Enhanced Recovery
Getting Started
 Introductions
 Housekeeping
 Objectives for the session
This Session
• Practical activities to get you started
• Based on the Implementation Guide
• Access to advice, guidance and support
• Discuss the key elements of your local
implementation plan
Overview
This Session:
Action Planning:
 Principles, elements
and
benefits of ERP
 Stakeholder Analysis
 Drivers for
Implementation
 Current and future
pathway

 Testing changes for
improvement
 Measuring Outcomes
Principles, elements and
benefits of Enhanced
Recovery
What is it?
 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
Your Better Sooner!!!
The Principles of ER
 Getting the patient in to the best possible
condition for surgery
 Ensuring the patient has the best possible
management during their operation
 Ensuring the patient has the best postoperative rehabilitation
Kehlets theory – 1980s
Example of ER elements
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
Physical impact
Clinical evidence compelling!
Colorectal Surgery: Length of stay
Large Intestine: Major Procedures
16
14
12
10
8
6
4
2
0
UK
Kehlet
Benefits being realised...
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
Process & capacity impact
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
Legend
The following denotes a trust is
working in this specialty:
(M) Musculoskeletal
(C) Colorectal
(U) Urology
(G) Gynaecology
Trusts with varying experience
of enhanced recovery pathways
North East
Gateshead NHS Foundation Trust (M)
Newcastle Hospitals NHS Trust (C)
City Hospitals Sunderland NHS
Foundation Trust (U)
Scotland
Northumbira NHS Trust (MSK)
NHS Lothian (M)
Gold Jubilee National
Hospital (M)
South Tees Hospitals NHS Foundation
Trust (C,G,U)
Yorkshire & The Humber
Enhanced Recovery Innovation Sites
are shown in red
Sheffield Teaching Hospitals NHS
Foundation Trust (G)
York Hospitals NHS Foundation Trust (C)
Scarborough Healthcare NHS Trust (C)
North West
Leeds Teaching Hospitals NHS Trust (C,G)
Calderdale and Huddersfield NHS
Foundation Trust (C,G)
Aintree University Hospitals NHS Foundation Trust (M)
East Lancashire Hospitals NHS Trust (C)
Hope Hospital, Salford (C)
Wirral University Teaching Hospital NHS Foundation Trust
(C)(M)
East Midlands
Derby Hospitals NHS
Foundation Trust (G)
Queen’s Medical Centre (C)
Sherwood Forest Hospitals
NHS Foundation Trust (C) (G)
Aintree University Hospitals NHS Foundation Trust
(C,M,UPGI,Li)
West Midlands
City Hospital NHS Trust, Birmingham (C)
Good Hope Hospital (C)
University Hospitals Birmingham NHS Foundation Trust (C)
Birmingham Heartlands NHS Trust
The University Hospitals of
Leicester NHS Trust
(C,M,G,U)
East of England
(C)University Hospital of North Staffordshire NHS Trust
(C,U,G)
Colchester Hospital University
NHS Foundation Trust (C)
West Suffolk Hospital NHS Trust
(M)
Cambridge University Hospitals
NHS Foundation Trust
(Addenbrookes Hospital)(G)
Robert Jones & Agnes Hunt NHS Trust
South West
North Devon Healthcare NHS Trust (C)
South Devon Healthcare NHS Foundation Trust
(C)(M)(G)
Royal Devon and Exeter NHS Foundation Trust
(U)
Royal Bournemouth Hospital (M)
North Bristol NHS Trust (Southmead
Hospital)(U)
Yeovil District Hospital NHS Foundation Trust
(C)(M)
Salisbury NHS Foundation Trust (C)
Dorset County Hospital NHS Foundation Trust
(C)
Plymouth Hospitals NHS Trust (C)
West Dorset NHS Trust (C)
South Central
South Devon Healthcare NHS Foundation Trust
(Torbay
Hospital)
(C,M,G,U)
Isle
of Wight
Healthcare
NHS Trust (C)
Milton Keynes Hospital NHS Foundation Trust (C)
Royal Berkshire NHS Foundation Trust (C)
Portsmouth Hospitals NHS Trust (C)
Southampton University Hospitals NHS Trust (C)
Oxford Ratcliffe(C)
NHHT M)Winchester & Eastleigh NHS Trust (C,M,G)
Royal Berkshire NHS Foundation Trust (C,M,G,U)
West Hertfordshire Hospitals NHS
Trust (C,M,G,U)
London
South East Coast
Brighton and Sussex University Hospital NHS Trust (C)
Darent Valley Hospital (Dartford and Gravesham NHS Trust)
(M)
Royal Surrey County Hospital NHS Trust (C)
Worthing Hospital (C)
East Kent Hospitals University NHS Foundation Trust (Queen
Elizabeth, the Queen Mother Hospitals)(G)
Medway NHS Foundation Trust(C)
Medway NHS Foundation Trust (C,M,G,U)
Brighton and Sussex University Hospitals (C,M,G,U)
Barnet & Chase Farm Hospitals NHS Trust (C)
Guy’s & St Thomas’ NHS Foundation Trust (C)
Hillingdon Hospital NHS Trust (M)
Imperial College Healthcare NHS Trust (C)
South West London Elective Orthopaedic
Centre (M)
St George’s Healthcare NHS Trust (C)(U)
St Mark’s Hospital (North West London
Hospitals NHS Trust) (C)
The Whittington NHS Trust (C) (M)
UCLH NHS Foundation Trust (C)
Whipps Cross University Hospital NHS Trust
(C)
The Hillingdon Hospital NHS Trust (C,G)
North Middlesex University Hospital NHS Trust
(C,M,G)
Drivers for Implementation
Bella Talwar
Implementation Plan
1.
2.
3.
4.
5.
6.
Understanding your current service
Team working
Action planning
Stakeholder analysis
Stakeholder engagement
Testing and making changes to your
pathway Understanding the risks
7. Understanding the investment required
8. Maintaining momentum
9. Sustaining the change
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
Audience: Multi-Disciplinary Teams
Enhanced Recovery is a new, evidence-based pathway that creates fitter,
patients who recover faster from major surgery
• 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
Mapping your pathway
against the Enhanced
Recovery Elements
Bella
Talwar
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
Care Pathway Project Plan
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
What investment may be
required?
Time
Focus
CommitmentLeadership
Financial
Engagement &
accountability
Training
Enhanced
Recovery
Change
management
Skills
Team-working
Communication
Systematic
improvement
Approach
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
Understanding and improving
systems and processes
Patient Pathway
Undertake mapping and tracking
Understanding your current
service - Exercise
 On the map provided: Understanding your
current service - Exercise
 Mark the interventions you already have in
place
 You should also consider when, where and how they
are provided and whether there is further opportunity
for improvement
 Identify the interventions you need to
establish and start to consider the sequence
for implementation
Stakeholder Analysis
Janine Roberts
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
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
Stakeholder Analysis
High
Influence
Little / No
Influence
Satisfy
Manage
•Opinion formers
Key Stakeholders need to
be fully engaged through
full communication &
consultation
•Keep satisfied
•Review regularly
Inform / Monitor
Not crucial to the process
but useful to keep informed
Little / No
Interest
Involve
•Voices that need to be
heard
•Need to be proactive
High
interest
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
Action planning and potential
challenges
Sophia Mavrommatis
Action Planning
Take time to deliberate; but when the
time for action arrives, stop thinking
and go in’
-Andrew Jackson quoting Napoleon
Bonapart
Managing Improvement
low
Test on
a very
small
scale
Agreement
amongst the
key players
Just
do it
JDI
high
high
Certainty
that the change
will work
low
Just Do it!




Little risk
Minimal cost
Broad agreement
Easy to do
Testing Changes for
Improvement
Sophia Mavrommatis
Enhanced Recovery Action Plan
Action
Owner
Resources
30
60
90
Action Planning & Challenges
 On your table provided start to fill in from the earlier
work today which actions need to be completed
 Who can deliver these actions
 What is the timescale – 30, 60 or 90 days
 Resourse – flag up what support you may need
here to deliver the action – eg connection into the
local PCT, facilitator to deliver a workshop
Include in this the top three challenges that you think
you will encounter and the actions you will put in
place to work through these challenges.
Measuring Outcomes
Bella Talwar
Outcomes
 Patient / staff
 Clinical - elements of the pathway
 Financial
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
Making your baseline
assessment
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
55
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
Ann’s story to the
Deputy Prime Minister
“ I had two hip
replacements last
year. One in June
and one in
December.
The second one
was much better,
the service is
fabulous!”
Benefits Realisation
Janine Roberts
Benefits Realisation
Next Steps
Janine Roberts
Next steps
Making it happen?
• What ongoing support can we provide?
• Implementation plan
• Follow-up session
Next Steps
What will be your first change you will
test or implement?
•
Remember the importance of a quick
win as well as a plan for sustainability
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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