Implementation of Enhanced Recovery in Orthopaedics across Scotlandthe story so far.

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1 Implementation of Enhanced Recovery in Orthopaedics across Scotlandthe story so far. Mr. David A McDonald CALEDonian Coordinator National ERP Clinical Implementer david.mcdonald@nhs.net

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5 The future of elective care day surgery or enhanced recovery?

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9 The key to success is the understanding of the word multidisciplinary by all the disciplines NB Once a surgeon and an anaesthetist are on your side anything is possible Dr Nick Scott

10 Enhanced Recovery Programme Scotland Aims and Objectives Audit Scotland Report (1) suggested reductions in length of stay, without compromising quality of care, is better for patients and will ensure better use of resources (Par 47). ERP is a multidisciplinary programme that aims to accelerate patient rehabilitation and reduce peri-operative morbidity thereby safely reducing hospital length of stay. Programmes should not be exclusive to the young, fit and healthy and, if conducted properly, every patient should benefit. The project aims to utilise evidenced based good practice and spreading it across Scotland to provide an equitable experience of patient care. The project is engaging with NHS Boards to understand their current pathways and then utilise the current expertise to support spread and adoption and support implementation of local action plans.

11 ERP National Programme engagement What is the current practice in Scotland? Do we know what everyone is doing? National snap shot audit All THR and TKR patients over a six week period n= units in Scotland Audited pre, peri and post operative components

12 Yes No All sites BGH Gartnaval/WIG QMH DGRI/Garrick RIE Raigmore GJNH RAH/VOL Perth GRI/Stobhill Wishaw IRH/Dunoon Hairmyres Monklands Ayr Forth Valley Ninewells/Stra ARI/Woodend Elgin VI SGH Crosshouse Percentage of patients Who is using ERP

13 NR QMH Gartnaval/WIG BGH All sites QMH Gartnaval/WIG BGH All sites RAH/VOL Perth GRI/Stobhill Wishaw IRH/Dunoon Hairmyres Monklands Ayr Forth Valley Ninewells/Stra ARI/Woodend Elgin VI SGH Crosshouse DGRI/Garrick DGRI/Garrick RIE 4 RIE 6 Raigmore 8 Raigmore 1 GJNH 7+ GJNH RAH/VOL Perth GRI/Stobhill 5-59 Wishaw IRH/Dunoon Hairmyres <5 Monklands Ayr Forth Valley Ninewells/Stra ARI/Woodend Elgin VI SGH Crosshouse ASA Grade Percentage of patients Age Percentage of patients Demographics

14 No co-m orbidities One co-m orbidity Tw o co-m orbidities Three co-m orbidities All sites BGH Gartnaval/WIG QMH DGRI/Garrick RIE Raigmore GJNH RAH/VOL Perth GRI/Stobhill Wishaw IRH/Dunoon Hairmyres Monklands Ayr Forth Valley Ninewells/Stra ARI/Woodend Elgin VI SGH Crosshouse Percentage of patients Co-morbidities

15 Ninewells/Stra General Spinal and regional/nerve block Spinal and LIA Other Spinal Spinal and Epidural General and Regional/Nerve block All sites BGH Gartnaval/WIG QMH DGRI/Garrick RIE Raigmore GJNH RAH/VOL Perth GRI/Stobhill Wishaw IRH/Dunoon Hairmyres 6 Monklands 8 Ayr Forth Valley BGH All sites RIE Raigmore GJNH RAH/VOL ARI/Woodend Gartnaval/WIG Elgin 4 QMH 6 VI 8 DGRI/Garrick 1 SGH Crosshouse Knees Percentage of patients Perth GRI/Stobhill Wishaw IRH/Dunoon Hairmyres Monklands Ayr Forth Valley Ninewells/Stra ARI/Woodend Elgin VI SGH Crosshouse Percentage of patients Type of anaesthesia 1 Hips 4

16 LIA + any other IV/IM/SC opioids+oral opioids+non opioids * IV/IM/SC opioids+non opioids* Nerve block w ith any other (not LIA) Oral opioids+non opioids * Other ** All sites BGH Gartnaval/WIG QMH DGRI/Garrick RIE Raigmore GJNH RAH/VOL Perth GRI/Stobhill Wishaw IRH/Dunoon Hairmyres Monklands Ayr Forth Valley Ninewells/Stra ARI/Woodend Elgin VI SGH Crosshouse Percentage of patients All sites BGH Gartnaval/WIG QMH DGRI/Garrick RIE Raigmore GJNH RAH/VOL Perth GRI/Stobhill Wishaw IRH/Dunoon Hairmyres Monklands Ayr Forth Valley Ninewells/Stra ARI/Woodend Elgin VI SGH Crosshouse Percentage of patients Post-op Analgesia

17 Sam e day or <12hrs post-op Second day post-op NR First day post op but >12hrs post-op Other All sites BGH Gartnaval/WIG QMH DGRI/Garrick RIE Raigmore GJNH RAH/VOL Perth GRI/Stobhill Wishaw IRH/Dunoon Hairmyres Monklands Ayr Forth Valley Ninewells/Stra ARI/Woodend Elgin VI SGH Crosshouse Percentage of patients IV Fluids Stopped

18 Pre-op Intra-op Post-op catheterised, but tim ing unknow n None All sites BGH Gartnaval/WIG QMH DGRI/Garrick RIE Raigmore GJNH RAH/VOL Perth GRI/Stobhill Wishaw IRH/Dunoon Hairmyres Monklands Ayr Forth Valley Ninewells/Stra ARI/Woodend Elgin VI SGH Crosshouse Percentage of patients Urinary Catheterisation

19 KNEES Percentage of patients HIPS 1 Percentage of patients 1 Pre-op Post-op Both pre and post-op RIE DGRI/Garrick QMH Gartnaval/WIG BGH All sites RIE DGRI/Garrick QMH Gartnaval/WIG BGH All sites GRI/Stobhill GRI/Stobhill Raigmore Wishaw Wishaw Raigmore IRH/Dunoon IRH/Dunoon GJNH Hairmyres Hairmyres GJNH Monklands Monklands RAH/VOL Ayr Ayr RAH/VOL Forth Valley Forth Valley Perth Ninewells/Stra Ninewells/Stra Perth ARI/Woodend Elgin Elgin ARI/Woodend VI VI SGH 4 SGH 6 Crosshouse 8 Crosshouse Blood Transfusion Intra-op Both intra and post-op None

20 Knees Elgin ARI/Woodend Ninewells/Stra Forth Valley Ayr Monklands Hairmyres IRH/Dunoon Wishaw GRI/Stobhill Perth RAH/VOL GJNH Raigmore RIE DGRI/Garrick QMH Gartnaval/WIG BGH All sites Elgin ARI/Woodend Ninewells/Stra Forth Valley Ayr Monklands Hairmyres IRH/Dunoon Wishaw GRI/Stobhill Perth RAH/VOL GJNH Raigmore RIE DGRI/Garrick QMH Gartnaval/WIG BGH All sites VI VI 4 SGH 6 SGH 8 Crosshouse 1 Crosshouse Percentage of patients Hips Percentage of patients Post op Mobilisation On day of op Second day post-op NR First day post-op Other

21 <=3 days 4-5 days 6-7 days >1 w eek All sites BGH Gartnaval/WIG QMH DGRI/Garrick RIE Raigmore GJNH RAH/VOL Perth GRI/Stobhill Wishaw IRH/Dunoon Hairmyres Monklands Ayr Forth Valley Ninewells/Stra ARI/Woodend Elgin VI SGH Crosshouse Percentage of patients Post-operative length of stay

22 Key Opportunities 8 units have developed an ERAS programme and only one has developed this for every patient. Blood transfusion rates are high Fasting and Fluids Most patients are now receiving regional (mainly spinal) anaesthesia Only 18% of patients had fluids discontinued within 12 hours of surgery High urinary catheterisation rate Only 29% of patients were admitted to hospital on the day of surgery. Hospitals that had higher transfusion rates, longer use of IV fluids and patient-controlled analgesia had lower early mobilisation rates and longer lengths of post-operative length of stay

23 Spread and adoption Utilised audit data to discuss local variation Supported boards develop local programme Site visits Team visits to leading centres Buddy list Sharing of practice Developed webpage

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25 ERP NHS Borders Improvement Programme Previous joint pathway ERP pathway (in first month) Length of Stay 8.5 days 4.2 days Same day admit % 75% Use of High Dependency Unit 1% % Blood Transfusion 3-4% < 5% Urinary Catheterisation 1% < 1% Mobilisation of patients on theatre day % 98%

26 Second Audit Summer 11 Repeat audit across Scotland n = 1245 All 22 sites Added post-op Hb Anaesthetist

27 One year comparison Summer 1 Summer 11 Number of sites 8/22 15/22 Same day admit 29% 41% Median post op LoS 5 days 4 days Urinary Catheterisation 35% 26% Blood Transfusion 14% 11% IV Fluids stopped in <12hours 22% 29% Mobilisation of patients within 81% 24 hours 92%

28 Findings Summer 11 Blood Transfusion Although seldom necessary to transfuse patients with a post-op Hb >9, this group accounts for almost 5% of the total number of patients transfused. Hospitals that had lower transfusion rates had higher early mobilisation rates (p=.1) and shorter lengths of postoperative length of stay (p=.3).

29 Other findings Patients who had pre-op education from physiotherapy had statistically significant reduction in length of stay Hospitals that had lower use of PCA had higher early mobilisation rates (p=.1) and shorter lengths of post-operative length of stay (p=.3). Hospitals that had shorter use of IV fluids had higher early mobilisation rates (p<.1) and shorter lengths of postoperative length of stay (p=.15).

30 Blood transfusion 25 % of 15 patients transfused 1 5 ERP patient Not an ERP patient

31 IV fluids discontinued 1 Not Recorded 8 Other Second day post-op IV fluids 6 discontinued (% of patients) 4 First day post op but >12hrs post-op Same day or <12hrs post-op ERP patient Not an ERP patient

32 Urinary catheterisation 1 None 8 Timing unknown Post-op Urinary 6 catheterisation (% of patients) 4 Intra-op Pre-op ERP patient Not an ERP patient

33 Post op mobilisation 1 Not known 8 Other Second day post-op Post-op 6 Mobilisation (% of patients) 4 First day post-op On day of op ERP patient Not an ERP patient

34 Post-operative length of stay 1 >1 week days Post-op 6 length of stay (% of patients) days <=3 days ERP patient Not an ERP patient

35 Change is possible and we are getting there Summer 1 Full ERP End of 11 One surgeon performing ERP No ERP

36 transformation doesn't have a finish line and success is not an entitlement, it has to be earned. We are not celebrating, we still have a lot to do Howard Schultz Chairman & CEO Starbucks

37 ..Yesterday is history, Tomorrow a mystery, But today is a gift That is why they call it the present! Master Oogway Kung Fu Panda

38 When things go wrong, as they sometimes will, When the road you're trudging seems all uphill, When the funds are low and the debts are high, And you want to smile, but you have to sigh, When care is pressing you down a bit- Rest if you must, but don't you quit. Life is queer with its twists and turns, As every one of us sometimes learns, And many a fellow turns about When he might have won had he stuck it out. Don't give up though the pace seems slow You may succeed with another blow. Often the goal is nearer than It seems to a faint and faltering man; Often the struggler has given up When he might have captured the victor's cup; And he learned too late when the night came down, How close he was to the golden crown. Success is failure turned inside out The silver tint in the clouds of doubt, And you never can tell how close you are, It might be near when it seems afar; So stick to the fight when you're hardest hit It's when things seem worst that you must not quit. Unknown