Enhanced Recovery Programme Elective Colorectal Surgery Hywel Dda Health Board Glangwili Hospital
Jan 21, 2016
Enhanced Recovery ProgrammeElective Colorectal Surgery
Hywel Dda Health BoardGlangwili Hospital
ERAS at Glangwili:
Implemented 13th September 2010
All elective colorectal surgical procedures
All 4 Consultant surgeons signed up
Full MDT involvement (physio, dietitian, colorectal CNS, anaesthetists, surgeons, pre-assessment, ward staff)
Data from initial 79 patients: Mortality n=3 (<4%) Data of remaining 76 patients Average age 69.1 years Re-admission rate n=3 (<4%) Open procedures n= 74 (97%) Laparoscopic n=2 (3%)
Total length of stay: 3 day reduction in LOS through implementation of
ERAS
10.6
7.6
0
2
4
6
8
10
12
Pre-ERAS
ERAS
Post-op length of stay: 9.6
6.7
0
1
2
3
4
5
6
7
8
9
10
Pre-ERAS
ERAS
Total LOS run chart: Length of stay - In Hospital
Hywel Dda Health Board, Glangwili Hospital Colorectalfrom Sep 2010 to Aug 2011
0
2
4
68
10
12
14
16
2 1 46 25 17 27 21 34 36 32 57 65 60 54 70 73
Patient ID
Day
s
No target
Reduction in LOS not achieved through change to DOSA as only 9% of patients admitted the day of surgery
If DOSA admission was implemented total LOS would be reduced to 6.7 days
Type of surgery:
Sigmoid colectomy
23%
AP-resection5%
Other7%
Ant resection31%
R-hemicolectomy
34%R-hemicolectomy
Ant resection
Sigmoid colectomy
AP-resection
Other
Bundle compliance: Immediate Care B2% pts complying with Immediate Care Bundle B2
Hywel Dda Health Board, Glangwili Hospital Colorectalfrom Sep 2010 to Aug 2011
0
20
40
60
80
100
Sep2010
Oct2010
Nov2010
Dec2010
Jan2011
Feb2011
Mar2011
Apr2011
May2011
Jun2011
Jul2011
Aug2011
Months
% p
atie
nts
Individual elements affecting B2 bundle compliance:
% pts weighed Hywel Dda Health Board, Glangwili Hospital Colorectal
from Sep 2010 to Aug 2011
0
20
40
60
80
100
Sep2010
Oct2010
Nov2010
Dec2010
Jan2011
Feb2011
Mar2011
Apr2011
May2011
Jun2011
Jul2011
Aug2011
Months
% p
atie
nts
Median 100.0
% pts with nutritional tool completed Hywel Dda Health Board, Glangwili Hospital Colorectal
from Sep 2010 to Aug 2011
0
20
40
60
80
100
Sep2010
Oct2010
Nov2010
Dec2010
Jan2011
Feb2011
Mar2011
Apr2011
May2011
Jun2011
Jul2011
Aug2011
Months
% p
atie
nts
Median 100.0
Bundle compliance: Intra-operative care B3
% pts complying with Intra-operative care bundle B3Hywel Dda Health Board, Glangwili Hospital Colorectal
from Sep 2010 to Aug 2011
0
20
40
60
80
100
Sep2010
Oct2010
Nov2010
Dec2010
Jan2011
Feb2011
Mar2011
Apr2011
May2011
Jun2011
Jul2011
Aug2011
Months
% p
atie
nts
Individual elements affecting B3 bundle compliance:
% pts weighed dailyHywel Dda Health Board, Glangwili Hospital Colorectal
from Sep 2010 to Aug 2011
0
20
40
60
80
100
Sep2010
Oct2010
Nov2010
Dec2010
Jan2011
Feb2011
Mar2011
Apr2011
May2011
Jun2011
Jul2011
Aug2011
Months
% p
atie
nts
Median 0.0
% pts where Bowel Preparation avoidedHywel Dda Health Board, Glangwili Hospital Colorectal
from Sep 2010 to Aug 2011
0
20
40
60
80
100
Sep2010
Oct2010
Nov2010
Dec2010
Jan2011
Feb2011
Mar2011
Apr2011
May2011
Jun2011
Jul2011
Aug2011
Months
% p
atie
nts
Median 36.7
DOSA: Identified as area for improvement at LS4
% pts admitted on day of surgeryHywel Dda Health Board, Glangwili Hospital Colorectal
from Sep 2010 to Aug 2011
0
20
40
60
80
100
Sep2010
Oct2010
Nov2010
Dec2010
Jan2011
Feb2011
Mar2011
Apr2011
May2011
Jun2011
Jul2011
Aug2011
Months
% p
atie
nts
Median 0.0
Bundle compliance: Post-operative Care B4
% pts completing Post Operative Care Bundle B4Hywel Dda Health Board, Glangwili Hospital Colorectal
from Sep 2010 to Aug 2011
0
20
40
60
80
100
Sep2010
Oct2010
Nov2010
Dec2010
Jan2011
Feb2011
Mar2011
Apr2011
May2011
Jun2011
Jul2011
Aug2011
Months
% p
atie
nts
Individual elements affecting B4 bundle compliance
% of patients (median):
- Timely IV fluid removal 66.7%
- Timely catheter removal 63.3%
- Sat out in chair 6-8 hours daily 86.1%
- Achieved x4 walks daily 63.3%
- Sat out in chair day of surgery 27.8%
Bundle compliance: Discharge/Follow-up B5
% of pts completing the Discharge/follow up bundle B5Hywel Dda Health Board, Glangwili Hospital Colorectal
from Sep 2010 to Aug 2011
0
20
40
60
80
100
Sep2010
Oct2010
Nov2010
Dec2010
Jan2011
Feb2011
Mar2011
Apr2011
May2011
Jun2011
Jul2011
Aug2011
Months
% p
atie
nts
Areas identified for improvement: Post-operative fluid management
Daily weighing of patients
Staff education due to recent ward changes
Increase bundle compliance
Positives: Improved team work Continued enthusiasm Sustained reduction in LOS Agreement with surgeons re: bowel prep Move towards DOSA Adapted ERAS documentation to include
POMS, daily weight and fluid management plan
Thank you