With enhanced recovering now being implemented across the NHS, the benefits to surgery and care pathways are being realised. NHS Improvement cancer director Ann Driver looks at how the key principles are making a big difference.
The principles of enhanced recovery (ER) in elective surgery are currently being implemented across the NHS and are transforming the approach to care before, during and after surgery.
This innovative evidenced-based practice has already resulted in dramatically improved recovery times for patients across colorectal, gynaecology, urology and muscular skeletal care pathways.
There have been dramatic reductions in unnecessary length of stay without an increase in post operative complications and readmissions. Hospitals benefit with lower complications and better bed utilisation as reductions have also been witnessed in the amount of high dependency and intensive beds which are normally required.
ER, also referred to as rapid recovery, involves the whole multidisciplinary team and healthcare community who are actively involved in the patient’s care before, during and after surgery.
For the patient this means being well informed and prepared preoperatively which helps to reduce possible exacerbating anxiety or stress levels prior to surgery and results in the patient making the correct decisions about their surgery and their recovery pathway.
There is an underlying principle within enhanced recovery which also empowers patients to actively contribute to their own recovery from surgery.
The Enhanced Recovery Partnership led by NHS Improvement working in partnership with National Cancer Action Team, SHA enhanced recovery leads, Cancer Networks and national clinical leads supports the NHS to implement and realise the benefits of enhanced recovery.
Success has been realised across all the care pathways where ER practice or adoption of the ER principles have become part of everyday practice. Such improvement stories have already been discovered within day case or the one night stay breast surgical model, which applies the ER principles in the delivery of major breast surgery - including cancer patients (excluding reconstruction).
Working in partnership with NHS acute trusts across England and generated from the 13 national clinical spread networks, the NHS Improvement cancer team tested the hypothesis that the streamlining of the breast surgical pathway could reduce unnecessary lengths of stay by 50 per cent by managing the patient’s expectations and changing clinical practice while still ensuring the system is as efficient as it can be with no loss of quality for the patient.
A recent audit of 2,087 patients treated on the breast pathway identified 78 per cent of patients were successfully discharged on the day of surgery or after a one night stay without increasing readmission rates and crucially the patients reported positive experience of their short-stay.
Clinical evidence for ER, which was released in March 2011, (see “Find out more”, below) showcases the overall benefits in colorectal surgery which demonstrates a reduction in lengths of stay, hospital morbidities and complication rates.
Post operative convalescence periods for women undergoing non-malignant gynaecological surgery have shown significant reductions from six weeks to one to three weeks with the introduction of an ER programme. In urology, this has also been shown with a reduction in length of stay, equal re-admission and morbidity rates for patients undergoing radical cystectomies when comparing those enrolled in an ER programme and those not.
In one cohort study of gynaecological nursing practise, nursing duties and time spent on routine activities was analysed. It was also shown that there was a reduction in the total time used for nursing activities during the patients stays by an average of 39 per cent during the observation period without increase in complications (see “Find out more”, below).
Before ER was implemented at Whipps Cross University Hospital Trust the current trend of care followed the traditional pre-operative and postoperative model of care where patients undergoing major colorectal surgery were experiencing long and variable length of stay.
This was due to many contributing factors which included a lack of shared vision and fragmented care seen on patient’s pathway due to a lack communication between the multidisciplinary team and no established audit or evaluation of care experience.
Since ER has been implemented an immediate reduction of length of stay was witnessed which resulted in bringing down the average length of stay from 11.6 days to 6.1 days.
NHS medical director Professor Sir Bruce Keogh praised staff at Whipps Cross Hospital: “I am very impressed with the hospital and its clinical teams who have demonstrated drive and are highly motivated in implementing an enhanced recovery programme which improves patient experience by reducing unnecessary delays and waits and ensures that pathways value patient time. This will bring about continued patient improvement.”
Celia Ingham-Clark, NHS Improvement’s national clinical lead for transforming inpatients who also attended the visit alongside Sir Bruce Keogh, commented: “I would now like to see other hospitals undertaking a high level of quality and productivity for the benefit of patients. NHS Improvement will continue to work with trusts across the NHS to spread the enhanced recovery model.”
There are many areas of work under the new health agenda that can be aligned to ER as it is recognised that ER could support the NHS to meet some of the major challenges that the NHS is currently facing. As the NHS needs to achieve up to £20 billion of efficiency savings by 2015 through a focus on quality, innovation, productivity and prevention strategies there is also the added pressure that this will be accompanied by a 40 per cent reduction in management costs.
It is imperative now more than ever that the care being provided is the best quality, most efficient and cost effective that it can be. ER is recognised within the QIPP programme and NHS Evidence where it is recommended as best practice.
The new government strategy is clear that patients must be involved in all decisions and aspects about their care and ER encourages clinically lead service redesign across primary, social and secondary care, and will lead to a pathway that is evidence based and one that is considered best practice.
The NHS Outcomes Framework, which sets the out the direction of travel in the patient’s journey towards improving outcomes, offers an opportunity for the NHS to begin to understand what an NHS focused on outcomes means for individuals, organisations and health economies.
The effects of implementing the principles and pathways of ER work which is being led by NHS Improvement can be mapped across the domains of the NHS Outcomes Framework and particularly Domain 3 which focuses on “helping people to recover from episodes of ill health or following injury”.
As more benefits are discovered they reveal more opportunities where this knowledge and expertise could be applied to other surgical areas. We are currently entering a new phase within the NHS, where the patient and the care providers are questioning the traditional care pathways for surgery and a new adaptive care models are emerging which is resulting in quicker recovery times and minimising the stress response on the patient’s body.
The work surrounding ER is available on the NHS Improvement website and incorporates all the work of the Enhanced Recovery Partnership. The website aims to share the learning as there is growing support for the ER principles to have universal application across surgical care.
There is also a variety of essential information, guidance and online resources available ranging from the Enhanced Recovery Implementation Toolkit, guidance on commissioning and a multitude of case studies across each surgical area, including patient experiences, and sharing of best practices.