Enhanced Recovery Programme: The Whipps  Cross University Hospital Experience Stefano M. Andreani Consultant Colorectal Surgeon

1. Enhanced Recovery Partnership
Enhanced Recovery Programme: The Whipps
Cross University Hospital Experience
Stefano M. Andreani
Consultant Colorectal Surgeon

2. Enhanced Recovery Partnership
• Back ground Hospital
• Local population
• How we started and how we
carried on
• Our Results in view of the
most recent literature

3. • North East London
• Covering Waltham Forest and
Redbridge PCT
• Population 350,000
• Built 1900
• 700 Beds

4. Socially Deprivated
Area
• Market Factor
• High % advanced stage cancer
• Cancer Survival compared to national
average

5. Income deprivation by London borough
More than 20%
employees are
paid less than
£7.50 per hour

6. • Social deprivation is an independent risk
factor for increased postoperative hospital
stay for colorectal patients.

7. 10 NHS Trusts with longest length of stay
for bowel surgery in England 2006/07
Trust
Average LOS Days above
–Days‐
national Average
Southport and Ormskirk Hospital NHS
27.94
12.05
Hammersmith Hospitals NHS Trust
22.47
6.58
Stockport NHS Fundation Trust
22.31
6.41
Royal Free Hampsted NHS Trust
22.07
6.17
Whipps Cross University Hospital NHS
Trust
21.43
5.53
Pennine Acute Hospital NHS Trust
20.8
4.9
The Hillingdon Hospital NHS Trust
20.71
4.81
Barts and The London NHS Trust
20.46
4.56
Surrey and Sussex Healthcare NHS Trust
20.05
4.15
City Hospitals Sunderland NHS Fundation T
19.96
4.06
www.reducinglengthofstay.org.uk

13. How we started ERP

14. Shifting Mentality
• Danish surgeon: Henrik Kehlet
Q: Why is the patient still in hospital?
Q: What can be done to safely
discharge him?

15. • within my team
– Reg, SHO, FY1
– CNS
– Stoma Nurse
• Looking for motivated people
– Ward
– Theatre
– Anesthetic department
– Dietitian
– ………..

16. Success Factor = Cultural
Shift
• Funding
• St Mark’s ERP course
> 60 people attended
•
•
•
•
•
•
•
•
Anesthetists
Ward nurses
Theatre Nurses
Physiotherapists
CNS
Stoma nurses
ODA
Dietitians

17. Steering Group Established
• Representative from each single
specialties involved
• Creation Pathway for each specialty
• Specialty LEAD responsible to produce
their pt care pathway
• Creation multispecialty pathway

18. • Appointment project manager
• Meetings: Once a month
• Baseline Study: Retrospective review
using HES
• Support from NHS improvement team
• Pilot site for ERP

19. Ideal Patient Pathway
• Pt Information – ERP explained
• Pt Assessment (Health and Risk)
• Referral to relevant specialties
• Managing Pts Expectations
• Discharge Planning
• Theatre – Laparoscopic/Open
• Epidural, CArdioQ
• NGT out before Patient Awake
• Pt Stable
• Recovery –encourage pt to drink a
glass of water
• Pt to sit up whilst on the profiling bed
• Transfer Pt to ward
• Ward Observation
• IV fluids – discontinued
• Remove catheter
• Recommended Diet – Build up drinks
• Pain team, Surgical team – Review pt
• Discharge – Pt informed of plans
• Pt Medically fit to go home
•Pt information Leaflet
•Emergency Contact details
•Stoma Care ‐ Community
•Follow Up appointment
Referral From
Primary Care
Pre‐Op
Assessment
Admission
• Managing Pre Existing co‐
Morbidities e.g.
diabetes/hypertension
• Optimising Haemoglobin levels
• Analgesia Review with Pt
• Pre‐Op drinks
• Stoma Marked
• Continual Pt education on ERP
Intra‐Op
Post‐Surgery
Post‐Op Day
1
Post‐Op Day
2‐4
Discharge &
Follow Up
• Monitor Catheter
• Observe Stoma
• Wound Review
• Out of bed 6hrs Post‐Op
• Pt reminded of ERP requirements
• Surgical and Anaesthetic team
review
• Ward Observation
• Out of bed – 8 hours in total
• Recommended Diet – Build up
drinks
• Pain team, Surgical team – Review
pt
• Discharge – Pt informed of plans

20. Prospective Audit
• How much are we implementing ERP?
• All colorectal cancer 1st January – 31st
June, 2010
– 1st Audit Jan- March
– 2nd Audit April-June
• Total number of patient = 38
• Number of patients included in ERP Audit
= 29

21. • Easy to collect data
• Prospective data
collection

22. Expected vs Actual LoS
29
P atien t id en tifier
25
21
17
LoS
13
9
5
1
0
5
10
15
20
Length of stay (days)
Since 2008, the LoS stay has been reduced from an
average of 11.6 days to 7.1 days.
25

23. Whipps Cross ERP Colorectal Audit 2010
14
12
Average LoS
10
8
11.6
~6 days
~3 days
10
(26
cases)
7.1
6
(29
cases)
4
2
0
WX Inpatient Audit
National HES
ERP Implemented
(Dec 2008)
Database (2008/09)
(Jan-Mar 2010)

24. ERP Audit
January – November 2010
(not July)
Total number of Surgical patients = 65
Number of patients included in ERP Audit = 51
Length of Stay
Total number of procedures in 10 months
Total number of bed days:
Mean LoS (days):
Enhanced Recovery
Partnership Programme
Total
51
344
6.75

25. Factors essential for
Successful
Implementation ERP
Strong leadership with motivation
Core group
Project Manager

26. What about sustain these results?

27. Implementation and
sustainability
•
•
•
•
•
Education
Management of Expectation
Reinforce of ERP concept and practice
Empowering nurses
ERP Nurse
– Keep the things going
– Educate
– Audit results

28. LOS

29. ERP – patients overview

30. ERP – patients overview

31. ERP – patients overview

32. Patients - overview

33. Patients - overview

34. Surgery

35. Quality data collection

36. Adherence to ERP protocol
Overall adherence to protocol
mean
69%
median
68%

37. Adherence to ERP protocol

39. •
•
Prospective cohort study before and after ERP protocol
953 patients with colorectal cancer:
– 2002‐2004 Adherence 43.3% in 464 patients
– 2005‐2007 Adherence 70.6% in 489 Patients
•
– Postoperative complications and symptoms declined significantly.
30‐day morbidity and readmissions were significantly reduced with
increasing adherence to the ERP protocol (>70%, >80%, and >90%)
compared with low ERP adherence (<50%)

40. Adherence
%
Mean
LOS
Days
p
50
9.4
< 0.001
70
7.4
80
7
90
6
< 0.001
< 0.001
< 0.001

41. Overall LOS
7.76
6
mean
median
max
min
days
7.76
6
25
2

42. Surgery

43. Laparoscopy in Combination with Fast Track Multimodal Management is
the Best Perioperative Strategy in Patients Undergoing Colonic Surgery:
A
Randomized
Clinical
Trial
(LAFA-study).
Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF, Gerhards MF, van
Wagensveld BA, van der Zaag ES, van Geloven AA, Sprangers MA, Cuesta MA, Bemelman WA;
on behalf of the collaborative LAFA study group.
Ann Surg. 2011 May 18. [Epub ahead of print]
• Multicenter RCT
• 9 centers in the Netherlands
• 400 patients eligible for segmental colectomy were randomized to:
‐ laparoscopic or open colectomy
‐ ERP or standard care

44. Results
Lap/FT
• Postop LOS Median
5
Open/FT
6
Lap/standard Open/standard
6
7 days
• Laparoscopy was the only independent predictive
factor to reduce hospital stay and morbidity:
Author’s conclusion:
“Optimal perioperative treatment for
colonic cancer is laparoscopic resection embedded
in a FT program. If open surgery is applied, it is
preferentially done in FT care”

45. Complications
Total
Pts with 1
complication
Pts with >1
complication
36
39%
30
33%
6
7%

46. Complications
Severity of complications
N°
tot
grade 1 or 2
grade 3 or 4
death
 Reoperations
 Readmissions
36
27
11
1
3
5
Reoperations
2 anastomotic leak ‐ ileostomy
1 perineal wound infection ‐ wound debridment
Readmissions within 30 day FU
2 Acute urinary retention
2 Acute renail failure
1 Splenic infarction

47. 2011
2011
• 4 RCTs
• 237 patients with colorectal surgery:
119 ERP
vs
118 conventional

48. Results
ERAS
Control
13 per 1000
25 per 1000
0.53
(0.12 to 2.38)
tot
54
105
0.51
(0.39 to 0.67)
minor
29
50
0.57
(0.38 to 0.85)
major
14
28
0.50
(0.28 to 0.92)
• Readmissions
10
13
• Length of stay
‐ 2.51 days
• Mortality
RR
(95% CI)
• Complications
0.79
(0.36 to 1.76)
95% CI ‐3.54 to ‐1.47
p < 0.00001

49. Cochrane
• Quantity and quality of data are low
• ERP seems safe
• Lack of sufficient outcome parameters and
poor quality of trials do not justify
implementation of ERP as the standard of care
• Role of laparoscopy not clarified
• Protocol compliance not investigated

50. • 12 Spanish hospitals
• 300 patients with elective colorectal surgery for cancer
following an ERP

51. Compliance overall
65 %

52. Results
• LOS
Median 6 days
(range 3 to 89)
• Complications
tot 89 (29.7 %)
surgical 71 (23.7 %)
• Mortality
3 (1 %)
• Readmissions
8 (2.7%)
• Reoperations
21 (7 %)

53. Conclusions
• Sustain ERP is more challanging than its
implementation
• Creation of a single document: paper pathway
• ERP Nurse is essential and it pays in the long
run

54. Thank you
• Whipps Cross Staff
• ERP core group
• Colorectal Unit