ENHANCE RECOVERY IN GYNAECOLOGY Daniel Rivilla Data collected as 5 th Year Medical Student Currently FY1 – Ipswich Hospital 13/09/2013 Detailed Audit in Current Practice Miss Shohreh Beski Consultant Obstetrician & Gynaecologist

Why Enhanced Recovery? -Relatively new concept -Could speed up patient recovery post procedure -Can improve patient experience -Economic benefits: Reduces cost of hospitalisations and complications - This audit was conducted between February and March 2013 with the supervision of Miss Shohreh Berski and Dr James M N Duffy Who was involved?

Objectives: Why This Audit? To assess the depth of implementation and awareness To understand any problems that could affect the implementation of enhance recovery To identify examples of good and bad practice To aid training of staff members once audit completed To review current practice and identify areas for improvement Aim:

Criteria and standards -Preoperative: CriterionStandardException Was the patient seen by the pre- assessment team? 100%None Was the patient given information about the procedure? 100%None Was the patient informed about the expected length of stay? 100%None Were complex carbohydrate drinks prescribed prior to the operation? 100%None -Perioperative: CriterionStandardException Was the patient informed that clear fluids are allowed up to 2 hours before anaesthesia? 100%None

Criteria and standards -Intraoperative: CriterionStandardException Delivery of antibiotics and thromboprophylaxis before incision 100%Concurrent use of anticoagulants Use of minimal access technique whenever possible 100%Minimal access technique not possible/indicated Avoidance of nasogastric, abdominal and vaginal drains 100%Already in situ preoperatively Intraoperative hypothermia avoided (bearhug or similar used) 100%None

Criteria and standards -Postoperative: CriterionStandardException Enhance recovery sticker attached to procedures notes 100%None Early feeding (within 12 hours)100%None Early mobilisation (within 24 hours)100%None Catheter removed within 12 hours after the operation 100%LTC in situ preoperative or not indicated

Population and Sample -The patients were selected directly from the gynaecology theatre lists as identified by Miss Beski and interviewed on the morning of the procedure. -A total of 13 patients were interviewed and followed up over a period of 4 weeks. -7 operations were observed. -The interviews were conducted by me using a questionnaire and confidentiality was always maintained.

Audit Results -Preoperative: CriterionStandardResult Was the patient seen by the pre- assessment team? 100%13/13=100% Was the patient given information about the procedure? 100%13/13=100% Was the patient informed about the expected length of stay? 100%12/13=92.31% Were complex carbohydrate drinks prescribed prior to the operation? 100%0/13=0% -Perioperative: CriterionStandardResult Was the patient informed that clear fluids are allowed up to 2 hours before anaesthesia? 100%0/13=0%

Audit Results -Intraoperative: CriterionStandardResult Delivery of antibiotics and thromboprophylaxis before incision 100%0/7=0% Use of minimal access technique whenever possible 100%7/7=100% Avoidance of nasogastric, abdominal and vaginal drains 100%7/7=100% Intraoperative hypothermia avoided (bearhug or similar used) 100%7/7=100%

Audit Results -Postoperative: CriterionStandardResult Enhance recovery sticker attached to procedures notes 100%5/7=71.43% Early feeding (within 12 hours)100%4/7=57.14% Early mobilisation (within 24 hours)100%6/7=85.71% Catheter removed within 12 hours after the operation 100%4/7=57.14%

100% of patients interviewed were seen by the pre-assessment team and given information about the procedure Minimal incision was used in 100% of the cases observed Early mobilisation was achieved in 6 of the 7 cases Nasogastric, abdominal and vaginal drain were not used for any of the patients observed Intraoperative hypothermia was avoided. A bearhug or similar was used in all procedures Areas for improvement: – Complex carbohydrate drinks were not prescribed for any of the patients interviewed, e.g. Polycal. Liquid® (200 ml/£2.15) (247 Kcal/100ml, mixture of carbohydrates and minerals) – No patient had been informed that clear fluids were allowed up to 2 hours before anaesthesia. Some staff were also unaware Observations

Information regarding Enhance Recovery to be distributed to staff to familiarise with it Feedback teams regarding areas of excellence and areas for improvement Continue to use stickers with checklist Recommendations and actions

Audit report to be written and disseminated to relevant staff Areas for improvement identified by audit to be monitored and corrected if necessary Re-audit in 6 months to assess impact of audit on behaviour, including a larger number of patients, if possible. Next Steps

Royal College of Obstetricians and Gynaecologists. Enhanced Recovery in Gynaecology. Scientific Impact Paper no. 36, Feb 2013 NHS Improvement website, Enhance Recovery section Cover image from: recovery/Pages/Introduction.aspxhttp:// recovery/Pages/Introduction.aspx Diagram: eticket=a2t%2b0oPpxlQ%3d&tabid=278http:// eticket=a2t%2b0oPpxlQ%3d&tabid=278 References