1. Ethos of Enhanced Recovery After Surgery Implementation of ERAS
The role of Physiotherapy in the Nottingham Upper GI Enhanced Recovery After Surgery Project
Ethos of Enhanced Recovery After Surgery
Thorough pre-op preparation of patient
Use of minimally invasive techniques
Milestones agreed by patients and clinicians
MDT approach
Access to treatment – 365 days year
Rapid mobilisation post-op
The Upper GI ERAS project was developed to focus on reducing the length of stay for patients undergoing oesophagectomy or gastrectomy at the Nottingham City Campus.
The Physio Role - Evidence shows that early mobilisation post oesophagectomy and gastrectomy improves outcomes and reduces associated complications such as DVT and chest infection. While mobilisation has always been a priority for post op physio, we found we could standardise and improve this further during the ERAS project. This was achieved by developing milestones that are met by the patient daily which are progressively more demanding. The patient is made aware of these milestones pre-operatively and encouraged to aim towards them daily post op. At pre-op assessment, patients are encouraged to stop smoking if appropriate and increase their cardiovascular activity. The post op milestones include breathing and chest clearance exercises as well as mobility goals.
PRACTICE pre-ERAS
Less structured pre-op assessment
Conservative mobilisation in early post-op period
Patients less independent with treatment
Ready for home day 12-14
Implementation of ERAS
Milestones agreed preoperatively with patient
Patient encouraged to exercise at home pre-op as chemo allows.
Smoking cessation encouraged by MDT
More aggressive mobilisation post op
Use of incentive spirometry to guide patients chest exercises
MDT reinforce milestones and aim for joint goals
Use of Band 3 Physio assistant to progress mobilisation
More frequent physio sessions
Use of minimally invasive techniques and alternative analgesia to reduce hypotension and allow mobilisation
OUTCOMES
Patients are better prepared for post-op journey
Rapid return to mobilisation
Less respiratory complications
Independence gained quicker
Patient takes better ownership of their recovery
Ready for home day 8
Audit data shows…
Patients report that they find the milestones provide a clear pathway which they can work to. They appreciate receiving this information pre-operatively so that they can prepare themselves for the challenge.
We found patients can meet their milestones regardless of age and co-morbidity in the majority of cases and some catch up even if they have had a complication post op.
Patients return to the ward on day one in the majority of cases and gain independence quickly.
Length of stay has reduced from days to 8-11 days in the majority of cases.
CONTACTS
Cath McLoughlin
Clinical Lead Physio
Laura Maddison
Senior Physio
nhs.uk
Reference list available on request
The future…
Work on patients pre-op physical activity level to enhance post-op mobility
Even earlier return to mobility
Post discharge rehabilitation clinic which would include exercise sessions combined with an advice /support component.
Provision of a 7 day enhanced recovery physio service.