Date post: | 12-Nov-2014 |
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London Feb 21st 2013
Dr Kerri Jones
Consultant Anaesthetist & Associate Medical Director
Adviser Dept Health Enhanced Recovery Programme
Better value, better outcomes
How to deliver quality and value in chronic care:
sharing the learning from the respiratory programme
Content
what is ‘Enhanced Recovery’
what is the proposition?
are the concepts transferable to medical admissions?
the Torbay pilot (S Devon Healthcare NHS
future developments
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What is ‘enhanced recovery’?
Henrik Kehlet, Professor of Surgery, Copenhagen
1980s showed the use of epidurals for major abdominal surgery
improved recovery by
managing pain
reduce stress response
He thought patients still stayed too long in hospital and by 2000
was describing a multimodal approach to care...
Fast-track/Accelerated/Rapid or Enhanced Recovery
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Physiological problem
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His proposition
Looked at factors influencing recovery
Designed a pathway to tackle
each element
What did he do?
created a structured approach
involved the patient
set expectations realistically
held his team to account
is the patient on track with the pathway?
‘why is this patient in hospital today?’
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Colorectal Surgery: Length of stay Large Intestine: Major Procedures
0
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6
8
10
12
14
16
UK Kehlet
days
UK adoption
sporadic
clinicians approached the DH for help to spread
country-wide programme
evidence-based; Kehlet & others
pathway defined
MSK, colorectal, gynae, urology
other specialties
proving to be very successful
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Enhanced recovery elements identified
Referral from
Primary Care
Pre-
Operative
Admission
Intra-
Operative
Post-
Operative Follow
Up
• optimise health / medical
condition
• informed decision making
• pre-operative health & risk
assessment
• patient information and
expectation managed
• discharge planning (EDD)
• pre-operative therapy
instruction as appropriate
• minimally invasive surgery
• use of transverse incisions
(abdominal)
• no NG tube (bowel surgery)
• regional / LA with sedation
• epidural management (inc
thoracic)
• optimise 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
• avoid systemic opiate-
based analgesia where
possible or administered
topically
• admit on day of surgery
• optimised fluid
hydration
• CHO Loading
• reduced starvation
• no / reduced oral bowel
preparation ( bowel
surgery)
• discharge when criteria met
• therapy support (stoma, physio)
• 24hr telephone follow up
• optimise pre operative
haemoglobin levels
• manage pre existing co
morbidities e.g. diabetes
Are the principles transferable to medicine?
illness is ‘stress’ just like an operation
simple adherence to fluid, nutrition & mobilisation plus
information are key and could be applied to all inpatients
no evidence base as yet – but from 2010, Kehlet has run a
research study in 2 patient groups
acute pneumonia
‘off legs’
he reports impact is ‘incredible’ though has found it difficult
patient/carer information is relevant to chronic disease
with repeated acute exacerbations
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ENHANCED RECOVERY: MEDICINE
Prof Ben Benjamin
Consultant Acute Medicine and Director of R&D South Devon Healthcare NHS FT
2012 – 2013
Why do it?
Improve
patient
and carer
experience
To reduce
length of
stay
To reduce
readmissions To improve
mobilisation
To gain early
independence
To reduce
deterioration
during
admission
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What is it?
a new approach to caring for patients admitted as a medical emergency to Torbay Hospital
involves patients and families/carers in decisions
patients are partners in their own care
patients, carers, families, nurses, therapists and doctors all work together to agree a plan for Rx and recovery
big focus on nutrition & mobility
What has happened so far??
Core project team
Director of Nursing and Quality – executive sponsor
Prof Ben Benjamin – clinical lead
Emergency Admissions Unit (EAU) manager and test lead
Matron for acute medicine
ER medicine project manager
OT
Carers’ lead
dietician, radiographer, matrons, consultants, ward managers
Wards/Units
EAU (medical assessment unit) – test bed
COTE
respiratory ward
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Which patients?
patients admitted as an emergency, requiring
medical interventions
patients requiring an inpatient stay on the EAUs,
respiratory patients), COTE wards
Getting you home; safely and at the right time
Getting you home; safely and at the right time
What’s happened so far?
current state and future state mapping sessions
baseline measurement – LoS, patient interviews
testing the concepts on patients with sepsis
communications – patient and carer information
pre hospital care – sepsis alert – antibiotic PGD
daily target setting
carers’ lead promoting the message in the community
GP engagement and awareness raising
focus on nutrition, mobility
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Daily target setting
Mobilisation
Oral fluids
Energy
drink Day clothes,
no PJs
Decision-making
between the patient,
medical team and
families/carers
Plan transport
early
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Measures
length of stay will take time as the culture change occurs
bed days
patient experience and satisfaction
oral/iv switch pulling notes and drug charts to capture iv/oral switch is time consuming
time to mobilisation
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Project Reflections so far
executive and clinical leadership – essential for success
baselining – walking the patient journey to identify waste in the system was compelling for the whole team – to get out of their silos
ask the people doing the job how best to change it; improvements have come from a bottom up rather than top down approach
time to carry out improvement – regular weekly huddles, an enthusiast seconded to drive improvements + service improvement project support
work across primary-secondary-social care boundaries
measurement for ER medicine has been challenging
Next steps
testing carried out on other EAU ward
roll out to other wards
CQUIN 2013/14 target
continued involvement of carers and GPs
learning and sharing best practice with colleagues
across the UK through
NHS South workshops
participation in RCP working group
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Further information
http://www.youtube.com/watch?v=pKUfCDQlglw
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