The Guildford Experience Enhanced Recovery: The story so far…. Dr Wendy King Anaesthetic Department, Royal Surrey County Hospital, Guildford, UK January 2015

Ward staff Surgeon Anaesthetist PATIENT Pre- assessment Discharge planners Oncology SALT Dietician Theatres & ICU staff Physio Endoscopy Radiology Multidisciplinary team

Enhanced Recovery After Surgery (ERAS) Multidisciplinary input Standardised pathway Components Preoperative Intraoperative Postoperative Day-by-day expectation of patient recovery

Preoperative Preadmission Multidisciplinary assessment Enhanced Recovery education  Prehabilitation Day before surgery Surgical checklist Limited fasting Preload  9pm - 2 sachets  6.30am - 1 Sachet

Intraoperative Standardised anaesthesia Nasal intubation Remifentanil infusion Arterial line / CVC Nasogastric feeding tube Glucose control Temperature control Bispectral Index monitor Goal-directed fluid therapy (LiDCO) Inotropes / Vasopressors Dobutamine Noradrenaline Antibiotic prophylaxis Thromboprophylaxis Doppler cuff

Postoperative Intensive Care Unit Remain intubated / sedated overnight Flap observation protocol GDFT continued 6 hours Early feeding Early mobilisation Head and neck ward Transfer on day 1 Flap observation protocol Daily record of progress

Postoperative Intensive Care Unit Remain intubated / sedated overnight Flap observation protocol GDFT continued 6 hours Early feeding Early mobilisation Head and neck ward Transfer on day 1 Flap observation protocol Daily record of progress

Patient groups Enhanced recovery after surgery (ERAS) Study group 40 consecutive patients treated January 2013 onwards Traditional recovery after surgery (TRAS) Control group 40 consecutive patients treated before January 2013

Tumour site Number of patients

Flaps Number of patients

Outcome measures Length of stay Complications 30 day readmission rates

Median length of stay (LOS) TRASERAS Median LOS (Days) 1410 Interquartile range (days) P=0.0014

Clavien-Dindo classification of complications Dindo D, Demartines N, Clavien P “Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey” Ann Surg. 2004; 240(2): GradeDefinition 1Any deviation from the normal post-operative course 2Requiring pharmacological treatment (includes blood transfusion / TPN) 3aRequiring surgical / endoscopic / radiological intervention not under GA 3bRequiring surgical / endoscopic / radiological intervention under GA 4aSingle organ dysfunction requiring ICU 4bMulti organ dysfunction 5Death

Complications

Median LOS (Days)

Readmission rates There were no patients readmitted within 30 days of discharge in either group

Tracheostomy TRASERAS Number (%)Median LOS (Days) Number (%)Median LOS (Days) Tracheostomy27 (67.5%)1517 (42.5%)10 No tracheostomy 13 (32.5%)1323 (57.5%)9.5

Tracheostomy TRASERAS Number (%)Median LOS (Days) Number (%)Median LOS (Days) Tracheostomy27 (67.5%)1517 (42.5%)10 No tracheostomy 13 (32.5%)1323 (57.5%)9.5

Age TRASERAS Number (%)Median LOS (Days) Number (%)Median LOS (Days) Age <60 years11 (27.5%)1123 (57.5%)10 Age > 60 years29 (72.5%)1417 (42.5%)11

Age TRASERAS Number (%)Median LOS (Days) Number (%)Median LOS (Days) Age <60 years11 (27.5%)1123 (57.5%)10 Age > 60 years29 (72.5%)1417 (42.5%)11

Tumour stage TRASERAS Number (%)Median LOS (days) Number (%)Median LOS (days) T1 / T221 (55%)1324 (71%)10.5 T3 / T417 (45%)1410 (29%)10

Tumour stage TRASERAS Number (%)Median LOS (days) Number (%)Median LOS (days) T1 / T221 (55%)1324 (71%)10.5 T3 / T417 (45%)1410 (29%)10

Other outcomes FeedingMobilisation Median number of days Median number of days

Conclusions The ERAS programme is both safe and effective for head and neck cancer patients undergoing free flap surgery Potential for reduction in both length of stay and complications Possible financial benefits for the treating institution

“ the immediate challenge to improving the quality of surgical care is not discovering new knowledge, but rather how to integrate what we already know into practice ” Urbach and Baxter, 2006

Aims for future Extend ERAS programme to include head and neck cancer patients undergoing other oncological treatments Continue to improve patient outcomes by undertaking collaborative research with other head and neck units participating in ERAS programmes

Thank you