CWERP Chichester and Worthing Enhanced Recovery Programme. Cathryn Eitel Consultant Anaesthetist 15 th November 2012

Transcription

1 CWERP Chichester and Worthing Enhanced Recovery Programme Cathryn Eitel Consultant Anaesthetist 15 th November 2012

2 CWERP Business case - how we went about it!

3 KSS numbers Aug 10-July 11 Hip Replacements Knee Replacements WSHT BSUH DVH SASH ASPH MFT EKHT MTW RSCH ESHT

4 WSHT Length of stay 2011 Hips (6.7 Days) v Knees (6.9 Days)

5 St. Richard s Snapshot Audit Jan 2012 Percentage Total knees 46 Total hips 54 Spinal + sedation 62 GA 20 Spinal + GA 18 Spinal opiate 78 Nerve Blocks 30 Morphine PCA 28 Urinary catheter 38 Blood Transf 12 LIA 14 PONV 38

6 CWERP

7 PROMS: VAS Knee Scores!"##$%#&'()#*#"+,$-$./-01$234$,)5%#,!"#$%&"#'&!"#$%&&'"()%%)(& ()"*+,-)$ *)+"*(, /6$$$$$$$7%#-5&$,)5%# /8$$$$$$75,+-5&$,)5%# 9#('+:$;(<"$=/8$ (>#%(;#$-$/6$ (>#%(;#? 0C DC E6 8.)1#*$%&2$1+$,/0*) D0 E0 6F 5$,#&6&."$,#$%&7)1# DE E6 G 9#"+:;"*# 3416 <=*> 3716!*$?"*( 6412 <"=*1'#/&6&@""%) 5015 A8 DH EI 0 9"%0/=%% "=#/&5$,#&5,,)B 5410 A3 DG E6 E

8 PROMS: Oxford Knee Scores!"##$%#&'()#*#"+,$-$JBK5%L$!"##$,)5%#,!"#$%&"#'& ()"*+,-) $!"#$%&'"()%%)(& *)+"*(, /6$$$$$$$7%#-5& /8$$$$$$75,+-5& 9#('+:$;(<"$=/8$ (>#%(;#$-$/6$ (>#%(;#? DG 6CMH6 I0MFD 60M80.)1#*$%&2$1+$,/0*) A CDEFF A3EGG CGE3H 5$,#&6&."$,#$%&7)1# 3512 GC CDEDA AHEAC C3EHG 9#"+:;"*# 3416 <=*> 3716!*$?"*( A8 CIEC8 ACEIG CFED 9"%0/=%% "=#/&5$,#&5,,)B 5410 AG CI AHEFC C3EFC

9 2011 operative technique! NO standardised anaesthetic! NO standardised LA infiltration! All knees drain use! Personal preference for dressings

10 2011 postoperative analgesia! Anything goes!!! Individual anaesthetists "Spinal diamorphine/iv Morphine "Nerve blocks "Morphine PCAs! Individual surgeons! FY1 prescriptions

11 2011 recovery! Patients stay average 75 mins! Commonest drugs given "IV Morphine boluses "Morphine PCA "IV Ondansetron! IV maintenance fluids, IV gelofusin (hypotension)! No mobilisation, patient not sat up

12 2011 physiotherapy! Mond Frid: 12.8 patients per physio per day! Weekend: 4 hrs sat/sun, 30% input to trauma patients! Significant residual spinal blockade up to 12hrs postop! Postop mobilisation Day 1 onwards (none day 0)! Physiotherapy ONLY mobilisation until 4.45pm, training ward nurses currently for twilight! Patients seen twice daily knees (staffing permits), once daily hips

13 Physiotherapy Orthopaedic Mobility Audit March 2011! Failure to mobilise within 24 hrs "Hypotension "Nausea/vomitting "Residual motor block "Pain "Lack of physio time, ~ 30% TKR not mobilsed at weekend

14 Physiotherapy Orthopaedic Mobility Audit March 2011! Length of stay significantly influenced by mobilisation within 24hrs! THR " LOS < 24 hrs 5.8 days " LOS > 24 hrs 7.9 days! TKR " LOS < 24 hrs 5.6 days " LOS > 24 hrs 6.7 days! Failure to mobilise within 24 hrs! LOS by 2 days

15 CWERP Implementation

16 CWERP Working group: November 2011

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18 Golden Jubilee National Hospital: Philosophy! Positive attitude by all staff! Clear description of technique! Emphasis on early mobilization! Empower the patient to lead their own course

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20 GJNH Results " Patients mobilised within 24 hrs 95% " Patients mobilised day of surgery 33% " Average LOS 3.8 days " No nausea or vomiting 79% " Urinary catheterisation rate 6.9% " Rescue analgesia 5% " Blood transfusion 0.6% " No significant change in complication rates

21 GJNH influence over UK and abroad - visitors 2010! UK " Northumbria " Norfolk and Norwich " Taunton " Ascot " South West London Elective Centre " Bournemouth " Carlisle " Manchester " Hull " Gloucester " Oxford " North Lancashire! International " University Hospital Bordeaux, France " CHU Hospital Central, Nancy, France " CHU Strasbourg, France " Hospital Nord Mayenne, France " Belgium " Vienna " Poland " Dublin " Houston, USA " Melbourne, Australia

22 Case studies! Borders General " Within 3 months of ERP Sept 2010: " Reduction HDU bed useage day 0 from 100% to 0% " Postoperative urinary catheterisation decreased from 100% to 10% " Reduction blood transfusion rates from 40% to 5% " Average LOS reduction from 7.2 days to 3.5 days " Hip/knee school introduced March 2011! Norfolk and Norwich University Hospital NHS Trust " NERP introduced September 2010 " 600 primary hip/600 primary knee arthroplasties annually " Reduction LOS from 8 days to average 4 days " Personal view Dr. John Dalgleish

23 13 members of CWERP, GJNH! Anaesthetists x 3! Surgeons x 3! ERP Facilitator! Physiotherapist! Occupational therapist! Preop assessment nurse! Pharmacist! Dietician! Recovery nurse Glasgow Feb 2012

24 CWERP Aims:! Well analgesed patient! Minimal nausea/vomiting! Able to mobilise on DOS! Minimal complications "Blood transfusion "Urinary catheterisation! Earlier discharge! Improved patient experience

25 CWERP: Premedication! Standardised "DOS 2hrs preop! Gabapentin 600mg! Dexamethasone 10mg! Paracetamol 1g! High carbohydrate drink! Omeprazole 20mg

26 CWERP: Anaesthetic Technique! Standardised for all patients "Single shot spinal! NO intrathecal opiates "Propofol TCI sedation "Supplemental ketamine sedation! NO midazolam "Tranexamic acid 1-2.5g IV EVERY joint "Flucloxacillin 1g/Gentamicin 240mg IV "Ondansetron 4mg IV

27 CWERP: LA infiltration! All hips and knees! 200 ml 0.2% Ropivacaine! Accurate placement, requires training and education, particularly knee infiltration

28 CWERP: Intra articular catheters! All knees! Placed under direct vision by surgeon during operation! Infuse 0.2% Ropivacaine " 10ml/hr Elastomeric pump " Discontinued morning after surgery

29 Specific negotiations!.! Oxycodone! Ropivacaine! Pre-filled elastomeric pumps! Tranexamic acid! Dexamethasone! Therapies investment! Data collector

30 Oxycodone! Oxycontin "3 to 5 prescribed doses " 1586! Oxynorm "Variable dose (~ 12 pharmacy calculations) " 2618! 4204 Not on formulary!.

31 CWERP protocol! Average ERP N+V rate: 11%! WSHT N + V rate: 40% " Assumption: N+V = 1 day LOS " 1100 joints annually (Target 1500) " 1 Day LOS = 300 " = on LOS alone " Unaccounted costs! Antiemetics! IV fluids/ giving sets/ venflons! Laundry/sick bowls/bed pans! Nursing/medical time

32 Ropivacaine! Ropivacaine 0.2% " 200ml bag 7.14! 1100 annual joints " 7854! Chirocaine 0.5% " 10ml ampoule 2.15 " 6 ampoules/jt " Saline/jt 4.50 " Total per jt 17.40! 1100 annual joints " Not on formulary!.

33 Why Ropivacaine?! Safer than Bupivacaine in high volumes! Less CNS/Cardiotoxicity! CHEAPER!! Over 30 published RCTs comparing LIA blocks with other analgesic regimes! Findings: "Less morphine consumption "Faster mobilisation "No evidence of local anaesthetic toxicity

34 Pre-filled elastomeric pumps! 1 pump per knee replacement! Options: "Accufuser (84 day shelf life) "Surefusor (30 day shelf life) "Bbraun 100 (Needs refridgeration)! 550 knees/annum! Total (Accufuser) 40975

35 Tranexamic acid! 2.5g patients standard VTE risk (~700) " Cost per patient 7.75 " Cost per annum 5425! 1g patients increased VTE risk (~400) " Cost per patient 3.10 " Cost per annum 1240 Total cost 6665! But 12% transfusion average 2 units " potential savings knees alone

36 Dexamethasone! Oral pre med 10mg! Cost per patient 0.69! Cost per annum 759

37 CWERP Expenditure Cost per item Annual Oxycontin 3 doses Oxynorm 12 doses ml bag Ropivacaine Prefilled elast pump Tranexamic Acid 7.75/ Dexamethasone Pre-op drinks Cryocuff Aquacel dressing Intra articular catheters Total

38 CWERP Savings - measurables Cost per item Annual Zomorph 3 doses Oramorph 12 doses % Chirocaine Morphine PCA Spinal diamorphine 5mg Urinary catheter Bellovac drains units blood Dressing x Recovery time Total

39 CWERP Savings - unmeasurables! DOS Cancellations/theatre efficiencies! Postoperative nausea/vomitting " IV anti-emetics " IV fluids/giving sets/venflons " Commodes/bedpans/sick bowls " Laundry/cleaners! Accurate units blood transfused! Medical/Nursing time! Improved patient experience

40 CWERP bed day savings! Current LOS 6.8 days! CWERP LOS 4 days Bed savings =

41 The Bigger Picture CWERP cost Present cost Trust savings =

42 Therapies investment! Physiotherapy " Weekend physio 8 4pm Sat and Sun " Chichester POOT " Business plan completed for CWERP cover! Occupational therapy " Weekend OT 8 4pm Sat and Sun " Business plan completed Get the therapies to produce own business plan!

43 Data collector! Require full time data collector! Needs to have clinical element "Attend orthopaedic unit am and pm for data "Blood transfusion, urinary catheters etc! Specific to CWERP, not other ERP or Orthopaedic data collection! Incorporated within surgical division budget

44 CWERP patient information booklet

45 CWERP Hip and Knee school

46 CWERP Integrated Care Pathway

47 TEMPLATE BY: om CWERP Anaesthetic technique! Single shot spinal " NO intrathecal opiates " 2-3ml 0.5% Bupivaciane! Propofol TCI " Aim Ce mcg/ml)! Supplemental ketamine sedation " NO midazolam! Tranexamic acid 1-2.5g every joint! Flucloxacillin 1g/Gentamicin 240mg! Ondansetron 4mg IV! Limit fluids 1 litre intraop POSTER CWER CWERP Anaesthetic technique 1. Spinal anaesthetic: 2-3 ml plain/heavy 0.5% Bupivacaine NO intrathecal opiates If spinal contraindicated/unsuccessful: GA using fentanyl NOT morphine for analgesia intraoperatively 2. Sedation: Propofol TCI aim Ce mcg/ml Supplemental ketamine wait until propofol commenced 10mg boluses, usually no more than 20mg required Avoid midazolam 3. Antibiotics: Flucloxacillin 1g / Gentamicin 240mg IV prior to start surgery If penicillin allergic: Teicoplanin 400mg / Gentamicin 240mg IV prior to start of surgery 4. Tranexamic acid (All joints): Timing: Hips: Give just before knife to skin Knees: Give 15 mins before tourniquet down Dose: 5. Fluids: Standard VTE risk: 2.5g slow IV push over 10 mins Increased VTE risk (ie previous DVT/PE) or cardiac stents/valve replacements: 1g slow IV push over 10 mins Limit to 1 Litre crystalloid intraoperatively Use metaraminol/ephedrine to treat hypotension 6. 4mg IV Ondansetron during surgery ml 0.2% Ropivacaine local anaesthetic infiltration by surgeon to all joints (recipe provided) 8. Postoperative analgesia: Please sign all drugs on pre-printed drug chart in integrated care pathway Additionally, prescribe list of PRN drugs in hospital drug chart Knees: Commence 0.2% Ropivacaine infusion 10ml/hr via elastomeric pump in theatre Have cryocuff placed on knee in recovery

48 CWERP Local Infiltration CWERP Local Anaesthetic Infiltration Hip CWERP Local Anaesthetic Infiltration Knee ml 0.2% Ropivacaine* 60ml (30ml x 2) into anterior and inferior capsule ml 0.2% Ropivacaine* 60ml (30ml x 2) into capsule at the back of medial femoral condyle and lateral femoral condyle, avoiding neurovascular bundle 60ml in suprapatellar pouch into quadriceps in fan-shaped manner 60ml into gluteus maximus, medius, fascia lata and surrounding deep tissues 60ml subcutaneously parallel to lines of incision 20ml around origin of vastus lateralis *If patient < 80kg, reduce 60ml doses to 50 ml doses 60 ml subcutaneous infiltration parallel to lines of incision Tunnel intra-articular catheter 5cm proximal and medial to the incision, insert tip of catheter to rest behind medial femoral condyle 20ml via intra-articular catheter at end of operation, prior to wound closure Attach intra-articular catheter to Elastomeric pump *If patient < 80kg, reduce 60ml doses to 50 ml doses

49 WSHT CWERP July 2012 Hips (3.8 Days) v Knees (3.7 Days)

50 CWERP August 2012 Hips (3.8 Days) v Knees (4.0 Days)

51 CWERP September 2012 Hips (4.3 Days) v Knees (4.2 Days)

52 CWERP July 2012 Jan 2012(%) July 2012(%) Total knees Total hips Spinal GA Morphine PCA 28 0 Urinary catheter Blood Transfusion Local anaesthetic Pumps (TKR) 0 84 Nausea/vomiting Tranexamic acid 0 95

53 July 2012(%) August 2012(%) Total knees Total hips Spinal GA Morphine PCA Urinary catheter Blood Transfusion Local anaesthetic Pumps (TKR) Nausea/vomiting Tranexamic acid September 2012(%)

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