Enhanced Recovery Programme.

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List of contents.

1.  abbreviations

2.  introduction

3.  further reading

4.  what are ER and ERP?

5.  what are the key components of ER and ERP?





ERP:   Enhanced Recovery Programme.


ER:     Enhanced Recovery.


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I started this page as a new topic in November 2010 and it is still being added to.


ER and the ERP are recent innovations which are becoming popular in the NHS, so may feature in the MRCOG.


The pioneering work was done in bowel surgery and the evidence base in gynaecology is small.


ER and ERPould form all or part of an OSCE and could feature in a MCQ or an EMQ.


You need to know the basics.


But your probably know enough already to pass.


Imagine your grandmother needs treatment for a prolapse and has asked you for advice.


She does not want pessaries, preferring surgery.




Take 5 minutes to write down all you would do and then read on.



She is in good health now, so you want to minimise the risk that the treatment would adversely affect that.


You want her to get the maximum benefit, both short-term and long-term from the treatment and you donít want her to have any adverse side-effects or complications.


You want her to be in hospital for the shortest possible time, to be well looked after when she comes home and to make the fullest and quickest possible recovery.


That is the basis of ER and you just need to throw in the full involvement of your granny, her family and any carers and top-notch information provision and you have almost the whole package.


You would want to ensure that she was as fit and healthy as she can be in anticipation of the surgery.


You would start by liaising with the GP about any current illnesses and treatments.


Any conditions and drug regimes would be checked to ensure that they are being managed in the best possible way.


Their potential effects on the surgery and vice versa would be taken into consideration.


You would check her history so that anything that needs to be taken into account, e.g. a DVT, is known about and influencing the management plan.


You would choose the best gynaecologist and one you knew would treat her nicely, listen to her and take all her concerns and desires into consideration.


When thinking of ďbestĒ you want the one who is likely to:

    do the operation as well as it can be done,

    in the least invasive way

    and have the lowest possible incidence of adverse consequences and complications.


You would like the WHO surgical safety check-list used.


You would like appropriate anticoagulation and antibiotic prophylaxis.


You would want the least invasive, evidence-based surgery that would deal with the immediate problems and give the best long-term outcomes


You would want her to be fully informed and an active participant in all the decisions.


She should be told about the admission date and likely time in hospital.


She should be able to alter the admission to suit her.


She should be fully informed about:

   the type of anaesthetic, preferably regional or local,

   pain relief after the operation,

   catheters etc.

   and how quickly she will mobilise after the surgery.


Her home circumstances should be taken fully into account when discharge planning is being done and she should be fully involved.


If she has carers / home helps etc., they need to be informed of when she is to be admitted and when she is likely to be home and any extra help she might need when she recovers.


She should be given good advice about what she can do to facilitate her recovery and the signs and symptoms that would indicate that things are going wrong with contact numbers so she can get advice.


You have just sorted out enhanced recovery for her!


To get a perfect answer for the exam you just need to add some new approaches to peri-operative fluid and food intake which are detailed below and a peppering of buzz-words:


    integrated care pathway,

    specialised nurse,

    information leaflets,

    staff training etc.


You would also mention that ER has been demonstrated to be of value in managing patients after bowel surgery.


And that there is a lack of research evidence to allow full evaluation of it usefulness in gynaecology.


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Further reading.


The RCOG's draft SAC advice: http://www.rcog.org.uk/files/rcog-corp/EnhancedRecovery.pdf.


And the final version when it appears.


A reasonable starting point is the NHS's Institute for Innovation and Improvement.


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What are ER and the ERP?

The ERP is an amalgation of:


          long-established best practice such as:


                          early mobilisation


              with new concepts like

                  reduced fluid restriction coupled with

                  early post-operative feeding


                               typically fluids are taken up to 2 hours pre-operatively and started early post-operatively

                                           and solids are allowed up to 6 hours pre-operatively and started early.



               to maximise the patientís chances of a full, un-complicated and speedy recovery.


It has loads of buzz words, which is always good for exams: multidisciplinary, evidence-based, patient and family involvement etc.



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What are the key components?


If I asked you to write out your thoughts about such a programme using only what you already know, you would probably start with the operation.


But sorting the patient out to be in the best condition for the surgery would take you back to involve the GP and as far as the initial referral.


Or even earlier: you might want to train the GPs so they are thinking about ER before they write the referral letter.


Is surgery the best treatment available and does it take all the patientís individual factors into consideration?


If she is 95 and infirm do we really need to operate on her prolapse?


And if she is 95 and as fit as a flea, is it wise to operate on her prolapse and perhaps cause problems that will significantly reduce her fitness, independence etc?


If there is high risk, would no treatment or a lesser treatment be better?


Once we have concluded that the operation is in her best interest, we would want to get her as fit as possible.


We need to optimise her general health, including her weight.


We want her as physically fit as possible so that she can mobilise.


We need to be sure that we identify all major concurrent problems and have them under best control.


Have we excluded the obvious ones like diabetes and hypertension?


Have we done the basics like check her Hb?


We must have protocols to reduce the risks of surgery: antibiotic and anticoagulant prophylaxis.


New ideas, which seem quite radical, are having an impact.


Particularly in relation to:


            fluid restriction pre-operatively


            fluid management during and after surgery,


            pre-operative food restriction


            and post-operative carbohydrate management.


Early mobilisation is essential and entails aggressive management of catheters and i.v. lines.


The pay-off is that patients do better and are discharged faster with fewer complications.


It needs a lot of organisation, but patients benefit greatly.


Trusts also benefit with reduced costs and faster patient turnover being good for the bean counters.


The NHSís Institute for Innovation and Improvement has assorted information but highlights four key aspects:


          pre-operative assessment, planning and preparation before admission.


          reducing the physical stress of the operation.


          a structured approach to intra-operative and immediate post-operative management, including pain relief.


          early mobilisation.


It adds that there are three things that contribute greatly to the smooth implementation and running of ER.


           staff training and learning


          improved processes and room layout


          procedure-specific care plans


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