The enhanced recovery programme
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The Enhanced Recovery Programme. Siobhan Kelly, CNM2. R.G.N.,H.Dip CVNS, Dip. HSM. Enhanced Recovery Programme. Pre-operative Assessment, planning and preparation before admission. Reducing the physical stress of the operation.

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The Enhanced Recovery Programme

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The enhanced recovery programme

The Enhanced Recovery Programme

Siobhan Kelly, CNM2.

R.G.N.,H.Dip CVNS, Dip. HSM

Enhanced Recovery Unit, Letterkenny General Hospital


Enhanced recovery programme

Enhanced Recovery Programme

  • Pre-operative Assessment, planning and preparation before admission.

  • Reducing the physical stress of the operation.

  • A structured approach to immediate peri and post operative management, including pain relief.

  • Early mobilisation

Enhanced Recovery Unit, Letterkenny General Hospital


The enhanced recovery programme

Aims

  • to optimise and improve all aspects of a patient’s journey in peri-operative care (planned surgery).

  • to ensure that the patient and their family/carer are active participants in planning and managing their surgery, recovery and after care

  • in an environment which is conducive to high quality patient centered care.

Enhanced Recovery Unit, Letterkenny General Hospital


The enhanced recovery programme

  • to achieve better outcomes and reduced length of stay

  • to increase the number of patients being treated

  • Reduce levels of resources needed

  • to enhance the clinical environment, to improve job satisfaction, increase morale, improve multidisciplinary communication and team work.

Enhanced Recovery Unit, Letterkenny General Hospital


Driver for role expansion

Driver for Role Expansion

  • Pre planned/organised theatre lists

  • Nurse Led Clinics

  • Morning of surgery admission

  • Early morning discharges

Enhanced Recovery Unit, Letterkenny General Hospital


Nurse role expansion

Nurse Role Expansion

Pre planned/organised theatre lists:

  • Planning theatre list in consultation with the Consultant

  • Triage list –

    Nurse Led clinic

    Anaesthetist Led clinic

Enhanced Recovery Unit, Letterkenny General Hospital


The enhanced recovery programme

Triage Protocol for Pre-Operative Assessment Clinic

Nurse-led

Anaesthetic Clinic

Age

< 75

≥ 75

BMI

< 40

≥ 40

Cardiac Hx

Chronic stable Angina

New or unstable angina

CABG or Stents

Myocardial Infarction

Valvular stenosis

Heart failure

Valve replacement

Creatinine

Normal

Raised (ever)

Diabetes

NIDDM < 5 yrs

NIDDM > 5 yrs

IDDM

Stable

Unstable

TIA / Stroke

1 TIA

2 or more TIA

Stroke

Exercise capacity

> 500m

< 500m

Surgery type

Other

Laparotomy

THR / TKR

Patient request

Patient request

Anaesthetic Hx.

Previous problem

Anticoagulants

Aspirin, Warfarin

Aspirin AND Plavix

Warfarin

ASA class

ASA III or IV

Enhanced Recovery Unit, Letterkenny General Hospital


Nurse led clinics

Nurse Led Clinics

  • Full Nursing Assessment (inc Discharge Planning)

  • Anaesthetic Assessment

  • Venepuncture /Pre-operative tests (for e.g. Group & Hold/ECG)

    using evidence based practice as per NICE Guidelines(2004)

    & LGH Transfusion Guidelines

  • Medication Advice

  • Carbohydrate Loading information

  • Education & information on preparation for surgery

  • Date, time of admission made in consultation with patient

  • Review Blood results prior to expected date of admission

Enhanced Recovery Unit, Letterkenny General Hospital


Morning of surgery

Morning of Surgery

  • Reassessment of patient

  • Completion of documentation

  • Intravenous cannulation

  • Administer medications as per Protocols

  • Consultation & communication with the MDT

Enhanced Recovery Unit, Letterkenny General Hospital


Early morning discharges

Early morning discharges

“Changing practice to support service delivery”

Guideline for Nurse/Midwife Facilitated Discharge Planning

Health Service Executive and

Office of the Nursing Services Director

June 2009

Enhanced Recovery Unit, Letterkenny General Hospital


The enhanced recovery programme

Clinical Discharge Criteria & Minimum Length of Stay following Elective Surgery

Letterkenny General Hospital

Enhanced Recovery Unit

(affix patient label here)

Part I: Pre-Operative Authorisation by the Surgeon:

This patient may be discharged as per Clinical Discharge Criteria outlined below and also subject to a Minimum Post-Operative LOS as indicated.

Clinical Discharge Criteria Instructions for Nursing Staff(Tick boxes as appropriate)

Min Post-Op LOS

□ Haemodynamicallystable

□ 1 night

□ Minimal post-op wound drainage

□ 2 nights

□ Able to tolerate fluids & light diet

□ 3 nights

□ Adequatepain relief with oral analgesia

□ 4 nights

□ No vomiting

□ 5 nights

□ No nausea (or minimal)

□ 6 nights

□ Mobilising well relative to pre-op status

□ 7- nights

□ Adequate urine output relative to pre-op status

□ 8 -nights

□ 9 -nights

Signed: (Cons / Reg.) Date:

Enhanced Recovery Unit, Letterkenny General Hospital


The enhanced recovery programme

Part II: Confirmation of Planned Discharge (post-op ward round):

Please proceed with planned discharge as indicated above.

Additional instructions (if any):

Signed: (Cons / Reg.) Date:

Part III: Confirmation of Planned Discharge (day before discharge)

Please proceed with planned discharge as indicated above.

Signed: (Cons / Reg.) Date:

Take-home analgesia packs are available from the Enhanced Recovery Unit.

They may be prescribed (if appropriate) using the preceding page of this booklet. The patient should collect the pack from the Enhanced Recovery Unit on their way home.

Enhanced Recovery Unit, Letterkenny General Hospital


Development of new skills competencies

Group & Hold – Trained by Haemoviglance Nurse

IV Venepuncture and Cannulation –Education, training & competency development through CNME

Anaesthetic Assessment/assessing Blood Results – training via Anaesthetic Department

Electrocardiograms

Developed Patient information leaflets ratified by LGH Editorial Committee

Developed medication protocols ratified by Drugs & Therapeutic Committee.

Developed Policies, Procedures and Guidelines – ratified through LGH Nursing & Midwifery PPG Committee & Multidisciplinary PPG Committee (Available on QPulse)

Development of New Skills/ Competencies

Enhanced Recovery Unit, Letterkenny General Hospital


Challenges

Changing the Status Quo

Bringing Consultants on board

Expansion of the Role of Nursing

Allocation of Beds for same day admission

Challenges

Enhanced Recovery Unit, Letterkenny General Hospital


Supports

Supports

  • Clinical Director/Consultant Anaesthetist

  • Director of Nursing and Midwifery

  • Assistant Director of Nursing/Service Manager

  • Nursing and Midwifery Practice Development Unit

  • Bed Managers

  • Multidisciplinary Support especially Allied Healthcare Professionals

Enhanced Recovery Unit, Letterkenny General Hospital


Benefits to the patient

Reduced risk of cancellation

Same day admission

Focus on post operative pain relief, nutrition and mobilisation

Familiar surroundings, meeting the same nurses

Decreased length of stay

“Patient Centred Care”

Benefits to the Patient

Enhanced Recovery Unit, Letterkenny General Hospital


Benefits to lgh

Benefits to LGH

  • Increased planned surgical patient admission

  • Standardisation of peri-operative tests

  • More productive Operating Theatre

  • Increase in number of same day admissions

  • Nurse led discharge criteria

  • Reduced length of stay, early morning discharge

Enhanced Recovery Unit, Letterkenny General Hospital


The enhanced recovery programme

Increased Multidisciplinary Teamwork and CommunicationIncreased morale and job satisfactionPatient Centred Care

“Primarily due to the

Role Expansion in Nursing”

Enhanced Recovery Unit, Letterkenny General Hospital


The enhanced recovery programme

Siobhan Kelly, CNM2

Letterkenny General Hospital

Thank You for Listening

Enhanced Recovery Unit, Letterkenny General Hospital


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