ENHANCED RECOVERY & COLORECTAL SURGERY Carole Berger Surgical Care Practitioner Gethin Williams Consultant Surgeon ERAS, Llandrindod Wells November 2010

RGH Newport 1 of 5 Colorectal surgeons Appointed Consultant May 2008 ‘Fellowship-trained’ laparoscopic surgeon at Leeds General Infirmary

Experience with ERAS ….. Learning from Leeds ! Patchy ERAS in Leeds Older surgeons, non-compliant NO CHO loading, bowel prep widely used Nurses did not use the rigid post-op care documentation…too complex Laparoscopic cases did well !

ERAS in Newport Newport would be different Common sense…’Keep it simple’ Good clinical care Team already providing ‘close care’

Basic principles For Enhanced Recovery After Surgery to be successful you must first provide Improved Preparation Before Admission IPBA – not quite so catchy!

Who would ‘drive’ ERAS Enthusiastic Anaesthetists Collaboration from other surgeons Nurses/ Physios’/ Dieticians/ Stoma nurses all keen to start an ERAS programme Team already providing ‘close care’ A Trainee Surgical Care Practitioner for 2 years, who would work in all areas.

Surgical Care Practitioner Would be the second ‘permanent’ member of the team Able to work in all perioperative areas Expert advice in PAC Collaboration with GP’s / MDT to optimise care Reduced delays and cancellations Enthusiastic advocate of ERAS

Traditional Perioperative Care Starve Stress Drown

Traditional care Right hemi 10 days Anterior resection 11 days APER 14 days English NHS 2005 Hospital Episode Statistics

Length of stay – key factors Stress response to surgery Post op ileus Slow mobilisation Complications – wounds, medical problems Stoma management TRADITION

How would we address this ? Education, Preparation and ‘consent’ to undergo ERAS in PAC (SCP). Early discharge planning. Medical optimisation Early stoma counselling if required Nutritional preparation & CHO pre-loading Selective bowel preparation

So why should we start ERAS ? Obvious benefits for the patient : Active participation in their own care No starvation, Reduced duration of ileus, Early mobility, Improved wound size and healing Shorter hospital stay

So why should we start ERAS ? Benefits for the Health Board: Better prepared patients Optimised for surgery prior to admission Facilitates DOSA Improved productivity for theatres Improved rates for SSI’s Reduced hospital stay Reduced readmission

Enhanced recovery after surgery Functional capacity Surgery Multi-modal intervention Traditional care DaysWeeks

What did we do ? Team empowerment and education Benchmarking in centres of excellence Shared values and goals Daily Consultant ward rounds

What did we need ? An Enhanced Recovery Co-ordinator Considered a vital element. This role was undertaken by the trainee Surgical Care Practitioner.

Pre-Assessment Clinic ‘Informal contract of care’ – clear explanation of expectations with patient and relative / friend Improved medical optimisation (primary care involvement) Discharge planning – improved awareness of patients’ needs Nutritional optimisation

Carbohydrate loading CHO loading – safe, cheap, well tolerated Improves well being with ‘minor ops’ Improves insulin resistance in ‘major ops’ Decreased length of stay ‘Nutricia Pre-Load’ now on hospital formulary »

In Theatre Regional anaesthesia – spinal morphine & TAP blocks Laparoscopic surgery – NO long laparoscopic operations !! Avoidance of NG tubes and wound drains Active warming Thromboprophylaxsis Careful fluid balance

On the wards Regional analgesia / avoidance of opiates Laxatives / stool softeners as required Sit out for an hour / clear fluids / supervised mobility & physio on Day 1. Mobility and return to soft diet on Day 2. Early catheter removal TEAM Approach DAILY CONSULTANT WARD ROUND

Discharge NOT necessary to wait for pt to open their bowels. Home with full explanation of expected course of events / contact numbers etc Telephone ‘follow up’ day after discharge Inform GP (now NPSA requirement) Telephone ‘follow up’, Day 10 after surgery or sooner if needed (Audit SSI’s). Discharge until OPD appt.

2010 perioperative Care Feed Educate Balance

First two years 129 elective colorectal resections Benign and malignant Prospectively maintained logbook 41 open procedures 88(68%) laparoscopic procedures ERAS principles for all

First two years.....results Open cases for advanced disease, high BMI or medical reasons 8 (9%) conversions to open NO deaths Laparoscopic group : NO anastamotic leaks, NO reoperations, 5 Morbidities Open group : 2 leaks, 3 reoperations, 8 morbidities

......results Readmissions – 2 laparoscopic, 4 open Length of stay (median) –Laparoscopic 5 days (2-17) –Open 6.5 days (4-39) Social problems in elderly cancer patients’ continues to delay discharge despite pre-op counselling.

What have we noticed ? Improved communication all round Problems picked up early have reduced delays SCP attending PAC has led to greater awareness and engagement Early discharge possible due to SCP telephone follow up Improved collaboration with Primary care

Where are we now Satisfied patients’ and their families Greater awareness Interest from other disciplines CHO loading *SCP attends PAC 2 further consultants involved in ERAS MDT clinical meetings

Future plans For the Patient: Simple documentation / information leaflet provided in PAC. Simple discharge information. For the Medical & Nursing staff: Teaching sessions and information. For Primary care: Communication of changes in care pathways and education re laparascopic surgery & ERAS

What’s Missing ? Oesophageal Doppler – gold standard for fluid management and one of the 17 essential elements of ERAS CPEX machine – cardiopulmonary exercise testing is also a PAC requirement ERAS Nurse / Co-Ordinator – To ensure a seamless ‘role out’ to all areas and co-ordinate data collection.

Does it work ? Day 2 Lap high anterior resection for colovesical fistula Father of a Consultant Anaesthetist Home day 4