enhanced recovery programme e-learning ‘ helping patients to get better sooner after surgery’
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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 fromPrimary Care
Pre-Operative
Admission
Intra-Operative
Post-Operative
FollowUp
• 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?
TCAB
Top Tips
Actual Bed Time
Nurse Dispensing
Protocol LedDischarge
Ticket Home
Discharge Lounge
Productive Wards
Pre – 11 am Discharge
ERP
What investment may be required?
Financial
Training
CommunicationSystematic
improvement Approach
Team-working
Change management
Skills
LeadershipEngagement & accountability
TimeFocus
Commitment
Enhanced Recovery
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 www.dh.gov.uk/enhancedrecovery
• 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 credibilityChampions:• respected opinion leaders who positively
promote workLeaders:• 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 ExperienceLength of Stay
Re-operation ratesReadmission ratesComplication rates
CLINICAL INTERVENTIONS CLINICAL SYSTEM
OUTCOMES
Understanding your current
serviceReferral
fromPrimary
Care Pre-Operative
Admissio
n
Intra-Operative
Post-Operative
FollowUp
•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 http://www.dh.gov.uk/en/Healthcare/Electivecare/Enhancedrecovery/DH_115638
Support materials
Government Vision
Putting patient first
Improving healthcare outcomes
Autonomy and accountability
Cutting bureaucracy and improving efficiency
12th 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 http://insight/departments/Projects/QEP/Pages/
home.aspx www.improvement.nhs.uk
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
BellaTalwar
Action planning and potential challenges
Sophia Mavrommatis
Measuring OutcomesBella Talwar
Enhanced Recovery Pathway‘Implementation & Sustainability’
Median LOS for Prostectomy
-2
0
2
4
6
8
Apr-0
9
Jun-
09
Aug-
09
Oct
-09
Dec-
09
Feb-
10
Apr-1
0
Jun-
10
Aug-
10
Oct
-10
Dec-
10
Feb-
11
Apr-1
1
Jun-
11
Median LOS for Abdominal Hysterectomy
2
3
4
5
6
7
8
Apr-0
9
Jun-
09
Aug-
09
Oct
-09
Dec
-09
Feb-
10
Apr-1
0
Jun-
10
Aug-
10
Oct
-10
Dec
-10
Feb-
11
Apr-1
1
Jun-
11
Median LOS for Primary Hip Replacement
3456789
10
Apr-0
9
Jun-
09
Aug-
09
Oct
-09
Dec-
09
Feb-
10
Apr-1
0
Jun-
10
Aug-
10
Oct
-10
Dec-
10
Feb-
11
Apr-1
1
Jun-
11
Median LOS for Colectomy
0
5
10
15
20
Apr-0
9
Jun-
09
Aug-
09
Oct
-09
Dec-
09
Feb-
10
Apr-1
0
Jun-
10
Aug-
10
Oct
-10
Dec-
10
Feb-
11
Apr-1
1
Jun-
11
ERP implementedRobotic Surgery
ERP implemented
CQUINS
Benefits Realised
Potential capacity released
Impact on Patient Pathway
Traditional pathway (£200 per day pp)= £2,200LOS Reduction ER = £1,000