Home: Enhanced Recovery
The programme involves: -
Which all sounds great unless, like me, you've become a bit cynical of NHS management initiatives. So what could be the catch?
Health providers (NHS and independent) are all keen to cut costs and one of the best way to do that is to discharge the patient as early as possible. This is something that most patients would readily agree to- as long as the patient has a caring family and that they are not discharged so early that there is a good chance of a subsequent readmission.
In this respect I was particularly wary of the 4th standard as post-operative care, particularly physiotherapy, has been slashed by many Trusts.
However my cynicism was challenged when I listened to a talk by Dr John John at a recent hip replacement conference.
Over the past 5 years there has been increasing evidence to support the implementation of an enhanced recovery programme to improve and speed up rehabilitation after hip and knee surgery
The primary aim of the programme is to achieve early mobilisation after surgery which is defined as walking within 3 - 4 hours. In the past, the first attempt to get out of bed would only be made on the day after surgery, and even then most patients will only get as far as a chair by the side of the bed. In the ER programme patients can often achieve a significant amount of mobility by the evening of the operation; the majority are independent on crutches by this time. This means that patients are able to go to the toilet and mobilise around the ward at night with minimal support. Such early mobilisation allows them to achieve the criteria for discharge far sooner than previously thought possible.
Good quality information is given to patients about what they can expect as soon as they enter the hospital. This is often done through hip and knee schools were healthcare professionals will present relevant and standardised information through a multimedia presentation. Patients will learn about the admission process, what things to bring to the ward, choices of anaesthesia and pain relief, the type of exercises to do after the operation, and the goals they need to achieve before it is safe for them to return home.
Most protocols will use a spinal anaesthetic as first choice either on its own or in combination with a light general anaesthetic (GA). I personally prefer the combination, as it enables me to keep the dose of both the spinal and the GA small. Smaller dose spinal anaesthetic will predictably wear off within 2-3 hours (i.e the numbness and heaviness of your legs) after which patient should be able to mobilise.
The main difference between the enhanced recovery concept and standard management techniques is the way in which pain relief is achieved. Traditional techniques use either morphine intravenously, epidurals or nerve blocks to provide analgesia. Morphine causes sedation and nausea, epidurals and nerve blocks cause muscle weakness and therefore same day mobilisation is difficult.
Instead the technique called LIA (local infiltration analgesia) is recommended. LIA involves the surgeon injecting about 150 ml of very dilute local anaesthetic into all the tissues that are traumatised during surgery. This is carried out in theatre during the operation. When done meticulously, this can provide high quality pain relief without the need for any morphine like drugs.
In addition the anaesthetist will prescribe regular oral pain killers like paracetamol and anti- inflammatories. Drugs like Pregabalin and Ketamine are also used routinely in some institutions.
There is a tendency to move towards a less invasive approach for hip replacements. Smaller incisions and less muscle damage during surgery can reduce pain and bleeding after surgery. Some surgeons however will argue that there is no evidence to support better long term outcomes.
The anaesthetist will often use specific drugs and techniques to reduce both intra and post-operative blood loss. Tranexamic acid is a drug used specifically for this. Although there is a wealth of evidence to support its use to reduce blood loss in surgery, it is not popular in orthopaedic surgery.
In addition a controlled drop in blood pressure is also used to minimise bleeding. Higher blood pressure during surgery will lead to increased bleeding simply because the flow through the arteries that are cut, are dependent on the blood pressure. In enhanced recovery protocols there is a conscious attempt from the anaesthetist to specifically drop the pressure to the lowest safe values during the main part of the operation. This is not routinely done in conventional anaesthesia.
Appropriate amounts of intravenous fluid used during and after the operation can lead to better outcomes. Minimising starvation times to no more than 2 hours and replacing blood loss accurately can promote the sense of well being after surgery. Blood loss is measured accurately in theatre and often replaced usually with appropriate intravenous fluids. Preventing dehydration can have a big impact on fainting episodes during mobilization.
The decision to discharge is often made by nurses, once set criteria have been met. The patient is keep well informed about the targets they have to achieve prior to discharge and are advised to prepare themselves and their carers for a pre-specified date of discharge.
A well run enhanced recovery programme will ensure that there is a means of tracking how patients are doing after discharge. This might mean access to a telephone help line or to clinics or a regular follow up call during the first week.
The criteria for discharge are the same using traditional methods as with enhanced recovery - the difference is that this new approach allows and encourages the patient to achieve those criteria earlier.
The approach concentrates on achieving early mobilisation. i.e. walking after a few hours of surgery. It does so by controlling the physiological changes that are inevitable after major surgery.
With the conventional approach the ability to mobilise early is often sacrificed due to a reliance on pain relief techniques that are not compatible with early walking. The downside to this approach is that it often involves a major change in the ethos within the organisation and requires several key members working together as a team in a standardised manner to produce better results. If team work suffers using the new approach, the outcomes can be worse than with the conventional approach.
In the UK there is a list of early adopters on this NHS site. There are several Danish hospitals and at least one Australian hospital also running the programme and I'm sure it will spread quickly. Check with your local hospital or national health organisation to see what is available locally outside of the UK.