NHS Trust East Midlands Derby Hospitals NHS Foundation Trust (G) Queen’s Medical Centre (C) Sherwood Forest Hospitals NHS Foundation Trust (C) (G) The University Hospitals of Leicester NHS Trust (C,M,G,U) East of England Colchester Hospital University NHS Foundation Trust (C) West Suffolk Hospital NHS Trust (M) Cambridge University Hospitals NHS Foundation Trust (Addenbrookes Hospital) (G) West Hertfordshire Hospitals NHS Trust (C,M,G,U) 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) London 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) 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 Devon Healthcare NHS Foundation Trust (Torbay Hospital) (C,M,G,U) South Central 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) Legend The following denotes a trust is working in this specialty: (M) Musculoskeletal (C) Colorectal (U) Urology (G) Gynaecology Enhanced Recovery Innovation Sites are shown in red Scotland NHS Lothian (M) Gold Jubilee National Hospital (M)

Enhanced Recovery Partnership Program Benefits being realised... 15

Enhanced Recovery Partnership Program Additional benefits Early detection of complications Decrease in HAI Patient safety Improved quality of care Empowered patients Harmonisation of care across NHS Knowledge of outcomes Team building Local education Improved focus on use of technology Closer working partnerships (primary care and acute) WCC Quality service commissioned Improved reputation of Trust International profile of care

Enhanced Recovery Partnership Program Example of enhanced recovery elements 17 Referral from Primary Care Pre- Operative Admission Intra- Operative Post- Operative Follow Up

Enhanced Recovery Partnership Program Example of enhanced recovery elements 18 Referral from Primary Care Pre- Operative Admission Intra- Operative Post- Operative Follow Up Optimising pre operative health state e.g. Hb levels Managing co morbidities e.g. diabetes Fit for surgery

Enhanced Recovery Partnership Program Example of enhanced recovery elements 19 Pre- Operative Admission Intra- Operative Post- Operative Follow Up PT information and expectation managed DX planning (EDD) No / reduced oral bowel prep (bowel surgery) Pre-operative therapy instruction where appropriate Optimised health / medical condition Informed decision making with companion Pre operative health & risk assessment e.g. (CPEX) Referral from Primary Care

Enhanced Recovery Partnership Program Example of enhanced recovery elements 20 Pre- Operative Admission Intra- Operative Post- Operative Follow Up Admission on the day of surgery Carbohydrate loading No pre med (sedative) Optimise fluid hydration Optimise Nutrition No / reduced oral bowel preparation (where appropriate) Referral from Primary Care

Enhanced Recovery Partnership Program Example of enhanced recovery elements 21 Pre- Operative Intra- Operative Post- Operative Follow Up Use of regional anaesthesia LA with sedation Individualised goal directed fluid management Minimally invasive surgery where appropriate Use of transverse incisions (abdominal) if appropriate Referral from Primary Care Admission

Enhanced Recovery Partnership Program Example of enhanced recovery elements 22 Pre- Operative Intra- Operative Post- Operative Follow Up Catheters removed early Regular oral analgesia Paracetamol and NSAIDS Avoidance of systemic opiate- based analgesia where possible or administered topically Planned mobilisation (24hrs post op) Rapid hydration & nourishment Appropriate IV therapy No wound drains No nasogastric tubes (bowel surgery) Referral from Primary Care Admission

Enhanced Recovery Partnership Program Example of enhanced recovery elements 23 Pre- Operative Intra- Operative Follow Up Audit & monitor outcomes Feedback DX when criteria met Therapy input (e.g. stoma / physio / dietician) 24 hour follow up call Referral from Primary Care Admission Post- Operative

Enhanced Recovery Partnership Program Example of enhanced recovery elements 24 Referral from Primary Care Pre- Operative Admission Intra- Operative Post- Operative Follow Up 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 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 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 Admission on day Optimised Fluid Hydration CHO Loading Reduced starvation No / reduced oral bowel preparation ( bowel surgery) DX when criteria met Therapy support (stoma, physio) 24hr telephone follow up Optimising pre operative haemoglobin levels Managing pre existing co morbidities e.g. diabetes

Enhanced Recovery Partnership Program Enhanced Recovery Clinical Team Patients Nurse specialists Physiotherapy Occupational therapy Social workers Anaesthesia Pain management Pre-assessment Nutrition / Dietician Team assistant Ward nursing staff Medical staff Management Primary Care Pharmacist

Enhanced Recovery Partnership Program Critical success factors and barriers Leadership and clinical engagement – 5-prong approach – consultant, anaesthetist, nursing/AHP, executive/management and primary care /commissioning Engagement/communication with patients and staff Capability and education Information Culture Barriers –Absence of the above

Enhanced Recovery Partnership Program ER Programme’s aim To improve the quality of patients care, through improving their clinical outcomes and experience, and reduce the length of elective care inpatient pathways across the NHS by utilising the good practice principles of enhanced recovery models of care. 27 ‘And to do this in 2 years not 20!’ Professor Sir Mike Richards, SRO

Enhanced Recovery Partnership Program Context – changing NHS  35 million patients registered in England  16,864 GPs  5,000 consultants  55 million patients registered in England  40,000 GP’s (8,500 Practices)  Greater levels of clinical specialisation  New treatments / complex pathways  Patients expecting much higher levels of service and outcomes  Clinical staff have higher expectations of what is required

Enhanced Recovery Partnership Program Every year the NHS carries out approximately: 250 million GP consultations 13.6 million first outpatient attendances 31.1 million subsequent outpatient attendances 664 million diagnostic tests 1.6 million ordinary admissions 4.2 million day case admissions

Enhanced Recovery Partnership Program Variation in pathways and LOS across the country

Enhanced Recovery Partnership Program ERP quality and productivity With the recognised need for the NHS to make billions of pounds worth of efficiency savings during while still focussing on quality improvement, the Enhanced Recovery Partnership Programme is perfectly placed to make a significant contribution. The programme delivers on: –Improved quality of patient care –Improved quality of working life –Innovative pre-, peri- and post-operative techniques are recognised to make a real difference to patient experience –Shorter length of stay increases productivity –Making sure the patient is in optimal health condition before surgery minimises risk (works towards prevention) of readmission and re-operation

Enhanced Recovery Partnership Program The future of elective care - Day surgery or enhanced recovery??

Enhanced Recovery Partnership Program The Impact 33

Enhanced Recovery Partnership Program Organisational capability to implement ER 34 High Capability Will implement anyway locally Innovative teams Stakeholders engaged & Committed Skills (project management / transformation) Locally aligned Potential capability Would be successful at implementing with some support / structure May need support with engagement internally & across LHC Once benefits understood could be implemented Low Capability / Capacity Key stakeholders not engaged / committed Not seen as a priority Other conflicting issues / priorities

supporting & learning from innovation sites Spread Adoption & Sustainability Clinical Leadership Clinical Network development ( 3 events) Local Alignment Change management and outcome measurement National Networks Proposed local support in partnership with SHA National ERPPNational ERPP Local / SHALocal /SHA Funding per SHA for Network Events design of content support National Network events (x2) design and Support materials National Expertise 1 WTE NHS Imp 2 WTE NHS Inst 4 WTE (DH) National ClinicalExpertise & funding allocated to support local clinical team Capacity & capability assessment for implementation & local Resource Alignment from: Cancer Networks Providers existing resources SHA Resource Existing work stream clinical leadership alignment Design and manage local network events based on proposed model

Enhanced Recovery Partnership Program Implementation guide 36

Enhanced Recovery Partnership Program Case studies and research articles

Enhanced Recovery Partnership Program ER Toolkit to support outcome measurement

Enhanced Recovery Partnership Program Colorectal & MSK Case Studies results 39

Enhanced Recovery Partnership Program What the patients say! 40

Enhanced Recovery Partnership Program The national team 41 DH National Director for Cancer & End of Life CareProf Sir Mike Richards National Clinical LeadsProf Monty Mythen Mr Alan Horgan National Programme LeadJanine Roberts National Clinical AdvisorsMr Nigel Acheson Mr Robin Crawford Mr John McGrath National Clinical Advisors Dr Kerri Houghton Mr Ian Bayley Mr Robin Kennedy Dr Michael Swart Dr Martin Kuper National Clinical Lead and Chair of Transforming InpatientsMs Celia Ingham-Clark Steering Group National Laparoscopic Clinical LeadMr Mark Coleman Policy leadsJane Allberry, Suzanne Clabby National Cancer Action Team Associate DirectorAndy McMeeking NHS Institute of Innovation Kate Hall NHS Improvement Cancer DirectorAnn Driver Primary Care AdvisorsDr Alan Nye Commissioner AdvisorPaul Carroll Nurse AdvisorTeresa Fenech AHP Advisor / representativeSarah Bazin

Enhanced Recovery Partnership Program Helping patients to get better sooner after surgery Next steps to support implementation 42

Enhanced Recovery Partnership Program Next steps Lessons learned – what drives success Engaging with and key messages for –Commissioners –Primary care –Social care Implementation strategy 2010/11 Materials to support Data collection ER Toolkit

Enhanced Recovery Partnership Program Phases of implementation of ER Locally Preparation Stakeholder Communication & engagement Project plan and local alignment Baseline position (0-3 months) Testing & Implementation Small scale changes Testing High priority areas Easy wins / JDIs Measurement of outcomes Refine and sustain & spread to other specialites Did the change you made make a difference (measurement) Does the pathway provide an improved quality experience? Continuous measurement / audit of outcomes to ensure sustainability 44

Enhanced Recovery Partnership Program What really is your baseline? 45 Referral from Primary Care Pre- Operative Admission Intra- Operative Post- Operative Follow Up 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 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 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 Admission on day Optimised Fluid Hydration CHO Loading Reduced starvation No / reduced oral bowel preparation ( bowel surgery) DX when criteria met Therapy support (stoma, physio) 24hr telephone follow up Optimising pre operative haemoglobin levels Managing pre existing co morbidities e.g. diabetes

Enhanced Recovery Partnership Program Stakeholder engagement Executive engagement essential MDT alone can not implement Measure outcomes – the benefits of measurement often overlooked Commissioner & primary care must be engaged 46

Enhanced Recovery Partnership Program Engaging with Commissioners Engaging with your commissioners means you will be able to: ensure commissioners understand aims and expectations for delivering ER develop a shared understanding of their role in the implementation of ER build commissioner support for the widespread implementation and rollout of enhanced recovery across your Trust ensure a dialogue and closer working to discuss how benefits will be realised without risk to either the provider or the commissioner but with maximum benefit to patients

Enhanced Recovery Partnership Program Can you demonstrate to your commissioner that your pathway provides: A high quality service for all patients Good patient experience e.g. through good pain management Innovation by using the most up-to-date techniques and technology A reduction in excess bed LoS A reduction in use of HDU/ITU beds A reduction in activity through informed decision making ( benefits of £150m may achieved ) Engaging with Commissioners

Enhanced Recovery Partnership Program Alignment with WCC Competencies WCC competency 3 – Engage with public and patients. Empowerment of patients (through patient information, informed decision-making, managing expectations) Improved patient experience by: returning to normal sooner after surgery improved patient clinical outcomes reduced complications thereby reducing HDU/ITU bed use reduced LoS which in turn can reduce risk of hospital acquired infections a reduction, or no increase, in readmission rates.

Enhanced Recovery Partnership Program WCC competency 4 – Collaborate with clinicians The ER pathway is clinically led putting clinicians at the forefront of patient care using innovative techniques and technology to improve quality and clinical outcomes thereby reducing complications Understanding the clinical pathway and it’s benefits will help ensure that the most appropriate services are commissioned for the local population Alignment with WCC Competencies

Enhanced Recovery Partnership Program WCC competency 6 – Prioritise investment Implementation of ER as a model of care will result in: less risk of excess bed days / specialised care ITU / HDU /post operative complications good return on investment reduced LoS Informed decision making outcome benefits for PCT / primary care Alignment with WCC Competencies

Enhanced Recovery Partnership Program WCC competency 8 – Promote improvement and innovation ER eliminates variation in the pathway utilises the most up-to-date techniques and technology is evidence based Alignment with WCC Competencies

Enhanced Recovery Partnership Program Engaging primary Care WIFM? - 2 levels Understanding –Understanding and knowledge of what ER as opposed to common assumption – Patients are fitter sooner! Active involvement - PBC pilots –Involvement & delivery in changing the pathway –IDM – benefits to primary care and PBC / PCT –Optimisation of health –Reduced clinical complications post operatively –More informed patients

Enhanced Recovery Partnership Program WIFM - 2 levels Understanding – and knowledge of what ER as opposed to common assumption – Patients are fitter sooner! Active involvement and engagement –Case studies demonstrating active early intervention and assessment Engaging primary Care

Enhanced Recovery Partnership Program National Support to increase wide spread adoption and implementation 55

Enhanced Recovery Partnership Program Organisational capability to implement ER 56 High Capability Will implement anyway locally Innovative teams Stakeholders engaged & Committed Skills (project management / transformation) Locally aligned Potential capability Would be successful at implementing with some support / structure May need support with engagement internally & across LHC Once benefits understood could be implemented Low Capability / Capacity Key stakeholders not engaged / committed Not seen as a priority Other conflicting issues / priorities

Enhanced Recovery Partnership Program supporting & learning from innovation sites Spread Adoption & Sustainability Clinical Leadership Clinical Network development ( 3 events) Local Alignment Change management and outcome measurement National Networks Proposed local support in partnership with SHA National ERPPNational ERPP Local / SHALocal /SHA Funding per SHA for Network Events design of content support National Network events (x2) design and Support materials National Expertise 1 WTE NHS Imp 2 WTE NHS Inst 4 WTE (DH) 1 National Clinical lead & funding allocated to support local clinical team Capacity & capability assessment for implementation & local Resource Alignment from: Cancer Networks Providers existing resources SHA Resource Existing work stream clinical leadership alignment Design and manage local network events based on proposed model

Enhanced Recovery Partnership Program Implementation guide 58

Enhanced Recovery Partnership Program Case studies and research articles

Enhanced Recovery Partnership Program ER Toolkit to support outcome measurement

Enhanced Recovery Partnership Program Additional materials available Generic slide pack ( download from ER web page) Example pathways from Trusts Example patient information packs from Trusts In development Map of medicine DVD – Vox Box Specialty specific pathways Patient experience materials Please note all on www. 18 weeks.nhs.uk via quick link /enhanced recovery – soon changing to central DH page

Enhanced Recovery Partnership Program What can you do? Communicate ER as the standard for elective care in the future Implement: if you have the capability / capacity If your already doing this and doing it well – –tell us –submit a case study –support local spread and adoption in your area 62

Enhanced Recovery Partnership Program Further questions / information 63