CLINICAL PATHWAY PLAN CLINIQUE GENERAL SURGERY CHIRURGIE GÉNÉRAL Enhanced Recovery After Surgery (ERAS) Bowel Surgery / Proof 2 Addressograph/Plaque Cancer Assessment Clinic (CAC) Date: yyaa mm dj Day of Surgery Pre-op SDA Jour de la chirurgie pre-opératoire Initiate Pre-operative education Initiate Pre-operative testing as per pathway PAU Unité pré-admission Seen by ERAS Study Coordinator Date: yyaa mm dj Date: yyaa mm dj Assessment and teaching per Same Day Admission standards of care and procedure specifi c education material. Pre-operative diagnostic testing as per Medical Directive for Pre-Admission Diagnostic Testing for Elective surgery. If patient seen in CAC, reinforce pre-operative education and verify and complete all pre-op testing. Assessment and teaching as per PAU standards of care and procedure specifi c education material. Pre-operative diagnostic testing as per Medical Directive for Pre-Admission Diagnostic Testing for Elective surgery. Tests Liver function tests: ALP, AST, ALT, GGT, Total bilirubin Electrolytes, Urea, Creatinine CBC Type and screen ECG if over 65 or has cardiac condition PT/PTT/INR for patient on warfarin (Coumadin) Chest x-ray if signs of lower respiratory infection Urinalysis if signs of urinary tract infection Pregnancy test if pregnancy possible Additional Testing if required For diabetic patients: Blood glucose by Point of Care Testing (POCT) PTT/INR: for patient normally taking warfarin (Coumadin) Unless normal result obtained after warfarin discontinued per pre-op instructions Electrolytes: for dialysis dependant patient unless acceptable post-dialysis results obtained within 24 h of surgery CBC if autologous blood donor Additional Orders As per physician orders ERAS Study Coordinator Provide patient education booklet A Guide to Enhancing Your Recovery After Bowel Surgery Review and explain patient Log Additional Orders For ostomy patients: Verify if Enterostomal Therapy (ET) nurse has been arranged and ostomy site marked on abdomen. If not call Stoma Clinic to make an appointment. Make sure patient has a copy of Ileostomy (CP 54 D) or Colostomy (CP 55 D) booklet given by ET nurse Discuss expected length of stay of 3 days for colon resection and 4 days for rectal operation As per patient history, identify issues that could cause delay of discharge and discuss discharge preparation. Ensure patient has A Guide To Enhancing Your Recovery After Surgery patient education booklet. Patient Teaching Understands pre-op instructions and events Understands usual post-op course, plan for pain management, and usual self care measures to prevent post-op complications per patient education booklet. Inform patient to bring two packages of gum to the hospital on the day of admission Understands the importance of keeping track of daily activities before and after surgery in patient Log Study Coordinator Signature: Date: Patient Teaching Adherence with pre-op instructions Understands usual events/expectations of operative day Understands usual post-op course, plan for pain management, and usual self care measures to prevent post-op complications per patient education booklet Understands usual lenth of stay and expected discharge time of 10 a.m. Appropriate discharge plan in place or if no suitable discharge plan in place, consult required health care provider as appropriate Patient progress corresponds with clinical pathway: Yes No Signature: Initial: Time: NTV circle above, VC Patient progress corresponds with clinical pathway: Yes No Signature: Initial: Time: NTV circle above, VC CP 97 A (REV 05/2013)
Day of Surgery Post-op PACU Jour de la chirurgie post-opératoire Oxygen saturation monitoring (SpO 2 ) and oxygen administration per PACU protocol Vital signs, assessment, treatment, and teaching per PACU standards of care Additional Orders Urinary catheter Offer sips of clear fl uids 2 hours post-op if awake, alert, and capable of swallowing Indicates adequate pain control achieved per APS guideline. Pain equal or less than 3 at rest, equal or less than 5 with activity; pain is not preventing movement; patient satisfi ed with pain control. Achieves PACU criteria for transfer to ward May transfer to ward when PACU discharge criteria is achieved CP 97 A (2 8)
Day of Surgery Post-op Ward Jour de la chirurgie post-opératoire Assessment/ Treatments Vital signs and SpO 2 q4h and prn Epidural/IV PCA Pain management Systems assessment q12h and prn Monitor q4h and prn Urine output Dressing Stoma (if applicable) Pain assessment Monitor q12h (if applicable) Ostomy output Closed drainage system (e.g. Jackson Pratt) Dangle legs within 4 hours after arrival to ward 10 to 15 min.: At h, for min, Initials Deep breathing exercises Foot and ankle exercises Sips of clear fl uids Urinary catheter Deep breathing and coughing 10 times per hour Foot and ankle exercises 4 to 5 times per hour Pain management Ensure patient has A Guide to Enhancing Your Recovery After Bowel Surgery booklet Ensure patient has the ileostomy or colostomy booklet as appropriate Log in the booklet A Guide to Enhancing Your Recovery After Bowel Surgery to be completed by patient Indicates adequate pain control achieved per APS guideline. Pain equal or less than 3 at rest, equal or less than 5 with activity; pain is not preventing movement; patient satisfi ed with pain control. Physiological SpO 2 within limits of titration protocol Effective deep breathing and coughing If stoma: pink-red and moist Temperature within normal limits Wound Drainage from closed drainage system: serosanguinous No evidence of wound redness, swelling or drainage Dresssing dry and intact Tolerating clear fl uids Urine output: Minimum 0.5 ml/kg/h when trended over 4h Drainage from closed drainage system: serosanguinous Stoma output (if applicable): serosanguinous and minimal volume Patient teaching Understands importance of ambulation, deep breathing and coughing and foot and ankle exercises Log completed by patient Identify issues that could cause delay of discharge and discuss discharge plans CP 97 A (3 8)
Post-op Day 1 Jour 1 post-opératoire Assessment / Treatment Vital signs and SpO 2 q4h until 24h post-op, then q12h and prn Epidural/IV PCA Pain management Systems assessment q12h and prn Monitor q4h and prn Urine output Stoma (if applicable) Dressing Pain assessment Monitor q12h and prn (if applicable) Ostomy output Closed drainage system (e.g. Jackson Pratt) Ambulate frequently q4-6 hours with assistance: At initials At initials At initials At initials At initials Up for meals in chair: Breakfast at initials Lunch at initials Dinner at initials Walk in hall at initials Begin to eat solid food as per Surgery diet, continue fl uids Dry food prn Chew gum 5 minutes TID Monitor for abdominal distention, fl atus, bowel sounds Discontinue urinary catheter if colon surgery If unable to void post-catheter removal, assess residual volume with bladder scanner; perform in and out catheterization if volume greater than 300 ml urine Up to bathroom to urinate Deep breathing and coughing 10 times per hour Foot and ankle exercises 4 to 5 times per hour Pain management Ensure patient has A Guide to Enhancing Your Recovery After Bowel Surgery booklet Ensure patient has the ileostomy or colostomy booklet as appropriate Log in the booklet A Guide to Enhancing Your Recovery After Bowel Surgery to be completed by patient Indicates adequate pain control achieved per APS guideline. Pain equal or less than 3 at rest, equal or less than 5 with activity; pain is not preventing movement; patient satisfi ed with pain control. Physiological SpO 2 within limits of titration protocol Effective deep breathing and coughing If stoma: pink-red and moist Temperature within normal limits Wound Drainage from closed drainage system: serosanguinous No evidence of wound redness, swelling or drainage Dresssing dry and intact Tolerating dry food and progressing to Surgery diet Urine output: Minimum 0.5 ml/kg/h when trended over 4h Drainage from closed drainage system: serosanguinous Stoma output (if applicable): serosanguinous and minimal volume May be bowel sounds and/or passing fl atus per rectum or ostomy Tolerating activity level Patient Teaching Understands importance of ambulation, deep breathing and coughing and foot and ankle exercises Log completed by patient Identify issues that could cause delay of discharge and discuss discharge preparation CP 97 A (4 8)
Post-op Day 2 Jour 2 post-opératoire Assessment/ Treatment Vital signs and SpO 2 q12h and prn Wean IV PCA infusion as per APS guideline if patient meets weaning criteria Consider weaning Epidural as per APS guideline if patient meets criteria Systems assessment q12h and prn Discontinue IV or convert to saline lock if drinking well; exception if epidural catheter in situ Monitor q4h and prn: Urine output Pain assessment Monitor q12h and prn (if applicable): Incision: Remove dressing, cleanse incision with N/S and leave open to air. Apply dressing if drainage present. Ostomy output Stoma Closed drainage system (e.g. Jackson Pratt): remove if output less than 30 ml in past 12 hours ET nurse performs stoma assessment including pouch fi tting, changes appliance and provides supplies for discharge Ambulate frequently q4-6 hours with assistance: At initials At initials At initials At initials At initials Up for meals in chair: Breakfast at initials Lunch at initials Dinner at initials Walk in hall at least 2 times: At initials At initials Eat solid food as per Surgery diet, continue fl uids Dry food prn Chew gum 5 minutes TID Monitor for abdominal distention, fl atus, bowel sounds Urinary catheter in situ if ordered Voiding if catheter discontinued POD 1 Deep breathing and coughing and foot and ankle exercises Pain management Teaching as per A Guide to Enhancing Your Recovery After Bowel Surgery booklet Initiate teaching re basic care of pouch as per Ostomy booklet if applicable Log in the booklet A Guide to Enhancing Your Recovery After Bowel Surgery to be completed by patient Indicates adequate pain control achieved per APS guideline. Pain equal or less than 3 at rest, equal or less than 5 with activity; pain is not preventing movement; patient satisfi ed with pain control. Physiological SpO 2 within limits of titration protocol Effective deep breathing and coughing If stoma: pink-red and moist Temperature within normal limits Incision No evidence of wound redness, swelling, excessive drainage or dehiscence Tolerating diet Urine output: Minimum 0.5 ml/kg/h when trended over 4h May be bowel sounds present and/or passing fl atus per rectum or ostomy May be minimal drainage volume per ostomy Tolerating activity level Patient/Family teaching Able to open and close ostomy clamp Log completed by patient If colon resection without complications: Discharge tomorrow at 10 a.m. Identify issues that could cause delay of discharge and discuss discharge preparation CP 97 A (5 8)
Post-op Day 3 / Expected discharge day for patient with colon resection/no complications Jour 3 post-opératoire Assessment/ Treatment Vital signs and SpO 2 q12h and prn Wean Epidural as per APS guideline if patient meets criteria Discontinue IV or convert to saline lock when drinking well Remove saline lock if discharged today Systems assessment q12h and prn Pain assessment q4h Monitor q12h and prn (if applicable): Incision/dressing q12h Assess stoma q12h Ostomy output Ambulate frequently q4-6 hours independently Up for meals in chair: Breakfast at initials Lunch at initials Dinner at initials Walk in hall at least 3 times: At initials At initials At initials Surgery diet Dry food prn Chew gum 5 min. TID Monitor for abdominal distention, fl atus, bowel sounds Discontinue urinary catheter if rectal surgery If unable to void post-catheter removal, assess residual volume with bladder scanner; perform in and out catheterization if volume greater than 300 ml urine Ensure patient can void adequately prior to discharge Pain management Teaching as per A Guide to Enhancing Your Recovery After Bowel Surgery booklet Reinforce teaching care of pouch as per Ostomy booklet if applicable Log in the booklet A Guide to Enhancing Your Recovery After Bowel Surgery to be completed by patient. Review discharge instructions if going home today For patient going home today: Inform patient of 10 a.m. discharge time Confi rm CCAC referral completed for all Ostomy patients including date for rod removal (if applicable), date for suture or staple removal, ET referral Complete Surgery Discharge Instructions and provide copy to patient Review discharge instructions as per education booklet If patient in ERAS study: Remove the patient Log from the booklet A Guide to Enhancing Your Recovery After Bowel Surgery and retain it for the ERAS study coordinator Indicates adequate pain control achieved per APS guideline. Pain equal or less than 3 at rest, equal or less than 5 with activity; pain is not preventing movement; patient satisfi ed with pain control. Physiological SpO 2 within limits of titration protocol Effective deep breathing and coughing Temperature within normal limits Incision No evidence of wound redness, swelling, excessive drainage or dehiscence Tolerating diet Urine output adequate Bowel sounds present and/or passing fl atus per rectum or ostomy. If stoma: pink-red and moist May be minimal volume per ostomy Tolerating activity level For ostomy patients empty and rinse pouch in bathroom with supervision May be discharged Post-op Day 3 (Colon Resection) if patient meets following Discharge Criteria: Adequate pain control allowing progression of activity Passing fl atus per rectum or ostomy Tolerating Surgery diet (at minimum adequate fl uid intake but progressing with diet) No evidence of wound redness, swelling or drainage Understands: Signs and symptoms requiring immediate medical attention, i.e. Signs and symptoms of sepsis Signs and symptoms of wound infection Discharge instructions per patient education booklet If applicable: Has ostomy supplies Able to empty, rinse and close ostomy pouch Patient gives Log to nurse before leaving the unit if participating in the ERAS study For patients not going home today: Inform patient of 10 a.m. discharge time tomorrow Identify issues that could cause delay of discharge and discuss discharge preparation CP 97 A (6 8)
Post-op Day 4 / Discharge Day for patient with rectal operation/no complications Jour 4 post-opératoire / Jour de congé Assessment/ Treatment Vital signs daily Pain assessment q4h Remove saline lock Ambulates q4-6 hours independently All meals in chair Surgery diet Dry food prn Chewing gum 5 min. TID Ensure patient can void adequately prior to discharge Discharge Criteria Adequate pain control allowing progression of activity Passing fl atus per rectum or ostomy Tolerating Surgery diet (at minimum adequate fl uid intake but progressing with diet) No evidence of wound redness, swelling, or drainage Understands: Signs and symptoms requiring immediate medical attention, i.e. Signs and symptoms of sepsis Signs and symptoms of wound infection Discharge instructions per patient education booklet If applicable Has Ostomy supplies Able to empty, rinse and close ostomy pouch Patient gives Log to nurse before leaving the unit if participating in the ERAS study Teaching as per A Guide to Enhancing Your Recovery After Bowel Surgery booklet Reinforce teaching care of pouch as per Ostomy booklet if applicable Log in the booklet A Guide to Enhancing Your Recovery After Bowel Surgery to be completed by patient Review discharge instructions Inform patient of 10 a.m. discharge time Confi rm CCAC referral completed for all Ostomy patients including date for rod removal (if applicable), date for suture or staple removal, ET referral Complete Surgery Discharge Instructions and provide copy to patient If patient in ERAS study: Remove the patient Log from the booklet A Guide to Enhancing Your Recovery After Bowel Surgery and retain it for the ERAS study coordinator If not discharged by end of pathway enter appropriate variance code CP 97 A (7 8)
Urine Output Chart kg Patient Weight Lbs Amount of Urine at 0.5 ml/kg/hr 40 kg 88 lbs 20 ml/hr 45 kg 99 lbs 23 ml/hr 50 kg 110 lbs 25 ml/hr 55 kg 121 lbs 28 ml/hr 60 kg 132 lbs 30 ml/hr 65 kg 143 lbs 33 ml/hr 70 kg 154 lbs 35 ml/hr 75 kg 165 lbs 38 ml/hr 80 kg 176 lbs 40 ml/hr 85 kg 187 lbs 43 ml/hr 90 kg 198 lbs 45 ml/hr 95 kg 209 lbs 48 ml/hr 100 kg 220 lbs 50 ml/hr 105 kg 231 lbs 53 ml/hr 110 kg 242 lbs 55 ml/hr 115 kg 254 lbs 58 ml/hr 120 kg 265 lbs 60 ml/hr 125 kg 276 lbs 63 ml/hr CP 97 A (8 8)