20,000 Days Campaign
Storyboard
Learning Session 3
11-12 March 2013
Collaborative Name: ERAS in Orthopaedics
Aim & Charter
Aim: To increase the number of surgical patients going through the
ERAS pathway to reduce length of stay, without increasing readmissions, and improving patient satisfaction.
Description:
We expect to achieve the implementation of an ERAS program throughout
Orthopaedics. By improving protocol adherence and compliance to the
ERAS pathway, the aim is to reduce the surgical stress response and
promote faster recovery after surgery with fewer complications.
primary
Secondary
Concept
intervention
ERAS Clinic
Patient
expectations
Pre-operative
Patient Education
Planned EDD
Patient
experience
Patient physically
prepared
ERAS Leaflets
Post discharge home support
in place
Preparation > 24
hrs prior to surgery
Pre-habilitation
Preparation <24hrs
prior to surgery
Optimised Nutrition/hydration
Carbohydrate Loading
Anaesthetic
Standardise
Use of local anaesthetic with
sedation
Avoid use of opiates
Increase number
of surgical
patients going
through the ERAS
pathway (leading
to reduced LOS,
without increase
in readmissions
and increased
patient
satisfaction)
Intra-operative
pain control
Minimal invasive
Staff education
Choice of incision
Provide local evidence of why
choices made
surgical procedure
Early mobilisation
Patient ready (to
go home)
Removal of IDC/Drains ASAP
Standardise
Rapid hydration and
nourishment
Swap to Oral analgesia ASAP
Post operative
Discharge criteria
Home support in place
Ongoing support
Follow-up post
discharge
(Post discharge)
care in the
community
Post-discharge clinic
Allied Health follow-up
Change Packages
Secondary
Drivers
Change Ideas Tested
(describe process)
(Theory of change)
Patient expectations
and experience
ERAS Pre-hab clinic use of standardized
questionnaires to assess mobility, life style
factors
Own clothes to be used from day 2 to
encourage patient to become independent
Patient Physically
prepared
Prehab preparation – OT assessment,
equipment
Discharge Criteria
Mobilisation on day two – assessed by
physiotherapist
Home support in place prior to discharge
Evidence of Improvement
(Run Charts)
Measures Summary
ERAS in Orthopaedics Dashboard
Average Length Of Stay for Primary Hips and Knees
Cummulcative bed days saved since June 2011
11
800
10
600
9
8
Bed days
Days
400
7
200
6
UCL
5
CL
Jun-13
Apr-13
May-13
Mar-13
Jan-13
Feb-13
Dec-12
Oct-12
Nov-12
Sep-12
Jul-12
Aug-12
Jun-12
Apr-12
May-12
Mar-12
Jan-12
Feb-12
Dec-11
Oct-11
Nov-11
Jul-11
Sep-11
Oct 2012
Sep 2012
Aug 2012
Jul 2012
Jun 2012
Apr 2012
May 2012
Mar 2012
Jan 2012
Feb 2012
Dec 2011
Oct 2011
Nov 2011
Sep 2011
Aug 2011
Jul 2011
Jun 2011
Aug-11
Jun-11
0
LCL
4
-200
% Patients mobilised day 1 post op.
Key reasons for being unable to mobilise patient
day 1 post op
100%
80%
30
60%
25
40%
20
20%
15
Week Commencing
Version 1 – 11th February 2013
04 Feb 2013
21 Jan 2013
07 Jan 2013
24 Dec 2012
10 Dec 2012
26 Nov 2012
12 Nov 2012
29 Oct 2012
15 Oct 2012
01 Oct 2012
17 Sep 2012
03 Sep 2012
20 Aug 2012
06 Aug 2012
0%
10
5
0
Motor block
Pain
Hypotension
Project Lead – Michelle McCallum Jones
Improvement Adviser – Ian Hutchby
Dizziness
transfusion
N+/-V
Project Manager – Penny Impey
Decision Support Analyst – Daniel Wong
Implementation
Implementation Areas
Changes to Support Implementation
Standardisation
Introduction of a protocol and pathway
Documentation
Introduction of the protocol as part of the patient record
Patient resources: Patient Journey book
Training
Measurement
Resourcing
Staff education in the principles of ERAS, use of documentation
and managing variation to the protocol
Length of stay
Readmission rates
Patient satisfaction
ERAS Clinical Specialty Nurse for Orthopaedics
New documentation costs
Adapted from “The Improvement Guide. A Practical Approach to Enhancing Organizational Performance” Gerald Langley et al., 2009, p180.
Highlights and Lowlights
-
The ERAS collaborative can now demonstrate a saving in bed days and
improved satisfaction. The aims of the project have been achieved in
Orthopaedics.
-
The collaborative team have found this to be a robust process. The analysis
of base line data showed some interesting things including where to focus
and where not to as not gains would be made. PDSA cycles to test change,
have been very useful.
-
Surgical services noe intend to spread ERAS as part of their management
against MOH targets for elective surgery. The orthopaedics ERAS
collaborative will inform this spread on what works well and how to get
results.
Achievements to date
-
We now have a change package that we believe is ready for introduction to the wider
multidisciplinary team across surgical services and this will be done through an
intensive workshop to standardize and agree on the protocol
-
All the multidisciplinary groups have been working well and independently within their
work streams and reporting back regularly on their achievements and learnings
-
We have learned from a patient satisfaction audit that we could be more consistent,
that the information we provide could be more comprehensive, but that overall
patients were well supported, and had a positive experience with their joint
replacement surgery. The ERAS protocol is well placed to enhance the areas for
improvement and consolidate the areas we are doing well in.