Breakout 1.1 - Dr Kerri Jones Consultant Anaesthetist & Associate Medical Director Adviser Dept Health Enhanced Recovery Programme Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013, Guoman Tower Hotel, London How to deliver quality and value in chronic care:sharing the learning from the respiratory programme

1. Better value, better outcomes
How to deliver quality and value in chronic care:
sharing the learning from the respiratory programme
London Feb 21st 2013
Dr Kerri Jones
Consultant Anaesthetist & Associate Medical Director
Adviser Dept Health Enhanced Recovery Programme
Content
 what is ‘Enhanced Recovery’
 what is the proposition?
 are the concepts transferable to medical admissions?
 the Torbay pilot (S Devon Healthcare NHS
 future developments
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2. What is ‘enhanced recovery’?
Henrik Kehlet, Professor of Surgery, Copenhagen
1980s showed the use of epidurals for major abdominal surgery
improved recovery by
 managing pain
 reduce stress response
He thought patients still stayed too long in hospital and by 2000
was describing a multimodal approach to care...
Fast-track/Accelerated/Rapid or Enhanced Recovery
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Physiological problem
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3. His proposition
Looked at factors influencing recovery
Designed a pathway to tackle
each element
What did he do?
 created a structured approach
 involved the patient
 set expectations realistically
 held his team to account
 is the patient on track with the pathway?
 ‘why is this patient in hospital today?’
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4. Colorectal Surgery: Length of stay
Large Intestine: Major Procedures
16
14
12
10
days
8
6
4
2
0
UK Kehlet
UK adoption
 sporadic
 clinicians approached the DH for help to spread
 country-wide programme
 evidence-based; Kehlet & others
 pathway defined
 MSK, colorectal, gynae, urology
 other specialties
 proving to be very successful
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5. Enhanced recovery elements identified
• optimise pre operative
Referral from haemoglobin levels • admit on day of surgery
• manage pre existing co • optimised fluid • planned mobilisation
Primary Care hydration • rapid hydration &
morbidities e.g. diabetes
• CHO Loading nourishment
• reduced starvation • appropriate IV therapy
Pre- • no / reduced oral bowel • no wound drains
Operative preparation ( bowel • no NG (bowel surgery)
surgery) • catheters removed early
• regular oral analgesia
• paracetamol and NSAIDS
Admission • avoid systemic opiate-
based analgesia where
• optimise health / medical possible or administered
condition topically
• informed decision making Intra-
• pre-operative health & risk
assessment • minimally invasive surgery Operative
• patient information and • use of transverse incisions
expectation managed (abdominal)
• discharge planning (EDD) • no NG tube (bowel surgery) Post-
• pre-operative therapy • regional / LA with sedation
• epidural management (inc
Operative Follow
instruction as appropriate
thoracic) Up
• optimise fluid management
• individualised goal directed • discharge when criteria met
fluid therapy • therapy support (stoma, physio)
• 24hr telephone follow up
Are the principles transferable to medicine?
 illness is ‘stress’ just like an operation
 simple adherence to fluid, nutrition & mobilisation plus
information are key and could be applied to all inpatients
 no evidence base as yet – but from 2010, Kehlet has run a
research study in 2 patient groups
 acute pneumonia
 ‘off legs’
 he reports impact is ‘incredible’ though has found it difficult
 patient/carer information is relevant to chronic disease
with repeated acute exacerbations
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6. ENHANCED RECOVERY: MEDICINE
Prof Ben Benjamin
Consultant Acute Medicine and Director of R&D
South Devon Healthcare NHS FT
2012 – 2013
Why do it?
To reduce
To gain early Improve length of
independence
patient stay
and carer
experience
To improve To reduce
To reduce
mobilisation readmissions
deterioration
during
admission
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7. What is it?
 a new approach to caring for patients admitted as a
medical emergency to Torbay Hospital
 involves patients and families/carers in decisions
 patients are partners in their own care
 patients, carers, families, nurses, therapists and doctors all
work together to agree a plan for Rx and recovery
 big focus on nutrition & mobility
What has happened so far??
Core project team
 Director of Nursing and Quality – executive sponsor
 Prof Ben Benjamin – clinical lead
 Emergency Admissions Unit (EAU) manager and test lead
 Matron for acute medicine
 ER medicine project manager
 OT
 Carers’ lead
 dietician, radiographer, matrons, consultants, ward managers
Wards/Units
 EAU (medical assessment unit) – test bed
 COTE
 respiratory ward
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8. Which patients? Getting you
home; safely and
at the right time
 patients admitted as an emergency, requiring
medical interventions
 patients requiring an inpatient stay on the EAUs,
respiratory patients), COTE wards
What’s happened so far?
 current state and future state mapping sessions
 baseline measurement – LoS, patient interviews
 testing the concepts on patients with sepsis
 communications – patient and carer information
 pre hospital care – sepsis alert – antibiotic PGD
 daily target setting
 carers’ lead promoting the message in the community
 GP engagement and awareness raising
 focus on nutrition, mobility
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9. Daily target setting
Energy
drink
Plan transport Day clothes,
early no PJs
Mobilisation
Decision-making
between the patient,
medical team and
families/carers Oral fluids
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10. Measures
 length of stay
 will take time as the culture change occurs
 bed days
 patient experience and satisfaction
 oral/iv switch
 pulling notes and drug charts to capture iv/oral switch is time consuming
 time to mobilisation
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11. Project Reflections so far
 executive and clinical leadership – essential for success
 baselining – walking the patient journey to identify waste in the system was
compelling for the whole team – to get out of their silos
 ask the people doing the job how best to change it; improvements have come
from a bottom up rather than top down approach
 time to carry out improvement – regular weekly huddles, an enthusiast
seconded to drive improvements + service improvement project support
 work across primary-secondary-social care boundaries
 measurement for ER medicine has been challenging
Next steps
 testing carried out on other EAU ward
 roll out to other wards
 CQUIN 2013/14 target
 continued involvement of carers and GPs
 learning and sharing best practice with colleagues
across the UK through
 NHS South workshops
 participation in RCP working group
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12. Further information
POSTER
jane.dewar@nhs.net
http://www.youtube.com/watch?v=pKUfCDQlglw
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