Enhanced Recovery
Compliance against elements of
ER pathway by Specialty
22th July 2011
Introduction
The aim of this report is to share national level data on enhanced
recovery pathways and so to provide benchmarking information to
organisations implementing ER.
The data included in this report was recorded on the national
enhanced recovery toolkit. This tool allows a trust to audit their local
implementation of enhanced recovery against a standard enhanced
recovery pathway and also to benchmark their local audit against
what others reporting around the country.
Introduction (cont)
• This report includes data from 29 trusts across England. These trusts are likely
to be a mix of those that are new to enhanced recovery as well as those that
have more experience of enhanced recovery pathways of care.
• Patients admissions were from 02/01/2011 to 03/06/2011
• The data extract includes
•658 colorectal patients (26 hospital trusts)
•467 gynaecology patients (13 hospital trusts)
•1,149 MSK patients (14 hospital trusts)
•50 Urology patients (5 hospital trusts)
• Each sheet shows compliance for a different element of the ER pathway and
how this varies between specialities. The definition for each element is shown at
the bottom of each page.
To access the toolkit: https://www.natcansatmicrosite.net/enhancedrecovery
Any comments to Andy.McMeeking@ncat.nhs.uk
Pre Op Visit- % compliant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Pre-operative visit?
95%
98%
100%
96%
98%
Record “ yes” if the patient visits the preadmission clinic in order to be informed about
ER care
- providing both verbal and written information - in order to condition expectations at
and after surgery. This process can be conducted by telephone but that also should be
accompanied by written information'
Patient Assessed for Surgery- %
compliant
100%
99%
100%
100%
100%
100%
80%
60%
40%
20%
0%
Patient assessed as fit for surgery
Record “yes” if patient attends a pre-assessment clinic to ensure optimal physical
preparation for surgery and is assessed as fit for surgery. This can occur at a
preadmission clinic attendance'
Patient Explanation ERP- % compliant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
96%
Patient given written and verbal
explanation of ER pathway
94%
96%
90%
71%
Record “Yes” if the patient is given written and verbal explanation of ER pathway and
related care and their role in their recovery
Therapy Education Given- % compliant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Preoperative therapy education eg
physiotherapy /OT
90%
90%
Record “Yes” if the patient had preoperative therapy education/preparation (can only
be recorded on ER toolkit for MSK patients)
Stoma Education Given- % compliant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
87%
Preoperative stoma education until
considered competent
87%
Record “Yes” if the patient attends a stoma care appointment and within this
appointment stoma education is commenced with the expectation that the patient is
supported to be competent with this skill prior to surgery.
90%
% Compliant - Oral Bowel Prep Avoided in Colorectal
patients
81%
80%
70%
60%
51%
50%
40%
30%
20%
10%
0%
Rectal
Oral bowel preparation avoided
Colon
Record “Yes” if oral bowel preparation (e.g. picolax) is not taken the day before surgery
to evacuate bowel contents. (Note that bowel prep may be used prior to an anterior
resection which includes TME (total mesorectal excision) (for colorectal patients only)
Patient Admitted on Day of Surgery- % compliant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
94%
96%
96%
63%
Patient admitted on day of surgery
Most patients are suitable to be admitted on the day of surgery;
Record “Yes” if patient admitted on day of surgery
87%
Carbohydrates Given- % compliant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
92%
Carbohydrate drinks given
preoperatively
74%
45%
38%
21%
maltodextran drinks given 12 hours prior to surgery and up to two hours before going to
the operating theatre provided gastric emptying is not impaired.
Avoidance of Sedatives- % compliant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
99%
Avoidance of long acting sedative
pre-medication
97%
97%
100%
98%
Record “Yes” if long acting pre- medication drug such as a temezepam / diazepam has
not been given within 24 hours of surgery
Antibiotics Prior- % compliant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
97%
Administration of appropriate
antibiotics prior to skin incision
98%
100%
97%
99%
Definition within 60 minutes of knife to skin as per the WHO/NPSA safer surgery
checklist (for colorectal patients only)
Epidural or Regional Analgesia- % compliant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
91%
80%
77%
Epidural or regional analgesia used
77%
45%
Epidural or regional analgesia used to provide adequate analgesia in the immediate
postoperative period and to allow mobilisation (Note there is not a consensus about
whether epidurals are necessary in laparoscopic surgery)
% compliant - Epidural or Regional Analgesia - shown by
Laparoscopic/Open
90%
80%
85%
79% 81%
70%
58%
60%
50%
40%
40%
30%
Open
20%
20%
Laparoscopic
10%
0%
Colorectal
Gynaecology
Urology
Was the operation
In order to simplify the data collection the toolkit asks whether the operation was started
commenced laparoscopically? laparoscopically. This includes both total laparoscopic and laparoscopically assisted procedures
Select from “Yes”, “No”, “Not Applicable”.
Epidural or regional analgesia used
Epidural or regional analgesia used to provide adequate analgesia in the immediate
postoperative period and to allow mobilisation (Note there is not a consensus about
whether epidurals are necessary in laparoscopic surgery)
Individual Fluid Therapy- % compliant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
79%
Individualised goal directed fluid
therapy
50%
53%
61%
60%
To prevent overloading with intravenous fluids during surgery; this may be achieved by
use of an oesophageal Doppler or other advanced haemodynamic monitor. Must be
individualised for each patient and administered to achieve specific haemodynamic
targets.
Hypothermia Prevention- % compliant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
98%
98%
Hypothermia prevention (intraoperative warming)
86%
100%
96%
Patient temperature 36.0-37.5 Centigrade throughout the operation (will usually
involve using active warming measures such as forced air warming and fluid
warmers).
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
% Compliant - Avoidance of abdominal drains by
colorectal operation
94%
78%
80%
83%
Anterior resection
APE
Colectomy
The avoidance of abdominal drains
except following TME
Colorectal - Other
Routine use of drains has not been shown to reduce complications and can actually
cause problems except following total mesorectal excision. (for colorectal patients only)
NG Tube Removed- % compliant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
94%
NG Tube removed before exit from
theatre
86%
94%
Definition not required (not applicable for MSK patients)
91%
Avoid Crystalloid Overload- % compliant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
89%
Avoidance of post operative crystalloid
overload
94%
97%
94%
94%
Intravenous crystalloid infusion discontinued on first postoperative day (day 1).
Avoid Systemic Opiates- % compliant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
88%
60%
Avoidance of systemic opiates used
postoperatively
60%
50%
56%
Analgesia that ideally does not include opiates is recommended to prevent
complications such as constipation.
Record “yes” if no oral, intramuscular or intravenous opiates used postoperatively.
Post-Op Nutritian- % compliant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
85%
Early post operative nutrition / solid
food intake
88%
97%
94%
92%
Patients are encouraged to eat and drink on day 0 (the operating day) after surgery, as
tolerated, and this to continue subsequently. To provide further nutrition in the
immediate post-operative period, nutritious supplement drinks are encouraged daily.
Nausea and Vomiting Control- % compliant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
96%
Targeted individualised nausea and
vomiting control
100%
98%
87%
92%
Managing the patient’s nausea and vomiting to enable them to eat and drink as soon as
appropriate post operatively.
Record “yes” if prophylaxis for PONV (Postoperative nausea and Vomiting) given during
surgery and antiemetics if nauseous postoperatively, as per agreed written protocol.
Early Mobilisation- % compliant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
89%
Mobilisation within 24 hours
94%
93%
100%
92%
Record “Yes” only if the patient is able to mobilise within 24hrs. For orthopaedic
patients this must be weight bearing mobilisation.