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A better journey for patients seven daysa week and better deal for the NHS
Enhanced recovery care pathway
Progress review (2012/13) andlevel of ambition (2014/15)
NHS Improving Quality in collaboration with NHS England
Improving QualityNHS
I am delighted to introduce this document onenhanced recovery (ER) that is intended toplace ER at the heart of modern high qualitycare pathways, and thus help to continuouslyimprove the quality of care for our patients.Enhanced recovery is not a new concept.There is increasing evidence that it improvespatient experience and shortens length ofstay with no increase in readmissions, so itshould be considered as the norm for highquality acute care pathways.
Quality is the driving principle of ER. ER improves the patient experience bygetting patients better sooner, and changesclinical practice to make care safer and moreefficient. Originally established in electivesurgery, ER consists of identifying many stepsin the whole care pathway where marginalgains can be made, leading to much betterquality outcomes, rather like the approach ofthe British Cycling team!
There are many components to a goodquality pathway, the starting point is the five P's:• Primary care ‘fitness for referral’ for
common conditions e.g. anaemia – managing the risk
• Patient involvement: shared decision making
• Prehabilitation, assessment and care planning
• Pain relief, fluid management, anaesthetics
• Preparation for and effective discharge.
Given the current national focus on deliveringquality clinical pathways seven days a week,integrated across the whole health caresystem and the Royal Colleges commitmentto drive the delivery of ER as standardpractice, this document sets out the levels ofambition to extend the principles of ERbeyond elective care.
Spread and adoption of ER is continuing tohappen to make it the norm. The principlesof ER as a good quality pathway are beingextended into emergency care, maternity careand acute medicine. A good example is thework on using ER in emergency laparotomy,where early results suggest a bigimprovement in patient outcomes and areduction in inpatient stay. Much of thedeveloping work in ambulatory acutemedicine is also based on the principles of ER.
This document demonstrates the widesupport for ER from patients and professionalorganisations. It describes some of theprinciples involved, with examples of specificsteps that can lead to improvement. It alsoshows some of the improvement gains thathave already been made nationally as a resultof the initial implementation of ER. Ourchallenge now is to embed the principles ofER across the whole pathway.
Celia Ingham ClarkNational Clinical Director for EnhancedRecovery and Acute Surgery
Foreword
3Enhanced recovery care pathways: a better journey for patients seven days a week and better deal for the NHS
From its inception, enhanced recoveryhas placed the individual patient at theheart of its pathway. Indeed, the twocomponents of this publication’s title areinextricably linked: it is because the patienthas a ‘better journey’ from enhancedrecovery that the NHS achieves the ‘betterdeal’. The enhanced quality of the patientexperience is what realises the secondarygains, such as reduced length of stay withoutany increase in unscheduled readmissions.
In these last 12 months, the potency of apatient-centred approach has helped to drivespread and adoption of enhanced recoverymore widely. In April 2012, when the thenHealth and Social Care Minister Paul Burstowlaunched the patient-developed leaflet ‘MyRole and My Responsibilities in helping toImprove My Recovery’, at the EnhancedRecovery Summit, this approach becamefurther embedded. Three months later, whenproviders across England had requested100,000 copies of this leaflet, it was clearthat policy commitments towards patient-centredness were rapidly translating intopractice.
The unique aspect of the leaflet, as it says onits front cover, is that it has been ‘designedby patients for patients.’ The EnhancingPatient Experience working group hadfollowed gold standard protocols based on acombination of the Department of Health(England) Information Standard and bestpractice imported from leading user-ledhealth charities working in the third sector.
By ensuring that experienced patientrepresentatives and individual patients whohad experienced enhanced recovery led onidentifying the need for this leaflet, designingit and advising on its content, a resource hasbeen established which is now benefitingthousands of patients and simultaneouslysupporting the spread and adoption ofenhanced recovery.
Importantly, this focus on the individual alsohelps maintain focus on the whole pathwayand not just the admission phase. To achievethe active role in their recovery which thepathway calls for, the patient must be wellprepared prior to admission and supported inadvance of discharge to achieve optimalreablement post-discharge. Any discontinuityacross the whole pathway would jeopardisethe desired outcome of a smoother journey,better outcome and improved experience forthe individual.
Enhanced recovery: a patientcentred approach
Neil Betteridge, Enhanced Recovery, Patient and Public Adviser
4 Enhanced recovery care pathways: a better journey for patients seven days a week and better deal for the NHS
Online viewing at:www.nhsiq.nhs.uk
Barry was admitted on the day of his colorectalsurgery and was out of hospital within four days.
From going to see the GP, surgeon and having theendoscopy, I knew exactly what was going on, andI got a copy of any letters sent - it was a levelplaying field and it all happened really quickly. Theday of the endoscopy they came back and said Ineed to have an operation. I was told to get asmuch exercise as I could to prepare for myoperation. I was given information that I couldunderstand on how to enhance my recovery, it wastailored to me and my specific problem.
I went in the morning of my operation and theywent through the information again. After theoperation they wanted you up and about the nextmorning. My catheter was taken out, they saidthe sooner you’re up the better, so I thought I willgo with it. They helped me get through theoperation and recover quickly but it took a little bitof effort on my part. I was out of bed and kept asactive as I could and I’m sure that’s what helped my recovery.
5Enhanced recovery care pathways: a better journey for patients seven days a week and better deal for the NHS
To promote preparedness amongst patients,as well as support more widespreadawareness and adoption, the EnhancingPatient Experience working group has beensystematically engaging with nationalvoluntary organisations relevant to specialtiescarrying out enhanced recovery protocols.
These have included Beating Bowel Cancer,Age UK, Cancer Research UK and Macmillanto date. Through the work of theseorganisations and others to whom peopleoften turn when considering or planningsurgery, we are ensuring that helplineservices, publications, websites and eventswhich are trusted by hundreds of thousandsof patients are featuring enhanced recoveryand making more people aware of what theycan do to support themselves along theirjourney.
So by keeping the patient at the centre ofthe pathway, what might otherwise bedistinct policy areas are able to convergecohesively. From shared decision makingwhen discussing options with their GP orspecialist nurse, through to alignment withNICE Quality Standards on PatientExperience, enhanced recovery continues toshow how transformational it can be whenpeople who use our services have theopportunity to inform them.
Truly a ‘win-win’.
Barry’s story
‘‘
’’
I was out of bed and kept active,that’s what helped my recovery.’’‘‘
Healthcare professionals want to deliverthe best possible care for their patients.Initial work by Kehlet1 in 1993 showedthat a focus on the whole care pathwayfor patients having elective colorectalsurgery enabled patients to recovermore quickly, with a shorter period ofweakness after operation and a shorterhospital stay. Early involvement ofpatients throughout the pathwayimproved their understanding andexperiences. In some cases patientscould lead their own pathway and itbecame clear that shared decisionmaking is key to success in improvingthe experience of care.
In 2009, the Department of Health inEngland set up the Enhanced RecoveryProgramme (ERP)2, across eight electivesurgical procedures, under theleadership of Professor Sir Mike Richardswith Professor Monty Mythen ananaesthetist/intensivist and Mr AlanHorgan, a colorectal surgeon, asnational clinical leads.
Clinicians identified and spread best practice through meetings,publications2,3 and a website. ER gainedprofessional consensus support from 17Royal Colleges and professionalassociations (see page 2). Patients ledthe production of an information leafletthat has been widely distributed acrossthe NHS.
Initially ER was introduced for majorcolorectal surgery and hip and kneereplacement. It spread to other majorcancer surgery, particularly in majorurology and gynaecology and has beentaken up and extended by a socialmovement of patients. It has beenendorsed by a broad consensus ofprofessional colleges and associations.
Recent studies provide evidence that ERis a cost-effective approach to care4
which significantly reduces the risk ofmedical complications and improvespatients quality of life5. ER is now beingextended to emergency surgery andacute medicine3 and recovery fromcritical illness.
Enhanced recovery: the story so far
1 Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78:606–617.
2 Guide to implementing Enhanced Recovery, Department of Health 2010 3 Fulfilling the potential; A better journey for patients and a better deal for the NHS, Enhanced Recovery Partnership 2012
4 Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery British Journal of Surgery 2013; 100: 1108 – 1114
5 Randomised clinical trial on enhanced recovery versus standard care following open liver resection British Journal of Surgery 2013; 100: 1015-1024
6 Enhanced recovery care pathways: a better journey for patients seven days a week and better deal for the NHS
Enhanced recovery is the process of delivering continuous improvement across thewhole acute care pathway, centred on shared decision-making between the patientand their healthcare team. It builds on the principles first established in day surgery, and isabout adding key steps systematically to as many care pathways as relevant, and aboutremoving redundant steps to shorten and smooth the pathway.
7Enhanced recovery care pathways: a better journey for patients seven days a week and better deal for the NHS
Brian’s story
Sandra’s story
Sandra went into hospital on the day of complex urological surgery and stopped smoking to enhance her recovery.
At pre-operative assessment clinic they explain everything to you, what was going tohappen and gave me two high energy drinks to drink, the day before to build me up forthe operation.
I suppose it’s common sense, you eat the right things. Now, I eat more fruit andvegetables than before. I was quite a heavy smoker and now I am puffing away on thatelectric thing.
Keith’s story
Keith was back at home within a day of his robotic prostate surgery.
In view of my age, the type of cancer,the risks associated, I felt that roboticsurgery was the best option for me, theconsultant supported my view. Myrecovery time was significantly shorterthan more invasive surgery. I followedthe guidance that was given to me asthis was my responsibility. I was inhospital at 7.30am, and the next daywas up and dressed, armed with urinarycatheter and released from hospital.
At home, it was the encouragement tokeep a diary which stimulated me to dothings. I was going for short walks daily,you make sure you rest when you haveto and exercise when you have to. At 10days I went to the church service.
Brian knew what to expect after surgery,his pain management enabled him towalk on the day after his operation.
I wanted to know what was goingto be done. The communicationwith me is what I wanted and what Iexpected. Being a retired pilot, I amused to being briefed. They tell youwhat they are doing.
At pre-operative assessment I wasallowed to ask pertinent questions,they discussed what would happenand how they would manage meand my pain. Anything that shouldhave happened did. The painsuppression I had was spot on and Ifound I could walk straight away.
Everything that should havehappened did …. the painmanagement enabled meto walk straight away.’’
‘‘I made the decision regardingthe type of surgery to have. ‘‘
I had high energy drinks the day beforemy operation to build me up.’’ ‘‘
’’
What is involved in enhanced recovery?
8 Enhanced recovery care pathways: a better journey for patients seven days a week and better deal for the NHS
‘Fitness for referral’Start shared decision making processes at consultation phase
Optimise patient health before admission
Discuss options for treatment using patient decision aids
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
IN PRIMARY CARE
BEFORE ADMISSION
Actions Examples
Pre-operative health and risk assessment
Shared decision making. Give thepatient information to make aninformed choice about contributingpersonally towards getting a highquality outcome
• Complete consent process before admission• Joint school• Multi-professional input to discharge planning• Agree care pathway plan including length of stay, likely
time to return to activities of daily living and return to work• Standardised pre-operative assessments• Cardiopulmonary exercise testing where appropriate• Pre-operative Patient Reported Outcome Measures
ADMISSION
Day of surgery admission
Involve patient in care pathway
Further optimisation
Prepare for discharge
• Share written plan again including estimated discharge date
• Venous thromboembolism prophylaxis • No bowel preparation• Carbohydrate loading• Reduced starvation
• Prepare for discharge plan and medication to take home
ER involves the whole pathway of care. In elective surgery better information enables a person tomake a fully informed choice to have a procedure and good preparation to optimise their fitnessfor surgery and understand the pathway ahead. It improves patient experience and the efficiencyof delivery of the care pathway. Post-operative care planning in advance means patients and theircarers know what to expect and what they can do to achieve better and faster recovery.
9Enhanced recovery care pathways: a better journey for patients seven days a week and better deal for the NHS
OPERATION
Optimise fluid balance and cardiacfunction
Manage pain control while minimisingpost-operative disability
Minimise post-operative nausea andvomiting
Minimise infection risk
• Goal directed fluid therapy using active monitoring techniques as indicated
• Aim for 'zero balance' avoiding crystalloid excess
• Regional or spinal anaesthesia with sedation where appropriate• Minimally invasive surgery
• Prophylactic antiemetics where indicated
• Intra-operative temperature control• Prophylactic antibiotics where relevant
Involve patient in care plan
Minimise starvation/catabolism
Minimise disability
Manage pain pro-actively
Prepare medication to take homebefore estimated discharge date
• Patient care plan +/- diary• Confirm estimated discharge date
• Early oral fluid and food• No nasogastric tube
• Stop intravenous fluids as early as possible• Planned early mobilisation with walking goals• Avoid drains and minimise catheter use
• Avoid systemic opiates where possible• Regular oral paracetamol and non steroidal
anti-inflammatory drugs if appropriate
POST-OPERATION
TRANSFER TO HOME/COMMUNITY
Actions Examples
Effective communications withprimary/community team
Criteria based discharge
• Reconfirm any support needed post discharge e.g. physio, stoma care
• Confirm expected discharge date
• May be nurse led against a protocol
FOLLOW UP
Telephone follow-up
Care plan includes information onlikely time to return to activity for dailyliving/work
• Use checklist with prompts to visits/reviews if needed
• Patient Reported Outcome Measure review• Patient experience review
10 Enhanced recovery care pathways: a better journey for patients seven days a week and better deal for the NHS
A range of outcome measures have beenused to evaluate the progress madenationally and locally across the original eightprocedures (colectomy, excision of rectum,cystectomy, prostatectomy, abdominal andvaginal hysterectomy and total hip and kneereplacements).
Key outcome measures include:• Patient experience• Length of hospital stay• Readmission rates• Day of surgery admission rates• Data from the enhanced recovery
reporting toolkit on process measures.
Improved patient experienceThe level of patients’ experience reported inTrusts who are implementing ER is higherthan that reported nationally as the nationalinpatient survey demonstrates (Figure 1).Four questions taken from the nationalinpatient survey were used to audit patientexperience.
Enhanced recovery: implementationprogress to date
Patient Experience: Enhanced Recoverycompared to National Inpatient Survey
100
90
80
70
60
50
40
30
20
10
0
Perc
enta
ge
Were you involved as much asyou wanted to be about your
care and treatment?
How much information aboutyour condition or treatment
was given to you?
Did you feel you were involvedin decisions about your
discharge from hospital?
Did hospital staff tell you whoto contact if you were worried
about your condition or treatmentafter you left hospital?
78% 78%
94% 95%
86% 85%92%
95%
74% 75%
89%91%
84% 85%
95%98%
2010 - National InpatientSurvey - elective only
2011 - National InpatientSurvey - elective only
2011 - Enhanced Recovery 2012 - Enhanced Recovery
Figure 1
11Enhanced recovery care pathways: a better journey for patients seven days a week and better deal for the NHS
170,000 fewer bed days since 2008/09Proactive management to help patientsget better quicker has resulted in areduction in length of stay. Despite rises inactivity for almost all of these procedures,there were nearly 170,000 fewer bed daysfor these procedures in 2012/13 than in2008/09.
It has been estimated that furtherimplementation of ER could save up to20,000 additional bed days per year.
Regular benchmarking data on ERmeasures and a national enhancedrecovery toolkit for local audit of ERimplementation is available to the NHS.
The ER toolkit enables organisations tobenchmark metrics such as length of stay, day of surgery admission rates,compliance with 19 elements of enhancedrecovery and readmission rates forprocedures against the rest of the country. In some localities it is used to monitorCQUINs. Brief guidance for commissionersis available at: www.nhsiq.nhs.uk
Figure 2
Figure 3
Length of stay: Colectomy, Excisionof Rectum, Cystectomy
(Quarterly HES Data)
Length of stay: Hip, Knee, Hysterectomy(abdominal and vaginal)
(Quarterly HES Data)
12 Enhanced recovery care pathways: a better journey for patients seven days a week and better deal for the NHS
20
18
16
14
12
10
8
6
4
2
0
Perc
enta
ge
of
emer
gen
cy r
ead
mis
sio
ns
Jan-June 2009
Emergency readmissions following selected operations asa percent of patients having the operation (HES data)
ProstatectomyCystectomyHysterectomyRectumColonKneesHips
Jul-Dec 2009 Jan-June 2010
Jan-June 2011 Jul-Dec 2011 Jan-June 2012
July-Dec 2010
Figure 4
Figure 5
No difference in readmission rates Readmission rates for organisations known tohave implemented ER are not significantlydifferent from the national average (Figure 4).
Increasing day of surgery admissionAdmission on the day of surgery continues toincrease. The pace of change varies acrossspecialties. Figure 5 also shows the baselineposition of other specialties who areembarking on the adoption of ER.
Percentage of patients having day of surgeryadmission for elective procedures
(Quarterly HES Data)
Since signing the consensusstatement and progressingprofessional and publicawareness of enhancedrecovery (ER) the RoyalCollege of Anaesthetistsacknowledge that ER is now astandard for appropriatecontinuous patient care, butthere is much to do to improvethe care of patients undergoingmajor surgery. We need to spread ER intourgent and emergencysurgery, we need to improvesystems for ‘fitness for referral’and develop better tools toidentify surgical risk andimprove shared decisionmaking. We are committed toembedding the principles ofER in all undergraduate, postgraduate and specialistprogrammes and recognise theimportance of building clinicalsupport for seven day servicesinto job plans to enable theappropriate recovery ofpatients seven days a week.
The Royal Colleges lead the way... EnhancedRecovery Consensus Statement in action
13Enhanced recovery care pathways: a better journey for patients seven days a week and better deal for the NHS
‘‘
’’Dr J P van Besouw, President,Royal College of Anaesthetists
I believe that the principles ofenhanced recovery can beapplied to emergency as wellas elective surgery and havethe potential to improve thequality of patient care and alsoreduce delays in carepathways.
‘‘’’Professor Norman S Williams,
President, Royal College ofSurgeons
14 Enhanced recovery care pathways: a better journey for patients seven days a week and better deal for the NHS
ER clearly demonstrates that system widechange is possible in “two years not 20years.” The work so far on enhancedrecovery has shown its ability to improvepatient experience, patient safety andoutcomes by ensuring that patients get thesame standards of clinical care seven days aweek. Its ability to reduce length of staywithout increase in readmissions provide realefficiency benefits for the NHS. There arepublications that show that ER improvesclinical effectiveness and reducescomplications after surgery. ER is now thestandard care pathway for many patientshaving major surgery, but we now need toextend its use, particularly into emergencysurgery and acute medicine.
For the future our challenge is as follows.Increase patient engagement • The ER patient information leaflet has been
very valuable to inform and empower patients, with over 100,000 copies printed and circulated. Going forward we need to extend the use of patient diaries and technology such as apps to help patients take control of their own acute pathways, supported by information from their healthcare team.
Ensure that all patients get the samestandards of clinical care seven days aweek • For patients requiring very resource
intense care pathways after elective surgery, operating schedules may need to be adjusted so that these patients have surgery early in the week to avoid excessivedemand at weekends
Summary and future levels of ambition
Develop systems to optimise patientsfitness for referral and pre-hospital riskstratification to improve patient safety • Work with primary care to improve ‘Patient
fitness for referral.’ We must work with GPs and practice nurses to improve systems particularly in relation to managing hypertension, diabetes and anaemia before referral for elective surgery
• Enhance systems for communication of risk with patients by developing pre-hospital triage of higher risk patients to ensure they can make informed decisions about their care,and to improve effective utilisation of critical care resources
Develop internationally comparableoutcome measures to further build on theevidence base• Work with Health Education England and
education providers to further embed enhanced recovery principles in all undergraduate and post-graduate training
• Improve the smooth transition from in-patientacute care to step-down care and ‘Hospital at Home’ where appropriate
• Implement the use of appropriate outcome measures such as disability-free one year survival to build on the evidence base internationally
Enhanced recovery is about delivering highquality 21st century care so we must makesure that all the patients who can benefitfrom this approach do so.
Acknowledgements and thanks go out to allof the many individuals, clinical teams,organisations, patient groups, Royal Collegesand Associations for their continued adviceand support in taking forward enhancedrecovery and building the momentum andmaking it the standard pathway of care acrossEngland and their this publication and forsupporting the National Enhanced RecoverySummit (April 2012) and importantly for theircontinued support in taking forwardenhanced recovery and building themomentum for enhanced recovery becomingthe standard pathway of care:
• Professor Sir Mike Richards• Professor Monty Mythen• Mr Alan Hogan• Department of Health• NHS Improvement• National Cancer Action Team• Advancing Quality Alliance (Aqua)• National Enhanced Recovery Clinical Leads
and Advisors• SHA Enhanced Recovery Leads• NHS Improvement Associates• The Enhanced Recovery Partnership
Advisory Board• Operational and Working Groups• The Enhancing Patient Experience
Working Group• Royal College of Surgeons• Royal College of Anaesthetists• Royal College of Nursing• Association of Surgeons of Great Britain
and Ireland
Acknowledgements
• British Association of Urological Surgeons• Royal College of Obstetricians and
Gynaecologists• British Orthopaedic Association• Royal Society of Medicine• British Gynaecological Cancer Society• Association of Coloproctology of Great
Britain and Ireland• BASO ~ The Association for Cancer Surgery• British Association of Day Surgery• Royal College of Physicians• Royal College of Radiologists• Faculty of Clinical Oncology• Future Forum• Royal College of General Practitioners• Faculty of Intensive Care Medicine• The Allied Health Professional Federation• The Enhanced Recovery Pathway
Steering Group• National Clinical Aanlysis and Specialised
Applications Team
Published by: NHS Improving QualityPublication date: November 2013Review date: November 2014Gateway ref: 01119
© NHS Improving Quality (2013)All rights reserved. Please note that this product or material must not be used for the purposes of financial or commercialgain, including, without limitation, sale of the products or materials to any person.
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