Enhanced Recovery in medicine Ben Benjamin Torbay Hospital Presentation from Shaping the Future Direction of Enhanced Recovery Care Pathway Seven Days a Week workshop held in London on 5 December 2013

1. Enhanced recovery in medicine
Ben Benjamin
Torbay Hospital

2. Why are you in hospital?
patient
doctor
nurse
notes
20% agreed on reason!

3. Hypothesis
If patients are given more information about the
expected process of recovery and involved in
the decision-making process they will recover
more quickly, feel safer, be more satisfied with
the care they receive and go home earlier.

4. Enhanced recovery elements
identified
•optimise pre operative
haemoglobin levels
•manage pre existing co
morbidities e.g. diabetes
Referral from
Primary Care
PreOperative
Getting you
home; swiftly
and safely
•admit on day of surgery
•optimised fluid
hydration
•CHO Loading
•reduced starvation
•no / reduced oral bowel
preparation ( bowel
surgery)
Admission
•optimise health / medical
condition
•informed decision making
•pre-operative health & risk
assessment
•patient information and
expectation managed
•discharge planning (EDD)
•pre-operative therapy
instruction as appropriate
•minimally invasive surgery
•use of transverse incisions
(abdominal)
•no NG tube (bowel surgery)
•regional / LA with sedation
•epidural management (inc
thoracic)
•optimise fluid management
•individualised goal directed
fluid therapy
•planned mobilisation
•rapid hydration &
nourishment
•appropriate IV therapy
•no wound drains
•no NG (bowel surgery)
•catheters removed early
•regular oral analgesia
•paracetamol and NSAIDS
•avoid systemic opiatebased analgesia where
possible or administered
topically
IntraOperative
PostOperative
•discharge when criteria met
•therapy support (stoma, physio)
•24hr telephone follow up
Follow
Up

5. What can we learn from enhanced
recovery in surgery?
• Unable to influence pre-hospital state
• Can give appropriate fluids, nutrition, exercise
• Can involve patients in process of recovery

6. What is the relevance to medicine?
• acute illness is ‘stress’ just like an operation
• simple adherence to fluid, nutrition &
mobilisation plus information are key and
could be applied to all inpatients?

9. Getting you
home; safely and
at the right time
Daily target setting
Energy
drink
Day clothes,
no PJs
Mobilisation
Decision-making
between the patient,
medical team and
families/carers
Oral fluids
Plan transport
early

10. Pre-hospital
• Information from GPs, Ambulance crew, carers
• Patient’s clothes in bag

11. Mobilisation
•
•
•
•
•
Get dressed! (no flappy gowns)
Avoid catheters (consider leg bag)
Is a monitor really necessary?
Is a drip really needed?
Drip-free mornings

12. Clothes
• The MAU is not a bedroom!

13. Clothes
• Bring in own clothes
• Supply of outdoor clothes (?laundry)

14. Fluids
Drip-free mornings

15. Energy drinks
• 10 am drinks round – now ER round
• Energy drink station for ambulant patients

16. Involvement of patients and carers
• Encourage carers and relatives to be involved
(problems with visiting times)

19. Communication
•
•
•
•
Posters
Video
ER motivation sessions – nurses/therapists
Talks to carers

20. Insert Pt leaflet

21. Benefits
To improve
patient and
carer
experience.
To reduce
readmission
rates.
To reduce
length of
stay.

22. Measurement
•
•
•
•
•
Patient experience interviews.
LoS data.
Survival rates.
Beddays used by patients on ER
Readmission rates.
Run charts –
• getting dressed by 10am
• Drip-free mornings
• Number of energy drinks consumed

23. Next steps
• Testing the process, approach and
methodology continues for patients admitted
on MAU.
• Rolling out to other medical wards.
• Involving patients and carers in the redesign
plans.
• Involving academic partners to help us
measure effect – new PhD student with Exeter
Business School!

24. Summary
In Torbay hospital we are testing the hypothesis
that patient involvement in the recovery process
from acute medical illness will result in more
rapid recovery, earlier discharge and greater
patient satisfaction.
We have developed a multidisciplinary approach,
based on enhanced recovery principles, which
encourages patients to achieve the goals
necessary to get home more quickly and safely

25. • Look at video – Torbay Hospital
Thanks to
Managers: Jane Dewar, Debbie Honeywill, Andrew Fordyce
Nurses: Erica Dunn, Nicki Joyce, Sue Bramwell
Carer lead: Stephen Black
OT: Becky Brixton