Enhanced Recovery Programme.
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2. introduction
5. what are the key components of ER and ERP?
ERP: Enhanced Recovery
Programme.
ER: Enhanced
Recovery.
Introduction.
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.
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 don’t 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 “best” 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:
multi-disciplinary,
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.
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.
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 patient’s 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.
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 patient’s 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 NHS’s
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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