1. What is currently happening in Wales with Enhanced Recovery? Mrs Joanna Hilton Laparoscopic Colorectal Fellow Singleton Hospital, Swansea

2. Outline Snap shot of ERAS across Wales – Questionnaire presented at WSS meeting in March 2010 ERAS programme in Singleton Hospital

3. ARE WE HELPING PATIENTS GET BETTER SOONER IN WALES? JR Hilton, C Beaton, U Khot, J Beynon, BI Rees *, M Davies. Singleton Hospital, Swansea and * University Hospital of Wales, Cardiff

4. INTRODUCTION Enhanced Recovery Partnership Programme launched in England Feb/March 2010 – Helping surgical patients to get better sooner ASGBI Issues in Professional Practice Guidelines for Implementation of Enhanced Recovery Protocols Dec 2009

5. AIM To ascertain our current enhanced recovery after surgery (ERAS) practice in colorectal surgery across South Wales To compare current practice to that of 2005 To identify any aspects of ERAS poorly implemented or managed

6. METHODS Simple questionnaire survey on key surgical elements of ERAS completed by SpRs working for colorectal units in South Wales (extended to consultants if SpR not available) Performed in 2005 and repeated 2010 Not anonymous or optional!

7. QUESTIONNAIRE 2005 Established ERAS programme Bowel preparation NG tubes Resumption of fluids/solids Peri-op IV fluid restriction Post-op analgesia Level of post-op care 2010 2005 PLUS Carbohydrate pre-load Intra-op goal directed therapy

8. RESULTS 2005 16 colorectal teams identified (9 units) Response from 14 (8 units) 1 unit had ERAS established 2010 26 colorectal teams identified (9 units) Response from 23 (8 units) 2 units have ERAS established (different units to 2005!) 2 units in process of setting up ERAS 4 units SpR not aware

9. BOWEL PREPARATION 2005 29% full prep R hemi 100% full prep TME 100% full prep APER 2010 5% full prep R Hemi 70% full prep TME (30% PO 4 enema) 26% full prep APER (57% no prep, 17% PO 4 enema)

10. NASO-GASTRIC TUBES

11. RESUMPTION OF NORMAL DIET

12. PERI-OP IV FLUID RESTRICTION

13. ROUTINE POST-OP ANALGESIA

14. LEVEL OF POST-OP CARE

15. CARBOHYDRATE LOADING Not questioned in 2005 10/23 teams routinely give in 2010 Varying products and protocols used

16. GOAL DIRECTED THERAPY Not questioned in 2005 8/23 teams have anaesthetists that regularly monitor intra-operative flow in 2010

17. DISCUSSION Encouraging shift in attitudes towards embracing ERAS principles in Wales: – Reduction in ‘unnecessary’ bowel prep – NGT removed quicker – Patients being fed quicker – Move towards non-opioid based analgesia

18. ....SO ARE WE GETTING PATIENTS BETTER SOONER IN WALES? Catching-up or are we leading the way? LOS of consecutive elective colorectal cases in Singleton March 2010 – Laparoscopic (n=16) median 6 days – Open (n=19) median 6.5 days LOS HES 2008-2009 data – Colectomy median 8 days – Excision of rectum 9 days

19. What we are doing in ABM-ULHB Department of Colorectal Surgery, Singleton Mr Khot appointed 2007 to establish laparoscopic colorectal service Prospective database of laparoscopic resections since then Principles of ERAS promoted along with laparoscopic approach

20. From 2009 Consensus within unit of ERAS programme Patient information sheets in pre-assessment Avoidance of bowel preparation (replenished) Reduced pre-op starvation period Changes in anaesthesia and analgesia Early resumption of diet Early mobilisation

21. From July 2010 Revised ERAS programme with prominent posters and displays around clinical areas Laparoscopic fellow to co-ordinate Same pre-assessment and advice with discharge planning and stoma training Addition of Preload (avoided in DM) and clear fluids until 2 hrs pre-op Promotion of anaesthetic techniques

22. High energy/protein shots x6/day until eating normally Physiotherapy regimes (4x60ms/day) Data collection of achievement of daily goals Bedside folders with information for patients and relatives

23. Monthly ERAS meetings – Open format – Education – Problem solving – Updates on compliance with programme

24. What is going well Higher profile of programme by raising awareness across disciplines and specialities Monthly meetings well attended/received – Empowerment of all team members, ‘not just the doctors’ Involvement of non-clinical staff (‘management’)

25. Patients recruited July to Oct 2010 = 21 – Median LOS 4 days (2-30) – Non ERAS median LOS 8.5 days (3-33) 5 patients stayed >1 week 1 readmission at day 3 3 major complications ( 1 leak, 2 SBO)

26. Problems encountered Recruitment onto programme – ‘opt-out’ solution? Data collection – Sheets not given out – Lost data sheets and folders Consultant preferences/deviance from programme

27. Our way forward Promote recruitment Patient diary combining pre-assessment information with data collection and discharge advice