enhanced recovery programme
TRANSCRIPT
Enhanced Recovery Programme
Bolarinde Ola FRCOGConsultant Gynaecologist
What is ERP
A new approach since 2010, to assist patients get better sooner after surgery by reducing stress responses (and
enhancing cost-effectiveness of surgery to hospitals) • When ERP was first developed it was offered to
healthier patients. • Subsequently health care teams realised that it would
speed up recovery in all patients, compared to conventional care.
• The ERP is now widely used for more…..• However, not all patients will be suitable for ERP
Two Cardinal Principles
• Clear communication: a full range of information and explanation – Clear leaflets, interpreters, healthcare teams
• A fully structured and well organised sequence of clinical care – All healthcare professionals will work from a care
pathway– Allows all elements of care to follow each other
promptly and efficiently.
During Consenting for Surgery• A doctor or nurse will make sure patients understand the
benefits and risks of operation, and alternative treatments.• What the patient can do to improve chance of rapid
recovery. • Also proposed anaesthetic and pain relief; and choices will
be explained. • Leaflets– A patient diary which describes what to expect on each day after
surgery– Also information about to expect at home
Components of ERP
• Pre-operative planning assessment – Consenting, planning and preparation before admission
• Involving primary carers / referring doctors• Reducing the physical stress of the operation
– High energy, carbohydrate drinks– Allow clear fluids until 2 hours before surgery– Avoiding traditional bowel preps
• Early mobilisation• Early nutrition• Early discharge
Those Not Eligible for ERP
• Those not well motivated / or with no mental capacity
• Those living alone at home / No relatives• Diabetic patients who should not take the
carbohydrate drinks • Very elderly patients• If surgeon or anaesthetists has concerns
because of co-morbidity
Pre-operative care by the hospital team
• Pre-assessment clinic visit– Comprehensive history and pre-op examination
• Talking to the surgeon again • Therapy advice from other health care
professionals: – e.g stoma or wound care nurses– physiotherapists, – and/or occupational therapists
Involving Primary Carers / Referring Doctors
• Give patient information to make an informed choice about:– (a) Having the operation or not– (b) Contributing personally towards getting a high quality
outcome• Correct anaemia• Manage hypertension• Improve diabetic control• Stop smoking• Encourage weight loss
Reducing the physical stress of the operation
• Carbohydrate drinks: A key part - Most pathways include carbohydrate nutritious drinks before arrival at the hospital to reduce physiological stress.
• Clear Drinks: New evidence-based guidelines show it is safe to drink water until two hours before operation.
• Traditional bowel preps: New evidence-based guidelines discourages old methods:– can cause large amounts of loose motions leading to
dehydration and imbalance electroytes
Effects of Starvation
• Increased glucagon• Increased cortisol• Catabolism• Increased Insulin Resistance• Gluconeogenesis• Hyperglycaemia
Effects of Surgery
These are exacerbated by starvation• Inflammatory response • Increased cortisol / cytokines• Catabolism / gluconeogenesis• Insulin resistance• Hyperglycaemia
Sum Effects of Starvation and Surgery
Plan of Carbohydrate DrinksDate Drink Morning List (Admit 7:00am) Afternoon list (Admit 10:ooam
1 8.pm (Day before operation)
10pm (day before operation)
2 9pm 11pm
3 10pm 7am (day of operation)
4 11pm 8am
5 6.am (day of operation) 10.am
6 6.30 am 11am
Clear Drink
Until 6.am Until 11am
Overseas Example of Non-Gas Carbohydrate Drink
Local Non-Gas Alternatives:
Day of Surgery
• Appropriate anaesthesia • Limited Local anaesthetic infiltration to the
wound in minimal-access surgery • Minimal-access surgery or transverse curved
incisions • Peri-operative antibiotics where indicated• Avoid nasogastric tubes or surgical drains if
possible
Early Mobilisation
• Analgesia• Thromboprophylaxis• Something to eat• Breathing exercises• Assisted with coughing• Sit out of bed after 6 hours for two hours at intervals• Support walking along corridors (60 metres)• Encourage early bladder function
Early nutrition
Aim is to stimulate gut motility• Early oral diets– From day 0 for hysteroscopic / laparoscopic
• 3 high protein drinks daily• Oral diet as tolerated from day ½• 10-15 drinks per day from day 2
Examples of High Protein Drink
Local High Protein Drinks
Early discharge
• Healthcare professional support: –means that all the practical support at home are in
place. • Discharge planning: –mean that everything patient needs at home is ensured.
• 24 hour telephone helpline
• Discharge leaflets
Early Discharge Targets for ERPProcedure DaysTotal abdominal hysterectomy +/- bilateral salpingo-oophorectomy (Midline line cut)
3 days
Total abdominal hysterectomy +/- bilateral salpingo-oophorectomy (bikini line cut)
2 days
Total Laparoscopic Hysterectomy 2 daysLaparoscopic Assisted / Or Vaginal Hyst. 1 daysOther Laparoscopic Surgery 1Anterior and / or posterior repair 1 dayHysteroscopic Surgery 0 day
Benefits to the Hospital
• ERP means early discharges– Evidence show 0.5-3.5 days saved per patient
• ERP is Cost effective– NHS tariffs for day-case costs for (Surgery + 1 day)• Each extra days is a loss (approx. £300) to hospital
– NHS tariff for in-patient costs for (surgery + 3days)• Each extra day is a loss (£300-£660) to the hospital
– However; avoidable readmissions within 30 days are not reimbursed
Conclusions
• Enhanced recovery enables patients recover from operation sooner by reducing the stress responses on the body
• The aim is to ensure patients are active participants in their own recovery process
• Benefits also accrue to the hospitals too