20,000 Days Campaign Storyboard Learning Session 3 11-12 March 2013 Collaborative Name: ERAS in Orthopaedics

Aim & Charter Aim: To increase the number of surgical patients going through the ERAS pathway to reduce length of stay, without increasing re-admissions, and improving patient satisfaction. Description: We expect to achieve the implementation of an ERAS program throughout Orthopaedics. By improving protocol adherence and compliance to the ERAS pathway, the aim is to reduce the surgical stress response and promote faster recovery after surgery with fewer complications.

primary Secondary Concept intervention ERAS Clinic Patient expectations Patient Education ERAS Leaflets Pre-operative Patient experience Planned EDD Post discharge home support in place Preparation > 24 hrs prior to surgery Pre-habilitation Patient physically prepared Preparation <24hrs prior to surgery Optimised Nutrition/hydration Carbohydrate Loading Anaesthetic Use of local anaesthetic with sedation Standardise Avoid use of opiates Increase number of surgical patients going through the ERAS pathway (leading to reduced LOS, without increase in readmissions and increased patient satisfaction) Intra-operative pain control Minimal invasive Staff education Choice of incision surgical procedure Provide local evidence of why choices made Early mobilisation Patient ready (to go home) Removal of IDC/Drains ASAP Standardise Rapid hydration and nourishment Post operative Swap to Oral analgesia ASAP Discharge criteria Home support in place Ongoing support Follow-up post discharge (Post discharge) care in the community Post-discharge clinic Allied Health follow-up

Change Packages Secondary Drivers Change Ideas Tested (Theory of change) Change Ideas Tested (describe process) Evidence of Improvement (Run Charts) Patient expectations and experience ERAS Pre-hab clinic use of standardized questionnaires to assess mobility, life style factors Own clothes to be used from day 2 to encourage patient to become independent Patient Physically prepared Prehab preparation – OT assessment, equipment Discharge Criteria Mobilisation on day two – assessed by physiotherapist Home support in place prior to discharge

Measures Summary

Changes to Support Implementation Implementation Areas Changes to Support Implementation Standardisation Introduction of a protocol and pathway Documentation Introduction of the protocol as part of the patient record Patient resources: Patient Journey book Training Staff education in the principles of ERAS, use of documentation and managing variation to the protocol Measurement Length of stay Readmission rates Patient satisfaction Resourcing ERAS Clinical Specialty Nurse for Orthopaedics New documentation costs Adapted from “The Improvement Guide. A Practical Approach to Enhancing Organizational Performance” Gerald Langley et al., 2009, p180.

Highlights and Lowlights The ERAS collaborative can now demonstrate a saving in bed days and improved satisfaction. The aims of the project have been achieved in Orthopaedics. The collaborative team have found this to be a robust process. The analysis of base line data showed some interesting things including where to focus and where not to as not gains would be made. PDSA cycles to test change, have been very useful. Surgical services noe intend to spread ERAS as part of their management against MOH targets for elective surgery. The orthopaedics ERAS collaborative will inform this spread on what works well and how to get results.

Achievements to date We now have a change package that we believe is ready for introduction to the wider multidisciplinary team across surgical services and this will be done through an intensive workshop to standardize and agree on the protocol All the multidisciplinary groups have been working well and independently within their work streams and reporting back regularly on their achievements and learnings We have learned from a patient satisfaction audit that we could be more consistent, that the information we provide could be more comprehensive, but that overall patients were well supported, and had a positive experience with their joint replacement surgery. The ERAS protocol is well placed to enhance the areas for improvement and consolidate the areas we are doing well in.