2. Collaborative Life Cycle
Local
work Continuous Improvement
Team asked begins
Topic to join the
programme
Reference Celebration
Initiation/LS1 LS2 LS3
Panel
Other support mechanisms
Faculty, Support from WSC Team
Web site, E Mail & Phone contact,
Reports, Development Sessions
3. JAN July JAN July JAN July JAN July JAN July
00 01 02 03 04
BCWD
First & Fast
Joints IV 6 NOF III 12
#NOFs II 26
National Back Pain I & II & III
#NOFs I 23
Joints III 33
Joints II 24
Joints I 30
Action on Orthopaedics
5. TORR
Torbay Orthopaedic Rapid Recovery
John Marshall
Clinical Director – Trauma and Orthopaedics
South Devon Healthcare NHS Foundation
Trust
6. Northumbria Fast Track
Total Hip & Total Knee
Replacement
Leigh Kelly
Acute Pain Specialist Nurse
&
Clare Casson
Senior Specialist Physio
7. Managing the Process of Implementing an
Enhanced Recovery Pathway
Tom Wainwright
The Royal Bournemouth Hospital
Department of Health, London – 23/09/2009
8. Enhanced Recovery Programmes
in Orthopaedics‐
Becoming the Gold Standard
Mr David Houlihan‐Burne
Consultant Knee Surgeon
The Hillingdon and Mount Vernon Hospitals
NHS Trust
9. Example of enhanced
recovery elements
Referral from •Optimising pre operative
Primary Care
health state e.g. Hb levels
Pre-
•Managing co morbidities e.g.
Operative diabetes
•Fit for surgery
Admission
Intra-
Operative
Post-
Operative
Follow
Up
9
11. Example of enhanced
recovery elements
Referral from • Optimised health / medical condition
Primary Care • Informed decision making with
companion
Pre- • Pre operative health & risk
Operative
assessment e.g. (CPEX)
Admission
Intra-
Operative
• PT information and expectation managed
• DX planning (EDD) Post-
• No / reduced oral bowel prep (bowel Operative
surgery)
• Pre-operative therapy instruction where Follow
appropriate Up
11
13. Example of enhanced
recovery elements
Referral from • Optimised health / medical condition
Primary Care • Informed decision making with
companion
Pre- • Pre operative health & risk
Operative
assessment e.g. (CPEX)
Admission
Intra-
Operative
• PT information and expectation managed
• DX planning (EDD) Post-
• No / reduced oral bowel prep (bowel Operative
surgery)
• Pre-operative therapy instruction where Follow
appropriate Up
13
14. Patient satisfaction of TKR
Satisfaction questions were completed by 8095
patients
Overall
- 81.8% were satisfied
- 11.2% were unsure
- 7.0% were not satisfied
The OKS varied according to patient
satisfaction (p<0.001)
14
15. Decision Aids reduce rates of discretionary
surgery
RR=0.76 (0.6, 0.9)
O’Connor et al., Cochrane Library, 2009 15
17. Example of enhanced
recovery elements
Referral from •Optimise fluid hydration
Primary Care
•Optimise Nutrition
•No / reduced oral bowel
Pre- preparation (where appropriate)
Operative
Admission
Intra-
Operative
•Admission on the day of surgery
Post-
•Carbohydrate loading Operative
•No pre med (sedative)
Follow
Up
17
18. Example of enhanced
recovery elements
Referral from
Primary Care • Minimally invasive surgery
where appropriate
Pre- • Use of transverse incisions
Operative (abdominal) if appropriate
Admission
Intra-
Operative
• Use of regional anaesthesia
Post-
• LA with sedation Operative
• Individualised goal directed fluid
management Follow
Up
18
19. LIA TECHNIQUE FOR TOTAL
KNEE REPLACEMENTS LIA TECHNIQUE FOR TOTAL KNEE
REPLACEMENTS
150 mls Ropivicaine 0.2 %
150 mls Ropivicaine 0.2 % Pre mix 100ml 0.2% Ropivicaine with 1ml 1:1,000 adrenaline
and 50 mls 0.2% Ropivicaine plain
50ml syringes with 18 G (Pink) Spinal needle
Pre mix 100ml 0.2% 1.BEFORE PROSTHESIS INSERTED
Ropivicaine with 1ml 1:1,000 50mls with adrenaline into posterior
capsule / gutters / extensor mechanism
adrenaline
and 50 mls 0.2% Ropivicaine
plain
2. AFTER PROSTHESIS INSERTED
50ml syringes with 18 G (Pink) 50mls with adrenaline into posterior
capsule / gutters / extensor mechanism
Spinal needle
3. BEFORE CLOSING THE SKIN
50mls without adrenaline into skin/
subcut tissues before clips applied
20. NHCFT fast-track anaesthesia
paracetamol 1g iv
+/- NSAID (as appropriate)
judicious intra-operative
vasopressor & iv fluids
no (routine) urinary
catheter
intra-operative infiltration LA:
100ml levobupivacaine
1.25mg/ml
intra-articular LA catheter
no surgical drains
21. Example of enhanced recovery
elements
Referral from • Planned mobilisation (24hrs post
Primary Care
op)
• Rapid hydration & nourishment
Pre-
Operative
• Appropriate IV therapy
• No wound drains
• No nasogastric tubes (bowel
Admission surgery)
Intra-
• Catheters removed early Operative
• Regular oral analgesia
• Paracetamol and NSAIDS Post-
• Avoidance of systemic opiate- Operative
based analgesia where possible or
administered topically Follow
Up
21
24. Example of enhanced recovery
elements
Referral from • DX when criteria met
Primary Care
• Therapy input (e.g. stoma /
physio / dietician)
Pre-
Operative • 24 hour follow up call
Admission
Intra-
• Audit & monitor outcomes Operative
• Feedback
Post-
Operative
Follow
Up
24
25. MDT discharge criteria
Independent with all transfers (bed/chair/toilet)
Independently mobile with appropriate walking
aid
Safe on stairs /step if indicated
Able to perform exercises correctly & happy to
continue at home
THR: patients aware of hip precautions
TKR: flexion >80°, good quadriceps control,
moderate oedema.
26.
27.
28. Comparison of the length of stay (LOS) and
demographics between the two groups
Traditional Fast Track P value
Number 3000 1571
Age (years) 69 68
THR 1368 657
TKR 1632 914
Mean LOS 8.5 4.8 <0.001*
Median LOS 6 3 <0.001*