ENHANCE RECOVERY IN GYNAECOLOGY

Daniel RivillaData collected as 5th Year Medical Student

Currently FY1 – Ipswich Hospital13/09/2013

Detailed Audit in Current Practice

Miss Shohreh BeskiConsultant 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:

Criterion Standard ExceptionWas 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:

Criterion Standard ExceptionWas the patient informed that clear fluids are allowed up to 2 hours before anaesthesia?

100% None

Criteria and standards

- Intraoperative:

Criterion Standard ExceptionDelivery 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:

Criterion Standard ExceptionEnhance 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:

Criterion Standard ResultWas 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:

Criterion Standard ResultWas the patient informed that clear fluids are allowed up to 2 hours before anaesthesia?

100% 0/13=0%

Audit Results

- Intraoperative:

Criterion Standard ResultDelivery 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:

Criterion Standard ResultEnhance 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. http://www.improvement.nhs.uk/enhancedrecovery/

• http://www.enhanced-recovery.com

• Cover image from: http://www.nhs.uk/conditions/enhanced-recovery/Pages/Introduction.aspx

• Diagram:http://www.improvement.nhs.uk/cancer/LinkClick.aspx?fileticket=a2t%2b0oPpxlQ%3d&tabid=278

References