- The enhanced recovery programme is about improving patient outcomes
and speeding up a patient's recovery after surgery.
- It results in benefits to both patients and staff.
- The programme focuses on making sure that patients are active
participants in their own recovery process.
- It also aims to ensure that patients always receive evidence based
care at the right time.
Outcomes of the enhanced recovery programme are
- Better outcomes and reduced length of stay
- Increased numbers of
patients being treated (if there is demand) or reduced level of resources
- Better staffing environment.
There are four elements to the enhanced recovery programme:
- Pre-operative assessment, planning and preparation before admission
- Reducing the physical stress of the operation
- A structured approach
to immediate post-operative and during (peri-operative) management,
including pain relief
- Early mobilisation.
There are also three areas that help the practical management of the
enhanced recovery programme:
- Staff training and learning
- Improved processes and room layout
- Procedure specific care plans
Some elements of the enhanced recovery programme are similar to
integrated care pathways.
- It brings together two best practices in organisation of care and
clinical management, whilst making sure that patients receive evidence
- It uses patients and their families as an appropriate resource in
planning and managing their own recovery and care
- It focuses on less invasive surgical techniques, pain relief and the
management of fluids and diet, which help patients to get on their feet
- It aims to make events in a hospital as normal as possible.
Elements of enhanced recovery programme
Improve pre-operative care
- For complex surgery in particular, it is important to involve family
and carers in all pre-operative education and planning processes, as
well as the patient's GP.
- This maximises the chances of the patient understanding and acting
on the advice given.
The aim of pre-operative assessment is to ensure that:
- Full assessment, including consultation with an anaesthetist, takes
place as soon as the decision to operate has been made
- The patient has the maximum opportunity to get their bodies as fit
as possible for surgery and anaesthetic
- The patient fully understands the proposed operation and is ready to
- Staff identify and co-ordinate all essential resources and discharge
- Dates for the operation and discharge are in everyone's diary.
Reduce the physical stress of the operation
Apply best practice to reduce the physical stress of the operation as
much as possible
- Minimally invasive operation techniques: either smaller incisions or
a laparoscopic approach
- Epidural local anaesthesia
- Keeping patients warm during the operation
Increase comfort post-operatively
The focus is to get patients moving and eating normally as soon as
possible after their operation.
- 'Vigorously treat' post-operative pain to reduce surgical stress
- Try to get patients moving with a suitable low dose epidural
- Do not use naso-gastric tubes routinely in patients undergoing
elective gastrointestinal surgery
- Help patients to resume a normal diet as soon as possible
Improve post-operative care
The focus is to continue enabling patients to move with a focus on
- Continue to mange post-operative pain
- Strong focus on nutrition and mobilisation
- Clear discharge and post discharge arrangements
Factors that help the enhanced recovery programme
There are five areas of focus:
- Learning about the evidence around speeding up recovery post-surgery
- Developing a mindset where patients are active in their recovery
whilst aiming to make life in the ward as normal as possible
- Surgical techniques
- Adoption of a consistent protocol by anaesthetists
- Consistent implementation of the programme
Improved processes and room layout
- Plan or schedule work around what needs to happen to patients and
when in order to smooth workflow
- Use this to plan ahead and know when the next step is ready
- Focus on the physical environment of the ward and workspace
- Use a spaghetti diagram as a method to identify unnecessary movement
of staff, patients and paperwork and see potential areas for improvement
Procedure specific care plans
- In addition to developing procedure specific care plans, patients
should have their own care plans
- This means that they know what should happen to them each day
- It includes things that the staff should do and that the patient
themselves should do
- Patients then become a check or reminder for their own care.
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Walter C J, Collin J, Dumville J C et al.
Enhanced recovery in colorectal resections: a systematic review and
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