Transcript Enhanced Recovery e-learning module

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
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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
Kellet’s Theory 1980
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
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
Referral from
Primary Care
• Optimising pre operative
haemoglobin levels
• Managing pre existing co
morbidities e.g. diabetes
PreOperative
• Optimised Fluid
Hydration
• Reduced starvation
• No / reduced bowel
preparation ( bowel
surgery)
Admission
• Optimised health / medical
condition
• Informed decision making
• Pre operative health & risk
assessment - CPEX
• PT information and
expectation managed
• DX planning (EDD)
IntraOperative
• 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 opiatebased analgesia where
possible or
administered topically
• Audit &
outcome
measures
Post-
Operative
• DX on planned day
• Therapy support
(stoma, physio)
• 24hr telephone follow
up
Follow
Up
9
Factors to
consider for
Surgery?
Fit for Surgery? Mythen MG. Anesthesia and Analgesia: April and May 2011
•10
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
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Change is Clinically Led with Senior Management Support
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Ethos of the Clinical Team
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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
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
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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
(shared) decision making
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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
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?
Pre – 11 am
Discharge
TCAB
Top Tips
ERP
Actual Bed
Time
Productive
Wards
Discharge
Lounge
Ticket
Home
Nurse
Protocol Led
Dispensing Discharge
What investment may be
required?
Time
Focus
CommitmentLeadership
Financial
Engagement &
accountability
Training
Enhanced
Recovery
Change
management
Skills
Team-working
Communication
Systematic
improvement
Approach
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
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:
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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
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
Opportunities for
Commissioners
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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 credibility
Champions:
• respected opinion leaders who positively
promote work
Leaders:
• lead by example
Understanding your current service
CLINICAL INTERVENTIONS
CLINICAL SYSTEM
Identify elements in place on
enhanced recovery pathway map
Process map / Walk the patient
journey
Track patient journeys
Audit of compliance with clinical
elements on an individual patient basis
OUTCOMES
Patient Experience
Length of Stay
Re-operation rates
Readmission rates
Complication rates
Understanding your
current service
Referral from
Primary Care
•Optimising pre operative
haemoglobin levels
•Managing pre existing co
morbidities e.g. diabetes
PreOperative
•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
•Admission on day
•Optimised Fluid
Hydration
•CHO Loading
•Reduced starvation
•No / reduced oral
bowel preparation (
bowel surgery)
Admission
•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
IntraOperative
•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
PostOperative
•DX when criteria met
•Therapy support
(stoma, physio)
•24hr telephone
follow up
Follow
Up
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
The core principles of
enhanced recovery are
aligned to the Health White
Paper:
 Putting patient first
 Improving healthcare
outcomes
 Autonomy and
accountability
 Cutting bureaucracy and
improving efficiency
12th July 2010
Just Do it!
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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.as
px
 www.improvement.nhs.uk
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Overview
This Session:
Action Planning:
 Principles, elements
and
benefits of ERP
 Stakeholder Analysis
 Drivers for
Implementation
 Current and future
pathway
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 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
Bella
Talwar
Action planning and potential
challenges
Sophia Mavrommatis
Measuring Outcomes
Bella Talwar
15
10
5
0
Feb-11
Dec-10
Oct-10
Aug-10
Jun-10
Apr-10
Feb-10
Jun-11
20
Jun-11
CQUINS
Apr-11
Median LOS for Colectomy
Apr-11
Feb-11
Dec-10
Oct-10
Aug-10
10
9
8
7
6
5
4
3
Jun-10
ERP implemented
Apr-10
Median LOS for Primary Hip
Replacement
Feb-10
2
Dec-09
3
Dec-09
4
Oct-09
Median LOS for Abdominal Hysterectomy
Oct-09
6
Aug-09
ERP implemented
Aug-09
7
Jun-09
8
Jun-09
6
Apr-09
Jun-11
Apr-11
Feb-11
Dec-10
Oct-10
Aug-10
Jun-10
Apr-10
Feb-10
Dec-09
Oct-09
Aug-09
Jun-09
Apr-09
8
Apr-09
Jun-11
Apr-11
Feb-11
Dec-10
Oct-10
Aug-10
Jun-10
Apr-10
Feb-10
Dec-09
Oct-09
Aug-09
Jun-09
Apr-09
Enhanced Recovery Pathway
‘Implementation & Sustainability’
Median LOS for Prostectomy
Robotic Surgery
5
4
2
0
-2
Benefits Realised
Potential capacity released
Impact on Patient Pathway
Traditional pathway
(£200 per day pp)= £2,200
LOS Reduction ER =
£1,000