Enhanced Recovery Programme E-Learning ‘ Helping patients to get better sooner after surgery’ To improve the quality of patients care by improving their experience and clinical outcomes This e-learning module will take 20 minutes and there will be a short assessment at the end.

What will I learn What is Enhanced Recovery What are the core elements Why it is important at UCLH and nationally What is in it for the patient, MDT, hospital, community and me What is my role What are the consequences of not doing it

What is Enhanced Recovery

What are the principle of Enhanced Recovery Patients have elective surgery with an innovative, high quality care approach Patients are in the optimal condition for treatment Patients have a better care experience before, during and after their operation – ‘There is a role for everyone’

It makes a difference to patients “ I had two hip replacements last year. One in June and one in December. The second one was much better, the service is fabulous!” In June there was no Enhanced Recovery Programme in place but in December there was!

Factors Influencing Patient Recovery HANNAH - Could this slide be combined in some way with the next one (mountain). Will need to include reference but we can do this later Kellet’s Theory 1980

What are the core elements

What is the purpose of the different stages of care pathway –Pre-operatively: Other health problems are identified & managed to enable the patient to be in the best possible condition for surgery –Intra-operatively: Best possible evidence based management is given to the patient during and after surgery –Post-operatively: Patients are encouraged with early mobilisation and timely discharge for the best rehabilitation with support

Examples of Enhanced Recovery Elements at key stages of the pathway 9 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 - CPEX PT information and expectation managed DX planning (EDD) Minimally invasive surgery Use of transverse incisions No NG tube (bowel surgery) Use of LA with sedation Epidural management (inc thoracic) Optimised fluid management 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 opiate- based analgesia where possible or administered topically Optimised Fluid Hydration Reduced starvation No / reduced bowel preparation ( bowel surgery) DX on planned day Therapy support (stoma, physio) 24hr telephone follow up Optimising pre operative haemoglobin levels Managing pre existing co morbidities e.g. diabetes Audit & outcome measures

10 Factors to consider for Surgery? Fit for Surgery? Mythen MG. Anesthesia and Analgesia: April and May 2011

Benefits Realised

Success for Sustainability What are the key drivers for change within the quality and safety framework:  Improve clinical quality, patient safety and clincial experience  Incentives with CQUINS and PbR tarrif  How do we measure this:  Collect high quality data to support practice change  Define what are outcomes  process (compliance with the clinical pathway)  clinical (complications)  patient experience (satisfaction)  Test, evaluate, refine and embed change based on evidence of own practice. Benefits realisation can take longer

Success for Sustainability  Change is Clinically Led with Senior Management Support  Clinical leadership is crucial for successful implementation  Leaders are respected role models who can influence peers and other MDT members  Involvement and engagement of all members within the MDT is required  Project management, Change management, Faciliators,, senior management support and key stakeholder support and engagement is an ongoing process, and not just at the outset of the implementation process  Ethos of the Clinical Team  Celebrate the success of your work and achievements  Show mutual respect and value the different and complementary roles of the MDT members  Engage in the top tips for patients  Organisational Culture  Support the ‘can do’ culture that empowers and enables clinical teams to test new ways of working, without fear, risk or blame  Share the strong relationships between managers and clinicians with quality & safety being high on the executive agenda

Benefits from Informed (shared) decision making – Decision aids provide: support to patients in making the best decision for their circumstances information to help them understand whether to have a diagnostic test Information of their condition and the progression of their disease the treatment options available to them, the side effects and benefits of each option Information about the issues that are most important to them/their preferences

Stakeholder Engagement  Full guide to stakeholder analysis and management: NHS Institute for Innovation and Improvement  ‘The Handbook of Quality and Service improvement Tools’  Section 3 Stakeholder and User Involvement

Why it is important at UCLH and nationally

What else is ER aligned to?

What investment may be required? Finance is not the only investment

National programme Support to SHAs to lead a local spread and adoption programme –Objective support and guidance Communications and resources –Web site Collating emergent evidence working with opinion leaders Stakeholder engagement with national bodies to embed enhanced recovery as the standard model of care Policy alignment to support local delivery Networking

What is in it for the patient, MDT, hospital, community and me

What’s in it for Patients Referral from Primary Care  Pre-operatively:  Other health problems are identified & managed to enable the patient to be in the best possible condition for surgery Admission  Intra-operatively:  Best possible evidence based management during and after surgery Follow UP:  Post-operatively:  Early mobilisation and timely discharge for the best rehabilitation with support

Top Tips to Enhance Recovery for Patients:  Make them a partner with you in their care  Prepare them for the DATE  Are all their questions answered  Prepare them for treatment and recovery  Get them moving soon after surgery  They will not gain if their in pain  Encourage them to behave as normal  Give them confidence to go home and get in touch if needed ‘No decision about me without me’

Audience: Patients Enhanced Recovery is a new way of improving the experience and well-being of patients who need major surgery. It helps people to recover sooner so that life can return to normal as quickly as possible It gives people a better overall experience due to higher quality care and services It lets people choose what’s best for them throughout the course of their treatment with help from their GP and the wider healthcare team (“No decision about me without me.”) Many people who have experienced Enhanced Recovery say that it makes a hospital stay much less stressful

Top Tips to Enhance MDT Working

Multi-Disciplinary Teams?  It give patients a better overall experience through higher quality care and services  It introduces innovative best practices that empower and motivate staff  It accelerates the clinical decision-making process by empowering MDTs  It doesn’t increase MDT workload  It ensures the most-efficient use of healthcare resources  Best-practice is day surgery or an Enhanced Recovery pathway

What does it mean for providers?  It improves patient safety and involvement and meets Care Quality Commission requirements  It reduces demand on resources such as critical care, surgical beds and patient uptake of procedures  It increases job satisfaction of Multi-disciplinary Teams through better ways of working and improved patient outcomes  It improves the reputation of the healthcare provider  Best-practice is day surgery or an Enhanced Recovery pathway

Commissioners?  It enhances the reputation of the healthcare provider  It helps patients recover sooner from surgery  Best-practice is day surgery or an Enhanced Recovery pathway  It improves patient experiences through increased partnership and empowerment (“No decision about me without me.”)  It motivates medical teams through best practice, empowerment and innovation  It reduces demand on resources such as critical care, surgical beds and patient uptake of procedures

What’s in it for Primary Care? It gives patients a better overall experience through higher quality care and services It puts GPs in control of commissioning the right pathways for their patients Earlier patient discharge doesn’t create extra workload for primary or social care services It improves efficiency and productivity whilst improving quality GPs and patients work in partnership through informed decision-making and greater choice It is a clinically proven approach to faster patient recovery

ER – Greatest Challenges – Opportunities for Commissioners Fitness for referral Patient education Truly informed consent Robust discharge planning

What is my role

Essential Roles Sponsors: authority to sanction change (organisational alignment / benefit) Change Agents: facilitate change, require knowledge, skills and credibility Champions: respected opinion leaders who positively promote work Leaders: lead by example

Understanding your current service Identify elements in place on enhanced recovery pathway map Audit of compliance with clinical elements on an individual patient basis Process map / Walk the patient journey Track patient journeys Patient Experience Length of Stay Re-operation rates Readmission rates Complication rates CLINICAL INTERVENTIONSCLINICAL SYSTEM OUTCOMES

Understanding your current service 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

Short-term investment  Support to change the pathway (e.g. service improvement, change manager, facilitator etc)  Training – new skills e.g. pre-assessment  Equipment – invest to save  Communication/awareness Find out what is already in place & going on Make the connections

Identifying the team Implementation requires a number of factors:  Changing clinical interventions  Changing care systems and processes  Creating a team to work across the patient pathway  Both require technical and behavioural change management  Lets start with thinking about who to engage and how to structure the project team

What are the consequences of not doing it

Support Materials

For copies of the clinical evidence compendium or further information contact

Support materials

Government Vision  Putting patient first  Improving healthcare outcomes  Autonomy and accountability  Cutting bureaucracy and improving efficiency 12 th July 2010 The core principles of enhanced recovery are aligned to the Health White Paper:

Just Do it!  Little risk  Minimal cost  Broad agreement  Easy to do

Next Steps Advice guidance and support – to change  Implementation guide  Enhanced Recovery Toolkit  SHA support  Local Network events  UCLH Implementation team  E-learning / DVD / Top Tips  px px 

Overview This Session:  Principles, elements and benefits of ERP  Drivers for Implementation  Current and future pathway  Action Planning:  Stakeholder Analysis  Testing changes for improvement  Measuring Outcomes

Testing Changes for Improvement Sophia Mavrommatis

Principles, elements and benefits of Enhanced Recovery

Drivers for Implementation Bella Talwar

Mapping your pathway against the Enhanced Recovery Elements Bella Talwar

Action planning and potential challenges Sophia Mavrommatis

Measuring Outcomes Bella Talwar

Enhanced Recovery Pathway ‘Implementation & Sustainability’ ERP implemented Robotic Surgery ERP implemented CQUINS

Benefits Realised

Potential capacity released

Impact on Patient Pathway Traditional pathway (£200 per day pp)= £2,200 LOS Reduction ER = £1,000