20,000 Days CampaignStoryboardLearning Session 3 11-12 March 2013

Collaborative Name: ERAS in Orthopaedics

Aim & Charter

Aim: To increase the number of surgical patients going through the ERAS pathway to reduce length of stay, without increasing re-admissions, and improving patient satisfaction.

Description:We expect to achieve the implementation of an ERAS program throughout

Orthopaedics. By improving protocol adherence and compliance to the ERAS pathway, the aim is to reduce the surgical stress response and promote faster recovery after surgery with fewer complications.

Increase number of surgical

patients going through the ERAS pathway (leading to reduced LOS,

without increase in readmissions and increased patient

satisfaction)

Pre-operative

Patient expectations

Preparation > 24 hrs prior to surgery

Optimised Nutrition/hydration

primary Secondary Concept intervention

Post operative

Intra-operative

Anaesthetic

surgical procedure

Follow-up post discharge

(Post discharge) care in the community

Post-discharge clinic

Ongoing support

Standardise

Use of local anaesthetic with sedation

Minimal invasive

Patient Education

ERAS Clinic

ERAS Leaflets

Pre-habilitation

Patient ready (to go home)

Standardise

Early mobilisation

Allied Health follow-up

Rapid hydration and nourishment

pain control

Patient physically prepared Preparation <24hrs

prior to surgery

Avoid use of opiates

Removal of IDC/Drains ASAP

Planned EDD

Swap to Oral analgesia ASAP

Choice of incisionStaff education

Provide local evidence of why choices made

Home support in place

Post discharge home support in place

Patient experience

Discharge criteria

Carbohydrate Loading

Change Packages

Secondary Drivers

(Theory of change)

Change Ideas Tested

(describe process)

Evidence of Improvement

(Run Charts)

Patient expectations and experience

ERAS Pre-hab clinic use of standardized questionnaires to assess mobility, life style factors

Own clothes to be used from day 2 to encourage patient to become independent

Patient Physically prepared

Prehab preparation – OT assessment, equipment

Discharge Criteria Mobilisation on day two – assessed by physiotherapist

Home support in place prior to discharge

Measures SummaryERAS in Orthopaedics Dashboard

Project Lead – Michelle McCallum Jones Project Manager – Penny ImpeyImprovement Adviser – Ian Hutchby Decision Support Analyst – Daniel WongVersion 1 – 11th February 2013

Average Length Of Stay for Primary Hips and Knees

UCL

CL

LCL4

5

6

7

8

9

10

11Ju

n 20

11

Jul 2

011

Aug

201

1

Sep

201

1

Oct

201

1

Nov

201

1

Dec

201

1

Jan

2012

Feb

201

2

Mar

201

2

Apr

201

2

May

201

2

Jun

2012

Jul 2

012

Aug

201

2

Sep

201

2

Oct

201

2

Day

s

% Patients mobilised day 1 post op.

0%

20%

40%

60%

80%

100%

06 A

ug 2

012

20 A

ug 2

012

03 S

ep 2

012

17 S

ep 2

012

01 O

ct 2

012

15 O

ct 2

012

29 O

ct 2

012

12 N

ov 2

012

26 N

ov 2

012

10 D

ec 2

012

24 D

ec 2

012

07 J

an 2

013

21 J

an 2

013

04 F

eb 2

013

Week Commencing

Key reasons for being unable to mobilise patient day 1 post op

0

5

10

15

20

25

30

Motor block Pain Hypotension Dizziness transfusion N+/-V

Cummulcative bed days saved since June 2011

-200

0

200

400

600

800

Jun-

11

Jul-1

1

Aug

-11

Sep

-11

Oct

-11

Nov

-11

Dec

-11

Jan-

12

Feb

-12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb

-13

Mar

-13

Apr

-13

May

-13

Jun-

13

Bed

day

s

Implementation

Implementation Areas Changes to Support Implementation

Standardisation Introduction of a protocol and pathway

Documentation Introduction of the protocol as part of the patient record

Patient resources: Patient Journey book

Training Staff education in the principles of ERAS, use of documentation and managing variation to the protocol

Measurement Length of stay

Readmission rates

Patient satisfaction

Resourcing ERAS Clinical Specialty Nurse for Orthopaedics

New documentation costs

Adapted from “The Improvement Guide. A Practical Approach to Enhancing Organizational Performance” Gerald Langley et al., 2009, p180.

Highlights and Lowlights

- The ERAS collaborative can now demonstrate a saving in bed days and improved satisfaction. The aims of the project have been achieved in Orthopaedics.

- The collaborative team have found this to be a robust process. The analysis of base line data showed some interesting things including where to focus and where not to as not gains would be made. PDSA cycles to test change, have been very useful.

- Surgical services noe intend to spread ERAS as part of their management against MOH targets for elective surgery. The orthopaedics ERAS collaborative will inform this spread on what works well and how to get results.

Achievements to date

- We now have a change package that we believe is ready for introduction to the wider multidisciplinary team across surgical services and this will be done through an intensive workshop to standardize and agree on the protocol

- All the multidisciplinary groups have been working well and independently within their work streams and reporting back regularly on their achievements and learnings

- We have learned from a patient satisfaction audit that we could be more consistent, that the information we provide could be more comprehensive, but that overall patients were well supported, and had a positive experience with their joint replacement surgery. The ERAS protocol is well placed to enhance the areas for improvement and consolidate the areas we are doing well in.