enhanced recovery blog

Across the country there are many hospitals who have made great progress with introducing enhanced recovery to specific clinical areas, but who have then struggled to spread adoption of the ER principles to other specialties within their own hospital. In this post we feature the work being undertaken at Nottingham and their structured approach to spreading adoption. We are delighted to feature the work as an example for others to adapt and replicate and the post is authored by Helen Scrimshire who has lead the work.

Enter Helen……

NUH is one of the country’s biggest acute teaching hospitals serving a population of over 2.5 million locally and a further 4 million in the Midlands region; across three sites it employs over 13,000 staff and treats over 88,000 day case and in-patients in 87 wards and 1700 beds. The ERAS project formed an integral part of an existing Trust-wide transformational programme (Better for You), which was initiated in December 2009.  Better for You aims to create a continuous culture of service improvement led by multi-professional teams.

The following 5 key steps are employed:

1. Set up and plan
2. Discovery
3. Design and Trial
4. Implementation
5. Embed.

Selection of specialty areas

Prior to my appointment, protocols for the adoption of ERAS within Hepatobiliary and Upper Gastrointestinal Surgery were under development. Selection of other specialities was based on those involved in the Trust transformational programme and included Gynaecology (oncology and benign), Urology Thoracics, and Orthopaedics.  Each specialty formed a multi professional development team who received my support for a period of 12 months.

Implementation

All specialities followed the process outlined on the left. Each speciality had its own project plan and timelines, meeting at least fortnightly. My role was to check and challenge the current practice against the key clinical elements of ERAS.

Once current practice and length of stay (LOS) were identified, the development of the ERAS care grid protocols began.  Where information was available, LOS was benchmarked against peer Trusts using Dr Foster data and information from the East Midlands Quality Observatory.  Benchmarking for Hepatobiliary and Upper Gastrointestinal Surgery was not possible as no other Trusts ran an ERAS programme within these specialties, therefore clinical expertise and best practice evidence were used to determine LOS.

I provided each development team with example protocol formats; however the final choice of format for the care grid remained with the individual speciality groups. Key to the success of this stage was commencing the ERAS programme based on a pilot protocol, rather than waiting for the ‘finished product’.  Numerous iterations of the protocol were developed during the process of change, however accepting the pilot as a starting point prevented elongation of ERAS implementation.

Communication and education were essential components and prior to commencing the ERAS programme all relevant staff received a short introduction to its principles and aims.  The vital role of patient education was acknowledged in order to establish effective partnership and informed decision making (DH 2010) and information was placed in the Pre-Operative Assessment Units to alert patients to the ERAS programme.

For each specialty a patient information or “milestone” document was developed. This mirrors the care protocol and identifies key stages in the patient journey. It is given out in the Out-patient or Pre-Operative setting, outlining what patients should expect to take place and their role in their recovery.

I organised and chaired monthly steering groups attended by all specialities. These have now evolved into a monthly advisory group where implementing specialties can share ideas, issues and current literature around ERAS. The group allows specialties to support each other as they implement ERAS and discuss challenges or problems incurred during the early weeks of implementation

Results

The table below illustrates the key outcomes at 6 months according to specialty area.  A 12 month projected reduction in LOS is also presented. Thoracic and orthopaedic data is not included as they remain in the early pilot phase.

Financial Impact

All specialties saw a reduction in LOS, with 1715 bed days saved. Assuming a cost of £250 per bed day, this suggests a notional saving of £428,750. The co-morbidities of some patient groups were taken into account when determining the target LOS, for example,  Upper Gastrointestinal Surgery estimated that only 40% of patients would achieve a maximum 8 day LOS. The wider contributions of ERAS to the Trust as a whole, enabled NUH to reduce the overall number of beds by 96 by March 2011, a saving estimated at around £5 million. Staff feedback was obtained via informal discussions during the implementation process and identified benefits regarding the standardisation of care and improved communication to patients and carers. The main difficulties reported related to the reluctance of junior medical staff to implement ERAS protocols in the absence of senior colleagues. Patient feedback was collected locally using postal questionnaire, telephone follow up and wards surveys. The responses have been positive with patients identifying the use of the milestone documents as the biggest benefit.

Summary

Implementation of ERAS via a nurse project lead has shown successful outcomes across 5 speciality areas. In addition to a reduction in LOS and cost saving, it has been a positive experience for staff and patients, findings that support those in earlier studies. Similar to other implementation sites challenges were faced when attempting to change the culture of nursing and medical practice.  I identified that education and early involvement of all staff groups assisted in breaking this barrier, in addition to senior medical and Trust executive support. The key to our implementation programme is clarity of structure, ownership and communication; the integration of ERAS within the structure of the wider Better for You programme, firmly places it as a cultural as well as process change. This also demonstrates the long term commitment to ERAS. The role of project lead is vital in facilitating and supporting the process, whilst developing ownership at specialty level.  In this role, I have developed a range of skills and knowledge which supplement my previous clinical skills, combined with the leadership of fellow clinical colleagues to provide credibility with the surgical specialties and theatre teams. NUH is continuing to support the further development of ERAS, having recognised the benefits to both quality and outcomes for patients and staff.

In this guest post Sheridan Methuen (Rapid Recovery Manager at Biomet) provides us with details of an upcoming conference in October. The program promises to be extremely useful for all those involved in orthopaedic enhanced recovery. I think the price of £100 for the conference plus accommodation is great value, so register quick!

Enter Sheridan….

In this era of unprecedented change where quality of service must be balanced by operational efficiency we are delighted to offer you the unique opportunity to meet with key opinion leaders from across the health care system to:

• Hear national and international key opinion leaders share their commitment to and experience of improving the entire patient pathway.
• Benefit from the philosophies of experts in pathway redesign; patient care and change management.
  • Gain insight into the impact of change on healthcare reform and learn from major change programmes that have combined quality with efficiency.
  • Join your colleagues from across the multi-professional healthcare community including clinicians, managers, commissioners and health reform specialists.
  • Discover the benefits of implementing different innovative solutions supported by published clinical evidence, case studies and practical examples that demonstrate enhanced patient experience, efficiency savings, and improved clinical outcomes.
  • Enhance your professional development, network with other professionals and key opinion leaders and gather practical initiatives from an intense 2 day programme.

The Rapid Recovery Symposium looks at all aspects of delivering a patient pathway from referral through to and beyond discharge. The Symposium offers insight into the benefits of setting up an enhanced recovery programme in your hospital.

Join us!

The Biomet Rapid Recovery Symposium will be held from 10^th to 11^th October 2011 in London and we warmly invite you to join us there.  Participation will earn you CME credits. In order to register please complete the registration form and return it to your local Biomet representative. You can also contact Louise Willis, Course Secretary, at Biomet Bridgend.  Tel:  01656 678310.  Email:  louise.willis@biomet.com Please note, applications will be taken on a first come, first served basis.   The cost of attendance at this meeting, including accommodation, is £100.00.

We look forward to seeing you in London!

Rapid Recovery UK Symposium Programme

It was great to meet everybody at yesterday’s South West HIEC Improvement Network Event.

If you would like the slides from my presentation or have any further enquiries about the work I presented please contact me by clicking here.

For event details and a list of delegates click here and for more information about  the South West HIEC click here.

Over the last month we have had a number of discussions and enquiries about CQUIN payments and enhanced recovery, so we thought we would signpost the following links and sources of information that you may find useful.

In essence, the Commissioning for Quality and Innovation (CQUIN) payment framework enables commissioners to reward excellence by linking a proportion of providers’ income to the achievement of local quality improvement goals. The original guidance was published in 2008 and introduced the CQUIN payment framework. It remains the key point of reference but there are more recently published national goals for 2011/12 which detail enhanced recovery payment schemes.

A good starting point is the NHS Institute website which gives a clear outline of CQUIN and good links to DOH documents without the need to search the DOH website – Click here to access

NHS London also have some good resources and examples and have included enhanced recovery in all of their CQUIN payment agreements with provider trusts – Click here to access an explanation of their approach and click here to go to their CQUIN homepage.

Click here for a link to the “Exemplar CQUIN goals” document – the enhanced recovery detail is on pages 41-43

We would like to know more about CQUIN payments for enhanced recovery across the country and would be grateful for your feedback and thoughts.

• Is enhanced recovery part of your trust CQUIN payments?
• What have you agreed locally as the indicators?
• How are you collecting data to prove compliance and improvements to the indicators?
• Do you have a specific enhanced recovery outcomes database?
• If you have already implemented enhanced recovery how are you further reducing length of stay? or have you chosen other indicator of improvement?

The deadline for abstracts for the 1st UK Conference on Enhanced Recovery has been extended until the 27th May 2011.

Click here to visit the conference website and submit your abstract and find details on how to register for the conference.

This blog post is based on a poster that we recently presented at the International Forum on Quality and Safety in Health Care. It describes the effects of changing your physio service from a 5-day to 7-day service.

Context

This work was completed in the orthopaedic department of a district general hospital in the United Kingdom. The project involved patients having a hip or knee replacement operation. It was identified that patients who had operations on different days of the week experienced different standards of rehabilitation after their operation. There was unacceptable variation in patient experience and quality of care provided.

Assessment of problem

Analysis was completed using Dr Foster software. This illustrated differences to length of hospital stay depending on the day of operation.The analysis used case-mix adjustment methodology to control for natural differences in demographics. Staff then completed a root cause analysis to ascertain why this was happening.

Intervention

The physiotherapy service was changed to remove artificial variation in the provision of rehabilitation to patients who had operations on a different day. A business case was made and supported to change the physiotherapy service from a 5-day Monday to Friday service, to a 7-day a week service with extended working hours until 8pm from Monday to Friday. Standardised operating procedures were also introduced so that each patient received the same physiotherapy program and timings of physiotherapy interventions were recorded.

Lessons learnt

Effective pathways need to be supported by organisational structures and staffing arrangements which allow them to work. Pathways usually centre on clinical processes, but we have learnt that these must be accompanied by managerial changes in order to allow the clinical changes to be performed for every patient.

Key Message

High quality patient pathways should remove all possible sources of artificial variation.We have illustrated the improvement to quality possible by removing the variability in our physiotherapy service provision

This is a two day conference being held in Bath on the 8th-9th September, 2011. It will be a forum to promote current research into all elements of enhanced recovery. Multi-professional teams from a wide range of specialties are encouraged to share their experiences and discuss best practice in what promises to be an exciting 2 days.

To get the latest information from the conference and details of how to register click here.

To submit an abstract click here. The closing date for submissions is the 29th April.

In a follow up to Wendy’s guest blog we would like to highlight an interesting paper written by Kris Vanhaecht. In his research Kris used a validated questionnaire called the Care Process Self Evaluation Tool (CPSET) to assess health professionals perceptions of the quality of their care processes with a clinical pathway. He gave the questionnaire to 309 healthcare workers, working across 49 hospitals who used a variety of different pathways.

The CPSET tool asked for respondents perceptions on the quality of care processes in five previsouly established elements of well-organized care processes. These were ‘patient-focused organization’ , ‘coordination of the care process’, ‘communication with patients and family’, ‘collaboration with primary care’ and ‘follow-up of the care process’.

He analysed group differences on CPSET scores in regard to different experience of pathway implementation: (1) Group A, no pathways in use; (2) Group B, pathways under development; (3) Group C, pathways in use for less than 1 year; and (4) Group D, pathways in use for more than 1 year.

Not surprisingly he found that the group with pathways in use for less than 1 year (Group C) had the highest CPSET overall score (i.e. this group had the tightest and most well managed care processes). Interestingly however, this score then decreased in the group with pathways in use for more than 1 year (Group D).

The findings reflect Wendy’s experiences and emphasise that multidisciplinary teams and managers need to closely monitor the life cycle of enhanced recovery pathways. The critical point for sustainability in enhanced recovery may be around 1 year post implementation.

To avoid regression we think it’s crucial to continuously collect good data and monitor the performance of your pathway. Training for new staff who join is also important, but perhaps the most important aspect is to not stop improving. Keep setting new goals within your unit to improve patient care. We must recognise that implementing enhanced recovery is not a goal in itself, but instead a method and approach we can use to achieve our primary aim of continually improving outcomes for our patients.

To see Vanhaecht’s article click here

How are you sustaining your enhanced recovery pathway?

Have you used the CPSET tool in your hospital? Was it useful in an enhanced recovery setting?

Get in touch to share your experiences and tips with other readers of the blog via a guest post by clicking here

If you would like a copy of our slides from recent meetings we are happy to share them.

Contact us by clicking here and we will send them out to you. Please include details of the conference you attended, your name, job title, and organisation.

West Midlands SHA Enhanced Recovery Meeting – Wednesday 30th March

The Royal College of Anaesthetists Enhanced Recovery meeting – Thursday 17th March

Monitor conference – Maximising quality, minimising cost: the concept of value for money in healthcare and the importance of clinical leadership – Monday 24th January

South West SHA Enhanced Recovery Meeting – Wednesday 26th January

We welcome Wendy Lewis as a guest contributor this week. Wendy talks about the challenges of sustaining an enhanced recovery colorectal pathway, based on her experiences as a ward manager at the Wirral Hospital.

Enter Wendy…..

We followed all the advice for implementing enhanced recovery that was available in 2006. We had a 3-pronged leadership approach from a surgeon, an anaesthetist, and a nurse. This was supported by a motivated team who were all “on board” and enthusiastic to improve the pathway. We gained agreement for the programme from all of our stakeholders and by September 2007 we were good to go!

Implementation was uneventful. The initial patients did well, any glitches were identified and addressed, and we had a simple data collection process measuring our outcomes. As the Ward Manager I was in the ideal position to lead the programme from the patient bedside, providing teaching and leadership to all staff involved in treating patients on the new pathway.

I acted as an educator, role model, change agent and, most importantly ensured that compliance to the programme was maintained for every patient, and was not dependent on the day of the week, which staff were on duty, or if the newly rotated SpR and junior medical team thought that Enhanced Recovery was a good idea.

We had defined our method and standard of care, resourced it, and any newcomers to the team were welcomed and told “this is the way we do things here”.

Initial length of stay (LOS) results were encouraging:

We were doing well! Readmissions were decreased, transfers to critical care were greatly reduced, hospital acquired infection rates were down, staff satisfaction improved and consequently involvement in the programme increased, communication across the patient pathway and between different departments improved, and most importantly, patient experience improved.

Our ER Nurse secondment (an 18 month secondment afforded within our ward establishment) finished in September 08 and as planned, the running of the programme just continued as before. Our aim for this post had always been to introduce and embed the principles in daily care delivery so ER became the norm, the default position.

Enhanced Recovery became the standard practice but it continued to need hands on leadership, particularly at times of medical staff rotation or when the ward was under pressure with other competing demands – for example; palliative care provision, gastro-intestinal failure patients, medical outliers, head injuries. (Remember we were a normal general surgical ward with an elective caseload of colorectal patients)

However, length of stay started to drift upwards from March 2010 and I think that we had taken for granted that ER was embedded in our multi-disciplinary practice. We didn’t appreciate the ongoing management that was required. Length of stay continued to drift, and a review showed that our LOS was 1-day higher than the previous 6 months, and 2 days higher than our best.

The numbers didn’t drift any further but the programme felt less tight, less of a priority, and required more input to ensure compliance with the individual elements. In October 2010 I did an objective review of the programme, a new baseline audit and the findings were really interesting.

• Compliance with the programme was there for 90% of the elements. There was non-compliance with managing patient expectation and criteria led discharge. These are probably two of the most important elements for consistently ensuring your best possible LOS. By failing to managing patient experience I mean that, if a patient attended Pre Op clinic with out a relative/friend/coach – it had become OK. If they then arrived on admission day without any provision in place for their timely discharge, that too had become OK. At the other end of the patients’ stay the nurses had stopped actively looking for criteria to be met.
• The nursing team had been significantly challenged for 3 reasons and this resulted in a new team without experienced leadership or that memory bank of the implementation of ER
  • The Ward Manager had disappeared off on a secondment to DH
  • The Deputy Ward Manager was on maternity leave
  • And, the Trust had re-organised shift patterns and ward establishments in July 09
• The most senior Consultant Surgeon left in September. This destabilised the medical team as that wealth of experience and clinical expertise was replaced by locum appointments.

These 3 factors were obviously going to have an effect on results. Even individually they would have proved significant. But I believe the most important was the lack of senior leadership, “The Nag” at ward level. Had there been a permanent ward manager with a commitment to ER in place, the new nursing team would have had the structures in place to adjust to a change in its membership and been in a position to support the changes in medical team’s leadership.

The lesson the Wirral learnt from this was to have an eye for the long game, beyond the implementation phase. We had followed the advice of the 3-pronged attack of leadership. Now the advice is that a successful and sustainable programme also has executive support and Primary Care engagement. We thought that having the principles embedded in practice would always give the results we got at the start. We were wrong. If we look at the NHS Institute’s sustainability model, we hadn’t addressed the factors beyond the ward doors, beyond our motivated clinical team. We’ve since used the sustainability model and it has been invaluable in helping us to understand what the real barriers were to sustaining our pathway.

Click here for The NHS Institute Sustainability guide

What next for Wirral?  Well in December 2010 the leadership at ward level was restored and this is already getting our results back on track. Medical staffing is stable and these two components are supporting each other with ER. The wider organisation has also become involved, a vital component of sustainability.

Wendy Lewis has been a Service Improvement Manager for the Enhanced Recovery Partnership Programme, at the Department of Health over the last year. She is now Service Improvement Lead at the Wirral University Teaching Hospital.