1. 20,000 Days Campaign Storyboard Learning Session 3 11-12 March 2013
Collaborative Name: ERAS in Orthopaedics

2. 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.

3. 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

4. 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

5. Measures Summary

6. 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.

7. 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.

8. 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.