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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