1. Post-Surgical Nursing MODULE 3
Created by MSQC for the purpose of initiating and maintaining ERP Quality Improvement Projects by hospitals in the Collaborative.

2. Objectives This clinical pathway is designed to:
Introduce Enhanced Recovery Program (ERP) principles and elements
Explain ERP’s benefit to your patients and INSERT YOUR HOSPITAL’S NAME HERE
Identify essential aspects of ERP Post-Surgical Nursing
Specify your role in patient engagement
Define your responsibilities in post-surgical ERP implementation
Offer strategies for successful implementation of post-surgical ERP at INSERT YOUR HOSPITAL’S NAME HERE
**Be sure to insert your hospital’s name where appropriate within slide.**
Who will benefit from this educational module:
Post-Surgical Nursing Staff
Post-Surgical Nursing Managers
Post-Surgical Floor Nursing Educator
Chief Nursing Officer
Post-Surgical Patient Care Staff
Quality Improvement Director
Quality Improvement Nursing Staff
Surgical Nursing Educator
Surgical Preoperative Nursing Staff
Surgical Intraoperative Nursing Staff
Surgical Postoperative Nursing Staff
Surgical Director
Surgical Managers
Surgeons

3. Enhanced Recovery Program
MSQC Enhanced Recovery Program provides a framework for sites to use in establishing and implementing standardized protocols directed at optimizing patient recovery during the preoperative, intraoperative and postoperative periods of care
A multimodal optimization of surgical care that began to get attention in the 1990s, with the aim of decreasing the surgical stress response in order to improve surgical patient care, reduce complication rates, and shorten hospital stays . Eskicioglu et al. (2009)

4. Benefits of Enhanced Recovery Program
Potential impact of ERP on:
Patient Outcomes
Patient Experience
(As reported by ERP Patients)
Your Hospital Here
Shortened length of stays (LOS)
NO increases in readmissions
Accelerated return to normal activities
Decreased morbidities
Better Patient Outcomes
They felt better-prepared for surgery
Their anxiety was reduced with better confidence in good outcomes
The surgery and hospitalization went according to plan
They were ready for discharge
They were likely to recommend
Better Patient Satisfaction
Improved patient outcomes
Improved efficiency on nursing workflow (due to increased patient engagement)
Improved public reporting
Increased reimbursement and shared savings
Cost Savings / Improved Reporting
**Be sure to insert your hospital’s name where appropriate within slide and notes.**
Developing and implementing an Enhanced Recovery Program has the potential to positively impact your patients and YOUR HOSPITAL’S NAME HERE. In addition to the patient outcomes listed, ERP can also decrease returns to the Emergency Department. Better patient satisfaction results in improved HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores. This combined with the effect on patient outcomes and workflow efficiency results in improved public reporting, decreased cost and increased reimbursement for YOUR HOSPITAL’S NAME HERE.

5. Essentials for Success
Multidisciplinary Teamwork
Planning
Implementation through every phase
Education
Engagement
Leadership
Health care providers
Development of customized ERP protocols and order sets
Pre-surgical
Intraoperative
Post-surgical
Analysis
ERP Compliance
Outcomes
Patient feedback
Cultivating ERP at YOUR HOSPITAL’S NAME HERE
Developing and implementing ERP begins/began with a strong commitment from your/our leadership. ERP will require “culture change” to some extent within your hospital, so their support and dedication to the program’s success is critical. A multidisciplinary steering committee is/was then established to plan customization of the program. The multidisciplinary approach is essential in every aspect of ERP implementation. Along with leadership, all involved health care providers (pre-surgical, intraoperative and post-surgical) must be actively engaged in learning the ERP process and incorporating the program into practice for their patients. In addition, there must be systems in place to assess program compliance and review it’s ability to meet patients’ needs, in terms of outcomes and feedback from the patient perspective.

6. Impact of Nursing on ERP
Nurses represent the “critical mass” required to sustain a powerful and effective Enhanced Recovery Program
Assessment
Diagnosis
Planning
Implementation
Evaluation
235U
236U
92Kr
141Ba
NURSING
PROCESS
(nuclear fission reaction of Uranium-235--self-sustaining because of its critical mass, producing very large amounts of energy.)
An organization with strong nursing representation and buy-in possesses the “critical mass” necessary to create and sustain a powerful and effective Enhanced Recovery Program.
Nurses have the ability to engage patients in an Enhanced Recovery Program in a way that is unique from all other disciplines involved because nurses are present in each and every phase of ERP. For this reason, nurses have the ability to greatly affect the success of patient outcomes.
Application of the nursing process to each phase of the Enhanced Recovery Program will ensure initiation and continuation of patient engagement, facilitation of shared decision-making and sustained motivation for Enhanced Recovery Initiatives. Utilization of the nursing process in establishing and maintaining compliance with ERP initiatives will result in successful outcomes for the patient in meeting set goals for recovery.
Shared Decision Making
Sustained Motivation
Better Compliance with Initiatives
Recovery Goals Met
PATIENT RESULTS:

7. Postoperative Interventions
Enhanced Recovery Program Elements
Preoperative Phase
Presurgical counseling, education, conditioning, readiness and preparation.
Explanation of hospitalization
Testing/ labs
Nutritional assessment
PONV scoring
Exercise monitoring
Mobilization targets
Smoking cessation/’fast’
Alcohol cessation
Fluid management
Pain management
Perioperative Phase
Intraoperative efficiency
Metabolic/fluid conditioning
Prevention of postop ileus
Antiemetic prophylaxis
Mechanical bowel prep with oral
antibiotics (colectomy cases)
VTE prophylaxis
Antimicrobial prophylaxis
Skin prep
Maintenance of normothermia
BP and glucose maintenance
Postoperative Phase
Postoperative Interventions
Early mobilization
Early oral feeding
Early removal of urinary catheters
Early removal of nasogastric tubes and wound drains
Glucose control
There are six basic elements to an Enhanced Recovery Program: Presurgical Counseling and Education; Presurgical Conditioning and Readiness; Presurgical Preparation, Intraoperative Efficiency, Targeted Postoperative Interventions and Patient Feedback and Outcomes Reporting and Analysis.
Within these six elements, are a suggested list of evidence-based practices that result in improved outcomes for surgical patient. An efficient and effective Enhanced Recovery Program will require repeated and regular evaluation of each component for efficacy and improvement.
Preadmission counseling:
ERP Education: procedure, ERP elements, why
Anticipatory Guidance: who, when, what will happen, why
Patient-centered: goal setting, responsibilities, expected outcomes
Pre-Surgical Conditioning and Readiness
Surgical Optimization
Smoking cessation
Optimize nutrition
Optimize mobility
Eliminate alcohol intake
Patient Readiness
Identification of a patient-centered support network (provider)
Surgery “buddy” (patient-chosen)—accompanies patient: second set of eyes and ears
Anxiety assessment and short-term intervention strategies
Presurgical Preparation
Bowel Preparation:
-mechanical bowel prep
-antimicrobial prophylaxis
Presurgical Carbohydrate Loading and Hydration:
-clear (12.5%) carbohydrate drink (800mL) before midnight.
-clear (12.5%) carbohydrate drink (400mL) 2-3 hours prior to induction.
-patient freely consumed clear fluids until 2h before anesthesia for surgery
Intraoperative Efficiency:
Standardized Anesthetic Protocols
-Minimal Use of Opioids
-Measures to Optimally Sedate and Anesthetize Patients
Standardized Thromboembolism and Antibiotic Prophylaxis Protocols
Minimally Invasive Surgery
Targeted Post Operative Interventions
VTE Prophylaxis
Early Mobilization
Early Oral Feeding
Antiemetic Prophylaxis
Early Removal of Catheters/Tubes/Drains
Glucose Control
Pain Management
Preop: administration of pain modulating medications
Post-op: early assessment and intervention
Discharge: good pain control with oral analgesia
Fluid Management
Patient Feedback and Outcomes Analysis
MSQC data collection and analysis allows for benchmarking of quality measure(s) performance specific to ERP

8. ERP-Perioperative Initiatives Nursing Interventions
Preoperative
Optimization
Perioperative
Initiatives
Postoperative
Recovery
Extended
Home
Hospital
FOCUS on Nursing responsibilities
for this time span
Preoperative Optimization
The intent of the prehabilitation phase is to optimize a patient’s health condition in order to prepare for surgical intervention. Adequate preparation and information on pain, fatigue and how to care for themselves following surgery will reduce needless suffering that is a result of a lack of preparation (Kruzik, 2009). Preoperative information and education provided to patients before their surgical and anesthesia procedures has been shown to decrease fear and anxiety (Kiyohara et al., 2004), increase patient satisfaction (Papanastassiou et al., 2011)), and improve pain (Egbert, 1964). Providing psychological counseling may also improve wound healing and recovery after laparoscopic surgery (Broadbent et al., 2012). Key components of ERP include dietary changes, smoking cessation, and mobilization requirements, which demands greater patient involvement and, therefore, an enhanced learning environment is necessary for patient adherence (Smith et al., 2014). Family should be included in all patient teaching so that the patient has support and reinforcements.
Perioperative Initiatives
Beginning while the patient is still in the home environment, the PAT nurse facilitates the patient’s transition from home to the day of surgery, picking up responsibilities for ERP from the surgeon’s office. The PAT nurse, as part of the standard preop patient assessment and preparation for surgery, should incorporate the relevant ERP elements. The PAT nurse is responsible for reinforcing elements from the Preoperative Optimization phase of ERP and introducing the components from the Perioperative Initiatives phase of ERP. On the day of surgery, the preop, intraop and PACU nurses who assume direct care for the patient are responsible for facilitating ERP initiatives in partnership with the patient, surgeon, and anesthesiology team until he/she is transferred to the inpatient unit.
Postoperative Recovery
ERP post-surgical initiatives and targeted postoperative interventions begin once the patient arrives to the post-surgical unit and continue through discharge from the hospital. The post-surgical nurse will pick up responsibilities from the PACU nurse/perioperative nursing staff. From there, assessment of the patient’s preoperative and perioperative “ERP course” will be done and specific post-surgical ERP elements and goal-directed activities will be initiated and carried out. It will be important to continually reinforce the education the patient received throughout the preoperative and perioperative phases, while also incorporating education on the new post-surgical ERP components. As with previous phases, communication of the multidisciplinary team will be essential. At any time during this phase, it may be necessary to work with the team and the patient in developing and maintaining contingency planning, for any patients that are unable to follow their “preplanned ERP course”. These responsibilities will continue until the patient is ready for discharge, and will be communicated appropriately (through thorough discharge instructions meeting ERP guidelines and/or report to the extended care facility) as the patient enters the “Extended Postoperative Recover” phase.

9. ERP and Post-Surgical Nursing
Post-Surgical Nursing responsibilities involve every phase of the Enhanced Recovery Program:
Pre-Surgical
Intraoperative
Post-Surgical
Pre-Surgical Counseling and Education
Pre-Surgical Conditioning and Readiness
Pre-Surgical Preparation
Intraoperative Efficiency
Targeted Postoperative Interventions
Patient Feedback and Outcomes Reporting and Analysis
The post-surgical nurse will need to focus on all phases of the Enhanced Recovery Program, not just the postoperative piece. It is essential to understand the patient’s compliance with the pre-surgical and intraoperative periods. This will contribute to post-surgical planning, patient coaching, and development of any contingency arrangements that may be necessary to get the patient “back on track” with their ERP program. Upcoming slides will address how each of these elements “fits into” post-surgical nursing care. In addition, there are resources and tracking tools designed to aid in implementation of this program.
The notes detailing the basic elements (also provided with slide 7) are again provided for reference in discussing this slide.
There are six basic elements to an Enhanced Recovery Program: Presurgical Counseling and Education; Presurgical Conditioning and Readiness; Presurgical Preparation, Intraoperative Efficiency, Targeted Postoperative Interventions and Patient Feedback and Outcomes Reporting and Analysis.
Within these six elements, are a suggested list of evidence-based practices that result in improved outcomes for surgical patient. An efficient and effective Enhanced Recovery Program will require repeated and regular evaluation of each component for efficacy and improvement.
Preadmission counseling:
ERP Education: procedure, ERP elements, why
Anticipatory Guidance: who, when, what will happen, why
Patient-centered: goal setting, responsibilities, expected outcomes
Pre-Surgical Conditioning and Readiness
Surgical Optimization
Smoking cessation
Optimize nutrition
Optimize mobility
Eliminate alcohol intake
Patient Readiness
Identification of a patient-centered support network (provider)
Surgery “buddy” (patient-chosen)—accompanies patient: second set of eyes and ears
Anxiety assessment and short-term intervention strategies
Presurgical Preparation
Bowel Preparation:
-mechanical bowel prep
-antimicrobial prophylaxis
Presurgical Carbohydrate Loading and Hydration:
-clear (12.5%) carbohydrate drink (800mL) before midnight.
-clear (12.5%) carbohydrate drink (400mL) 2-3 hours prior to induction.
-patient freely consumed clear fluids until 2h before anesthesia for surgery
Intraoperative Efficiency:
Standardized Anesthetic Protocols
-Minimal Use of Opioids
-Measures to Optimally Sedate and Anesthetize Patients
Standardized Thromboembolism and Antibiotic Prophylaxis Protocols
Minimally Invasive Surgery
Targeted Post Operative Interventions
VTE Prophylaxis
Early Mobilization
Early Oral Feeding
Antiemetic Prophylaxis
Early Removal of Catheters/Tubes/Drains
Glucose Control
Pain Management
Preop: administration of pain modulating medications
Post-op: early assessment and intervention
Discharge: good pain control with oral analgesia
Fluid Management
Patient Feedback and Outcomes Analysis
MSQC data collection and analysis allows for benchmarking of quality measure(s) performance specific to ERP

10. ERP Nursing Responsibilities
Clinical Guidelines
Patient Engagement
Contingency Planning
Key Components of ERP Nursing Responsibilities
Three components must be considered to ensure success for the Enhanced Recovery Program patient:
Clinical Guidelines – These are the evidence-based clinical care factors set forth by ERP. MSQC recommended ERP protocols have been customized for YOUR HOSPITAL NAME HERE. These outline the processes to follow through the entire program; including pre-surgical, intraoperative and post-surgical. It will be very important to understand your patient’s compliance with ERP protocols at the time they reach the post-surgical unit, as well as document and communicate their progress throughout the post-surgical phase.
Patient Engagement – This includes “coaching” your patients toward their “postoperative targets” through continuous encouragement and reinforcement of their active role in their recovery.
Contingency Planning – This component may not be necessary for every patient, but it will be important to always be prepared and ready to make changes to the “routine ERP course” (should the situation warrant). The nurse’s ability to quickly develop and adapt to an alternative plan will help get the patient back on their ERP course, make the patient comfortable and give them confidence in their “revised ERP course”. Patient engagement will be extremely important to cases requiring contingency planning, as deviation from the anticipated course may be discouraging and/or anxiety producing for the patient.

11. Postoperative Clinical Guidelines
Evidence-Based
Clinical Guidelines
VTE prophylaxis
Control of postoperative nausea and vomiting
Postoperative pain control
Early postoperative (oral) feeding
Early mobilization
Avoidance of nasogastric tubes
Avoidance of wound drainage
Fluid management
Urinary catheter removed postoperative day (POD) 1-2
Alvimopan
Postoperative glucose control
Multidisciplinary communication and teamwork is a key element of success
This slide represents a list of the postoperative clinical guidelines. While these components are specific to the postoperative phase, it is still very important to remember that nursing care for ERP patients requires the nurse to be aware of all phases of ERP.
The clinical guidelines are evidenced-based recommendations, and have been used to create ERP protocols customized to your hospital. They are intended to be utilized along with a multidisciplinary approach to care.
Francis et al., 2012
Gustafsson et al., 2013

12. Patient Engagement
Decision Making
Health Literacy
Patient Centered
Self-Care
Self-Manage-ment
Patient Safety
“…the goal is to support and strengthen patients’ determinations of their health care needs and self-care efforts with a view to obtaining maximum value and improved health outcomes.”
Coulter (2012)
To maximally engage patients, they need to be well supported and informed. In addition, they must be provided opportunities to participate in their care and decision making. For patients that require contingency planning, the patient should be at the center of the planning process and involved in determining the alternate plan. Motivation and reinforcement of the ERP process will help keep patients actively engaged.
There are multiple facets to patient engagement:
Health Literacy: A fundamental piece of patient engagement as patients must be able to understand and process health information. This also involves addressing patient expectations of care. Patient empowerment is key to meeting this facet.
Decision Making: Ensuring patients are well-informed and taking their preferences into account in deciding treatment(s) results in shared decision making, a goal of patient engagement. Use of coaching and question prompts can help patients improve this facet.
Self-Care: Patients need to take actions to maintain physical and mental health.
Self-Management: Patients need to play an active role in managing the day to day aspects of their chronic conditions (if applicable). Educating patients on self-management and helping them to self-administer treatments can help patients improve this facet.
Patient Safety: Patients can advocate for the safest care possible by being actively involved in monitoring care processes, recognizing and informing health care providers of complications, and effectively managing treatment. Positively reinforcing treatment regimens can help patients improve this facet.
It is important that health professionals are granted the means to gain the necessary expertise and skill to effectively engage patients.
Coulter, Ellins (2007)

13. Arrival to Inpatient Floor
*History – Assess pre-surgical and intraoperative ERP compliance*
Initial Assessment and Intervention
VTE Prophylaxis  apply/obtain order(s) if not already complete
Mechanical (compressions stockings and intermittent pneumatic compression devices)
Pharmacological (heparin/low molecular weight heparin)
Postoperative Nausea and Vomiting  assess score and treat using multimodal approach
Pain Control  assess score and medicate for relief (if necessary), reinforce pain goals/targets
Early Oral Feeding  assess whether the patient has received clear fluids/food and if tolerated
Alvimopan  verify has been ordered and is on patient’s list of scheduled medications
Fluid Management begin recording fluid type and amount received
When the patient arrives to the post-surgical floor, initial actions to take include obtaining their ERP history, assessing key initial postoperative ERP clinical factors, and initiating the postoperative ERP checklist.
Refer to clinical guideline specific nursing tip sheets for specific interventions and supporting rationale.
Postop nausea/vomiting pocket card also available as an easily accessible resource to keep on hand.
For the
Initiate post-surgical ERP checklist
Francis et al., 2012
Gustafsson et al., 2013

14. ERP Nursing Guidelines
Patient Engagement >
Ensure patient is receiving mechanical and (timely) pharmacological prophylaxis
Periodically reassess VTE risk
Educate patients regarding importance
Notify physician of missed doses/refusals
VTE PROPHYLAXIS
Perform PONV post-surgical risk assessment
Perform regular patient assessments (through 48 hours past discharge from PACU)
Be aware of potential de novo PONV patients
Use multimodal treatment approach
POSTOP NAUSEA AND VOMITING
Continue through discharge from hospital
Patient engagement and contingency planning (as necessary) are to be continued throughout the post-surgical hospital stay, until discharge from the hospital.
VTE Prophylaxis: (see VTE Prevention Nursing Tip Sheet and MSQC Recommended VTE Risk Scoring System Pocket Card)
Pharmacological = SQ heparin/low molecular weight heparin
Ensure timely administration and adherence to schedule, reoffer missed doses (unless too close to next administration time)
Document and notify surgeon/physician of any missed doses or patient refusals
Mechanical = compression stockings and sequential compression devices/intermittent pneumatic compression devices
SCD/IPC devices should be worn continuously until patient is fully ambulatory
Assess for and ensure patient compliance
Educate patient regarding importance of compliance
Education
Continuously reinforce rationale for prophylaxis
Provide and/or refer to written patient education materials
Encourage and prompt patient to ask questions and express any concerns they may have regarding prophylaxis
Educate family member(s) along with patient when possible
Patient Engagement
Encourage patients to become actively involved in making sure they are complying with appropriate prophylaxis
Teach patient to be an advocate of their medication schedule (pharmacological prophylaxis)
Make patient aware of the importance of reporting missed doses
Address Extended Prophylaxis
Remind multidisciplinary team/surgeon/discharging physician to assess whether patient should be prescribed continued pharmacological prophylaxis post-discharge
This may be especially important to consider for patients with colorectal cancer
Postop Nausea and Vomiting: (see PONV Risk Assessment Nursing Tip Sheet and ERP Nursing Pocket Card)
Assessment
PONV score needs to be reassessed upon arrival to post-surgical unit
PONV should be reassessed at regular intervals through 48 hours past discharge from PACU (it may be helpful to perform these along with regular pain assessments)
Know the PONV risk for each patient and be aware of the medications they have ordered/available
Know if your patient is a “de novo” PONV patient - has a PONV Risk Score of moderate or high and/or received a rescue antiemetic in PACU, and is therefore at high risk for developing PONV that “begins again” on the post-surgical unit
Management
Management of these symptoms is essential to ERP patients being able to meet post-surgical “targets”, as PONV can delay the patient from engaging in activities to promote recovery
Continuously communicate score and uncontrolled nausea/vomiting to the multidisciplinary team and utilize multimodal interventions to prevent and manage accordingly
It is very important to communicate PONV assessments/interventions during shift change and unit transfers
Educate patients on PONV as it pertains to their particular assessed risk, including providing intervention strategies
Encourage patients to be involved in managing their PONV, including communicating associated needs (such as symptoms and medication schedule)
Complications associated with PONV
suture dehiscence
aspiration of gastric contents
esophageal rupture
CONTINGENCY PLANNING >
Francis et al., 2012
Gustafsson et al., 2013

15. ERP Nursing Guidelines
Patient Engagement >
Perform regular assessments of pain status
Reinforce and educate patients regarding pain expectations and targets
Follow multimodal approach to treatment, encouraging non-narcotic medications
PAIN CONTROL
Same day as surgery: start clear fluids (as soon as possible following surgery), begin normal food and provide oral nutritional supplements
Postop day 1+: patient should receive fluids as desired, normal meals and oral nutritional supplements
NUTRITION
Continue through discharge from hospital
Patient engagement and contingency planning (as necessary) are to be continued throughout the post-surgical hospital stay, until discharge from the hospital.
Pain Control:
Assessment/Management
Early assessment (done at regular intervals) and intervention will be important to ERP progression, as poor pain control will inhibit patients from participating in other ERP activities
Goal = good pain relief – but must also be such that the patient can participate in mobilization and early oral feeding
Postoperative ERP protocol may be dependent upon surgical approach (open vs. laparoscopic)
Use of opioids should be avoided when possible, and should be prescribed for break-through pain only as they can delay return of gut function and cause PONV
Multimodal treatment approach should be utilized, which includes NSAIDS and IV Acetaminophen
Communicate uncontrolled pain with multidisciplinary team
Education
Reinforce information/materials presented and provided during preoperative and perioperative phases
Reinforce postoperative pain goals and expectations
Patient Engagement
Encourage patients to become advocates of their pain control and communicate associated needs (such as medication schedule and symptoms)
Be sure to include the patient in discussions and decisions related to pain control
Nutrition:
Day of Surgery
Start clear fluids as soon as possible following surgery (likely will have occurred in recovery/PACU)
Begin normal food a couple hours after clear fluids were started
Oral nutritional supplements should be provided
Postoperative day one and on (unless contraindicated based on patient condition(s):
Patient should be allowed to drink fluids as desired
Normal meals should be provided
Oral nutritional supplements should continue
Other Management Considerations
Early oral feeding will help to prevent postop ileus, but may cause postop nausea and vomiting, so it will be very important to assess for this frequently and intervene appropriately
Vomiting or ileus - If presents, stop intake for a couple of hours  start again with fluids only  if fluids tolerated, continue food again
Patient’s not meeting their nutritional requirements by 72 hours after surgery should be assessed by a dietician
Make sure fluids/food are accessible to patient (order tray if necessary)
Encourage patient to make decisions regarding meals
Additional Assessment
Be sure to consider any special needs your patient(s) may have based on status or other ongoing issues (e.g. elderly, chronic diseases, alcohol problems, other known deficiencies
It is very important to be aware of the patient’s pre-surgical nutrition status and their preoperative compliance with carbohydrate loading and hydration (see Carbohydrate Loading and Optimizing Hydration Nursing Tip Sheet)
Document patient’s daily intake, and communicate to surgeon/physician and oncoming nurse at shift change
CONTINGENCY PLANNING >
Francis et al., 2012
Gustafsson et al., 2013

16. ERP Nursing Guidelines
Patient Engagement >
Day of surgery: patient to be out of bed for 2 hours
Postop day 1+: patient to be out of bed 6 hours/day
Assess for barriers to mobilization
Motivate patients to achieve “targets”
Key element in preventing postop ileus
EARLY MOBILIZATION
Remove postoperative day 1 or 2 (unless contraindicated)
URINARY CATHETER
Continue through discharge from hospital
Patient engagement and contingency planning (as necessary) are to be continued throughout the post-surgical hospital stay, until discharge from the hospital.
Early Mobilization: (**This is a key element in preventing postoperative ileus)
Day of surgery
Patient should be out of bed for 2 hours – helped with sitting up in a chair
If unable to get up to chair, should be assisted with gentle mobility
Postoperative Day 1 through Discharge
Patient should be out of bed 6 hours/day (total time out of bed)
This may include sitting in chair and ambulating (when patient able)
Reinforce preoperative plan/materials and encourage activity progression (as applicable)
Management
Assess for potential barriers including inadequate pain control and IV fluids/tubes/drains/catheters in place
Create and maintain a patient environment that allows and encourages mobilization
Manage comorbidities to allow patient to participate in early mobilization
Incentive spirometry will be especially important to patients unable to mobilize early (as immobilization can cause pulmonary atelectasis and worsened pulmonary functioning)
Complications of Immobilization
VTE
Loss of muscle strength
Urinary Catheter:
If patient is unable to have removed on postoperative day 1 or 2, continue to assess and advocate for removal when no longer a contraindication
Ensure extended use of catheter does not impede meeting other postoperative targets (such as mobility)
Patient Engagement
Keep patient actively involved in meeting postoperative targets despite unexpected extended catheter use
Help patient to set new goals/targets where appropriate
CONTINGENCY PLANNING >
Francis et al., 2012
Gustafsson et al., 2013

17. ERP Nursing Guidelines
Patient Engagement >
Enteral fluid as soon as possible
Discontinue IV fluids as early as possible (recommended postop day 1)
Manage fluids according to specified ERP protocol
Record fluid administered
FLUID MANAGEMENT
Nasogastric tubes and wound drains should be avoided whenever possible
If necessary, assess and advocate for removal when appropriate
TUBES AND DRAINS
Continue through discharge from hospital
Patient engagement and contingency planning (as necessary) are to be continued throughout the post-surgical hospital stay, until discharge from the hospital.
Fluid Management:
Unless contraindicated, encourage patients to drink as much as they want (at least 1000 mL/day)
Discontinue IV fluids as soon as possible – with the goal being postoperative day 1
Document intake and communicate to oncoming nurse at shift change to ultimately achieve complete record of patient’s daily intake
Communicate fluid intake as appropriate to multidisciplinary team
Tubes and Drains:
Management
Tubes and drains should be avoided if possible
If in place upon arrival to post-surgical unit, nursing should continually assess for the ability to remove tubes and /or drains as they:
can cause discomfort to the patient
may inhibit mobilization
may contribute to pulmonary complications
may delay return of gut function
For patients requiring nasogastric tubes and/or wound drains, ensure these are not a barrier to mobilization and reinforce the importance of early mobilization with patient; work with patient to develop a “mobilization plan” that accommodates the tube/drain and is feasible/comfortable for the patient
A nasogastric tube may be inserted (for emptying) in the event of gastric retention, but should be removed immediately after “emptying” completed
Avoidance/early removal of tubes/drains will help prevent postop ileus. If a patient has an ileus, a nasogastric tube may be left in for a longer duration, but should be removed as soon as possible.
CONTINGENCY PLANNING >
Francis et al., 2012
Gustafsson et al., 2013

18. ERP Nursing Guidelines
Patient Engagement >
Avoid hyper- and hypoglycemia
Adhere to glucose management protocols
GLUCOSE CONTROL
Ensure ordered and scheduled on patient medication list
Administer per medication schedule (until discontinued)
ALVIMOPAN
Continue through discharge from hospital
Patient engagement and contingency planning (as necessary) are to be continued throughout the post-surgical hospital stay, until discharge from the hospital.
Glucose control:
Manage according to specific glucose protocols
Cautiously use insulin, to avoid hypoglycemia
Educate patients regarding insulin use while in the hospital
Communicate patient’s response to insulin protocol / scale (if applicable)
Alvimopan:
Assess whether ordered and administered preoperatively
Ensure ordered postoperatively, scheduled on MAR and administered accordingly
Monitor for return of gut function
document findings as appropriate
Communicate status to multidisciplinary team (as appropriate)
CONTINGENCY PLANNING >
Francis et al., 2012
Gustafsson et al., 2013

19. How do I get my patient “back on the ERP track”?
Contingency Planning
Notice deviation from routine ERP course
Form “contingency plan” with patient:
Provide reassurance and education regarding options
Set new “targets” for the patient to work toward
How do I get my patient “back on the ERP track”?
Provide reinforcement through motivation toward new targets and encouragement of plan
It is important to remember that the ERP patient has been preparing for every phase of the program as soon as they made the decision to have surgery. They will have followed protocols to get them in the most optimal pre-surgical condition, learned what to expect from their hospitalization and planned “targets” for their recovery. Deviation from this planned out course has the potential to make the patient feel discouraged, scared and/or anxious. It is crucial that the nurse be able to quickly recognize any deviation and immediately begin contingency planning to get the patient “back on the ERP course”.
In doing so, it will be necessary to educate and involve the patient in developing an alternate plan, provide reassurance, and reinforce the redirected focus. In addition, any changes should be communicated to the surgeon/physician, oncoming nurse for the next shift, and any other necessary members of the multidisciplinary team.
In training post-surgical staff for implementation of ERP, it may be helpful to have open discussion about different “potential scenarios” of patients deviating from the routine ERP course. This will increase staff awareness and create prepared strategies they can share/offer when planning alternate courses with patients. Some scenario suggestions include:
Delayed oral feeding
Delayed mobilization
Presence of drains
Development of postop ileus
Delayed discharge (complication or patient not meeting discharge readiness requirement)
** All changes should be communicated to surgeon/physician, oncoming nurse at shift change and multidisciplinary team members**

20. Elements to determine if your patient is ready for discharge
Discharge Readiness
Patient’s pain is adequately controlled with oral analgesia.
Patient is tolerating solid food and no longer requires IV fluids.
Patient is returned to pre-surgical functional status.
Patient feels ready and willing to go home.
Preparation for all discharge needs is complete.
Elements to determine if your patient is ready for discharge
Discharge planning will also have begun at the time the patient decided to have surgery. Since the plans have already been in place, it is important to verify them with the patient once they have settled in on the post-surgical unit. It will also be necessary to incorporate any new needs that are being anticipated since the surgery. The patient should receive reinforcement of their discharge goals (established prior to surgery), motivation to meet these goals and encouragement of their active involvement in the recovery process. Communication regarding the elements of discharge readiness should occur daily between nursing at shift changes; and nursing should inform the surgeon/physician of the patient’s progress.
Helpful consults that may be needed for the patient:
Case management (should be utilized for all patients)
Social Work
Physical Therapy
Dietary
Enterostomal Nurse
For patients requiring contingency planning, it may be necessary to adjust the discharge plan as well. Again, it will be important to develop this change with the patient, and provide reassurance and reinforcement of this new plan.
Francis et al., 2012
Gustafsson et al., 2013

21. Discharge from Hospital
PATIENT NEEDS AT DISCHARGE:
Written discharge instructions
Specific Contact Information
Verbal review of all discharge information and verification of patient understanding
Once the patient meets all requirements of discharge readiness, and is deemed medically appropriate for discharge by the surgeon (and other physicians following the patient), they can proceed to discharge. The patient should be provided written discharge instructions that address specific information pertinent to their continued recovery at home. Nursing should review and ensure the patient fully understands the instruction, and also provide them with any necessary prescriptions. Finally, the patient must receive detailed contact information so they know exactly how to proceed should they require additional needs and/or encounter any issues once they return home.
Francis et al., 2012
Gustafsson et al., 2013

22. Implementation “Ideas”
Hold regular ERP team meetings where clinicians have the opportunity to discuss ERP.
Review patient level data for ERP and non-ERP patients to demonstrate impact of the program.
Select “clinical champions” from multiple areas that are excited about the program and willing to work to engage other clinicians.
Acknowledge and celebrate ALL successes!
Helpful implementation ideas are also a great topic for discussion at ERP meetings. Encouraging “front line” staff to present their thoughts and ideas about the most beneficial way(s) to implement a new program (especially one that potentially involves a “culture shock”) will increase their engagement and likely offer viable solutions, as they are well aware what will work best in their everyday practice and routines.
Reference website:
NHS
Enhanced Recovery Partnership Programme - Sharing The Learning

23. This clinical pathway:
Summary
This clinical pathway:
Identified essential aspects of ERP Post-Surgical Nursing
Specified your role in patient engagement
Defined your responsibilities in post-surgical ERP implementation
Offered strategies for successful implementation of post-surgical ERP at INSERT YOUR HOSPITAL’S NAME HERE
Explained ERP’s benefit to your patients and INSERT YOUR HOSPITAL’S NAME HERE
**Be sure to insert your hospital’s name where appropriate within slide.**

24. Questions
NEXT PHASE
Next phase: Post-discharge from hospital

25. Questions

26. Our goal is that this guide
will serve as a resource to help you guide patients to achieve optimal preparation for surgery and success in realizing the many benefits of the Enhanced Recovery Program. Through monitoring, educational efforts, system changes and coordination of services of the healthcare team and many hospital divisions, patients will attain improved length of stay, decreased readmission rates and reduced morbidity and mortality, and the hospital will demonstrate a return on investment which exceeds the incremental costs of these efforts.