1. Enhanced Recovery Compliance against elements of ER pathway by Specialty 22 th July 2011

2. Introduction The aim of this report is to share national level data on enhanced recovery pathways and so to provide benchmarking information to organisations implementing ER. The data included in this report was recorded on the national enhanced recovery toolkit. This tool allows a trust to audit their local implementation of enhanced recovery against a standard enhanced recovery pathway and also to benchmark their local audit against what others reporting around the country.

3. Introduction (cont) This report includes data from 29 trusts across England. These trusts are likely to be a mix of those that are new to enhanced recovery as well as those that have more experience of enhanced recovery pathways of care. Patients admissions were from 02/01/2011 to 03/06/2011 The data extract includes 658 colorectal patients (26 hospital trusts) 467 gynaecology patients (13 hospital trusts) 1,149 MSK patients (14 hospital trusts) 50 Urology patients (5 hospital trusts) Each sheet shows compliance for a different element of the ER pathway and how this varies between specialities. The definition for each element is shown at the bottom of each page. To access the toolkit: https://www.natcansatmicrosite.net/enhancedrecoveryhttps://www.natcansatmicrosite.net/enhancedrecovery Any comments to Andy.McMeeking@ncat.nhs.ukAndy.McMeeking@ncat.nhs.uk

4. Pre-operative visit?Record “ yes” if the patient visits the preadmission clinic in order to be informed about ER care - providing both verbal and written information - in order to condition expectations at and after surgery. This process can be conducted by telephone but that also should be accompanied by written information'

5. Patient assessed as fit for surgeryRecord “yes” if patient attends a pre-assessment clinic to ensure optimal physical preparation for surgery and is assessed as fit for surgery. This can occur at a preadmission clinic attendance'

6. Patient given written and verbal explanation of ER pathway Record “Yes” if the patient is given written and verbal explanation of ER pathway and related care and their role in their recovery

7. Preoperative therapy education eg physiotherapy /OT Record “Yes” if the patient had preoperative therapy education/preparation (can only be recorded on ER toolkit for MSK patients)

8. Preoperative stoma education until considered competent Record “Yes” if the patient attends a stoma care appointment and within this appointment stoma education is commenced with the expectation that the patient is supported to be competent with this skill prior to surgery.

9. Oral bowel preparation avoidedRecord “Yes” if oral bowel preparation (e.g. picolax) is not taken the day before surgery to evacuate bowel contents. (Note that bowel prep may be used prior to an anterior resection which includes TME (total mesorectal excision) (for colorectal patients only)

10. Patient admitted on day of surgeryMost patients are suitable to be admitted on the day of surgery; Record “Yes” if patient admitted on day of surgery

11. Carbohydrate drinks given preoperatively maltodextran drinks given 12 hours prior to surgery and up to two hours before going to the operating theatre provided gastric emptying is not impaired.

12. Avoidance of long acting sedative pre-medication Record “Yes” if long acting pre- medication drug such as a temezepam / diazepam has not been given within 24 hours of surgery

13. Administration of appropriate antibiotics prior to skin incision Definition within 60 minutes of knife to skin as per the WHO/NPSA safer surgery checklist (for colorectal patients only)

14. Epidural or regional analgesia usedEpidural or regional analgesia used to provide adequate analgesia in the immediate postoperative period and to allow mobilisation (Note there is not a consensus about whether epidurals are necessary in laparoscopic surgery)

15. Epidural or regional analgesia usedEpidural or regional analgesia used to provide adequate analgesia in the immediate postoperative period and to allow mobilisation (Note there is not a consensus about whether epidurals are necessary in laparoscopic surgery) Was the operation commenced laparoscopically? In order to simplify the data collection the toolkit asks whether the operation was started laparoscopically. This includes both total laparoscopic and laparoscopically assisted procedures Select from “Yes”, “No”, “Not Applicable”.

16. Individualised goal directed fluid therapy To prevent overloading with intravenous fluids during surgery; this may be achieved by use of an oesophageal Doppler or other advanced haemodynamic monitor. Must be individualised for each patient and administered to achieve specific haemodynamic targets.

17. Hypothermia prevention (intra- operative warming) Patient temperature 36.0-37.5 Centigrade throughout the operation (will usually involve using active warming measures such as forced air warming and fluid warmers).

18. The avoidance of abdominal drains except following TME Routine use of drains has not been shown to reduce complications and can actually cause problems except following total mesorectal excision. (for colorectal patients only)

19. NG Tube removed before exit from theatre Definition not required (not applicable for MSK patients)

20. Avoidance of post operative crystalloid overload Intravenous crystalloid infusion discontinued on first postoperative day (day 1).

21. Avoidance of systemic opiates used postoperatively Analgesia that ideally does not include opiates is recommended to prevent complications such as constipation. Record “yes” if no oral, intramuscular or intravenous opiates used postoperatively.

22. Early post operative nutrition / solid food intake Patients are encouraged to eat and drink on day 0 (the operating day) after surgery, as tolerated, and this to continue subsequently. To provide further nutrition in the immediate post-operative period, nutritious supplement drinks are encouraged daily.

23. Targeted individualised nausea and vomiting control Managing the patient’s nausea and vomiting to enable them to eat and drink as soon as appropriate post operatively. Record “yes” if prophylaxis for PONV (Postoperative nausea and Vomiting) given during surgery and antiemetics if nauseous postoperatively, as per agreed written protocol.

24. Mobilisation within 24 hoursRecord “Yes” only if the patient is able to mobilise within 24hrs. For orthopaedic patients this must be weight bearing mobilisation.