Enhanced recovery programmes; coming to a hospital near you!
Article first published online: 14 SEP 2011
© 2011 The Authors. Anaesthesia © 2011 The Association of Anaesthetists of Great Britain and Ireland
Volume 66, Issue 10, pages 864–868, October 2011
How to Cite
Morris, C. and Gold, S. (2011), Enhanced recovery programmes; coming to a hospital near you!. Anaesthesia, 66: 864–868. doi: 10.1111/j.1365-2044.2011.06883.x
- Issue published online: 14 SEP 2011
- Article first published online: 14 SEP 2011
There is little doubt that the National Health Service (NHS), central Government and increasingly, clinicians and patients, are getting enthusiastic about ‘enhanced recovery programmes’ (ERPs). What does this mean for anaesthesia and anaesthetists? In their role as peri-operative physicians, anaesthetists would have a central role in ERPs, so it is essential that we are aware of them and contribute to the end-product. Implementation is being driven by a core of enthusiasts, supported at high level in the NHS and Department of Health (DoH), and is linked both with developments such as peri-operative fluid optimisation and early mobilisation, and with other groups and commercial companies championing surgical outcomes [1–4]. The ‘top-down’ model of implementation, through Strategic Health Authorities (SHAs) with flexible local interpretation, has met many challenges, not the least of which is the perhaps ironically named White Paper Liberating the NHS which states that SHAs will be abolished as statutory bodies during 2012/13 [5–10].
What is an ERP ? The Enhanced Recovery Programme Partnership is a collaborative approach in association with NHS Improvement, the NHS Institute and the DoH Cancer Action Team. It calls for a dramatic revision of the patient journey with the primary intention of reducing hospital stay [9, 11–14]. A 2011 ‘stakeholder roundtable discussion group’ described ERPs as ensuring that the patient: is in the best possible condition for surgery; has the best possible management during and after his/her operation; and experiences the best postoperative rehabilitation. And no one should be in any doubt as to the strength of feeling involved: ‘Every patient has the right to expect to be offered an enhanced recovery pathway … and this should not be prevented through clinical and organisational inertia’.
Key goals of ERPs are reducing time spent in hospital (e.g. admission policies), challenging traditional delivery of care (e.g. with prominent non-medical team members) and reducing resource consumption. It is less clear which other outcomes will improve or from whose perspective. The ERP partnership demands that colleges and professional associations push ERPs as ‘best and standard care’, but could this be premature? Whilst components of ERPs are straightforward, implementing up to 31 interventions (that commence in outpatient departments and continue through pre-operative assessment to day-of-surgery admission, standardised surgical, anaesthetic and postoperative care, criterion-led discharge and robust follow-up) is not simple. To anaesthetists, pre-operative assessment and planning and delivery of peri-operative/critical care support are intuitive to our role. However, ERPs require effective and timely co-operation at all peri-operative stages and particularly across specialities. Traditional roles will be challenged and the multidisciplinary ERP does not sit comfortably with the traditional UK system of having a named consultant providing care and taking responsibility; whether or not parent consultants will release this control whilst still taking ultimate responsibility remains unclear.
Some components of ERPs require planning and allocation of resources before implementation of others, e.g. pre-operative assessment for day-of-surgery admission in which an anaesthetist may be meeting the patient for the first time in the operating theatre. Unsurprisingly, planned admission to critical care facilities following major surgery, rather than unplanned admission following a catastrophe, improves outcomes [3, 4]. As pre-operative assessment allows planning, perhaps this is where anaesthetists should concentrate their efforts. However, we have, and have had for years , a severe shortage of critical care beds (typically under 2% of acute hospital beds in the UK vs 20% in the US ). When elective cases compete for critical care beds (e.g. winter pressures), the former generally fare poorly. The lack of explicit funding, ring-fenced critical care beds or similar, as we attempt to deliver ERPs, will almost certainly result in cancellations.
So, what are anaesthetists clinically ‘doing’ as part of an ERP? Weighty documents abound with enthusiasm and management-speak but there is a lack of clinical clarity. Examples of local interpretation of an ERP are given [8, 9, 11–14], but there is no ‘core’ set of elements. When does mere good clinical care become an ERP? A cynic might say this is what anaesthetists already do, or should be doing. Perhaps this is one result of ERPs, encouraging standardisation of high quality care? If ERPs represent best practice we should be able to distil the key components and implement them nationally. One model that may suit ERPs is being delivered in ‘bundles’ of care, as has occurred elsewhere e.g. in sepsis management . Bundles are key, time-limited interventions, ideally no more than five in number (or people forget them), implemented en bloc. The evidence base for, and relative contribution of, individual elements of the sepsis bundle was often controversial, and yet outcomes improved . Care bundles achieved what is generally regarded as ‘unachievable’ in health care, i.e. widespread behaviour modification. If ERPs are to become reality, clinical staff need to know what part they play in them.
A ‘colorectal ERP’ bundle might include: (i) pre-operative assessment, risk stratification and allocation to ward, high dependency or care postoperatively; (ii) standardised anaesthetic and analgesic techniques; (iii) intra-operative fluid optimisation; (iv) a standardised postoperative pain, fluid, nutrition and mobilisation plan; and (v) nurse-led, criterion-based discharge without medical review. Readers may disagree with some of these components, highlighting the challenges in trying to standardise complex medical care. Which bits to keep in, which bits to miss out? What about intra-operative warming, pre-operative carbohydrate drinks and postoperative anti-emetics, all of which have a (poorly defined) suggested role in ERPs? Some individual elements of ERPS really matter, others probably do not, yet the current evidence base does not allow us to dissect out these interventions to determine their comparative effectiveness. It is contradictory to insist that ERPs use key, high-impact interventions, when the process is open to local interpretation and implementation. When financial constraints are a major issue, which interventions can we afford to keep? Does peri-operative hypothermia impact on outcome more than intra-operative fluid optimisation, for example – and if not, do we choose the most cost-effective, accepting that we may not currently know which this is?
Anaesthesia would face profound changes; whilst based in science, most anaesthesia contains elements of ‘art’. There will be tensions if we try to standardise anaesthesia, especially if this is perceived as an imposed change. For ERPs require a standardised anaesthetic/analgesic regimen [9, 11–14].This will limit ‘clinical freedoms’, and whether or not the speciality is able to accept this is questionable. Anaesthetists have debated the superiority of regional vs general anaesthesia for proximal femoral fracture for decades, so most clinicians should have equipoise . Currently, the evidence base favours use of a technique that facilitates oesophageal Doppler optimisation [20, 21], yet the vast majority of UK operations are performed under spinal anaesthesia. Anaesthetists’– indeed most doctors’– preferences are complex decisions, resisting rational discussion and evidence-based review. Similarly, evidence evolves; for example, whereas the oesophageal Doppler consistently reduces hospital stay and is a cornerstone of many ERPs, a colloid-based strategy in colorectal surgery increased length of stay and worsened organ function . In the absence of research evidence, frequent review of local ERPs, informed by robust audit of outcomes, is required, but concern remains about starting a process before having this information. Accurate metrics are the only way to validate whether or not ERPs work outside of enthusiastic pilot centres. It is questionable whether the NHS is currently equipped for this large amount of data collection, processing and analysis, especially in the widespread absence of electronic data collection.
Similarly, almost all research into ERPs focuses on shortening length of (hospital) stay, despite recognising that ‘… successful implementation cannot be measured by length of stay alone’ . Outcomes that the patients value, demand consideration, but are open to interpretation and manipulation. We are repeatedly told that patients want to go home as soon as possible after surgery, and this sits well with limited resources. Conversely, the public’s desire for enough nurses, or a 24/7 funded acute pain team, attracts less support from the DoH. Indeed, we are encouraged to ‘educate’ patients to embrace ERPs, rather like selling people something they never knew they needed. Patients’ knowledge of their surgical pathway is often incomplete and any effort to bridge this gap should be a positive step. However, unless primary and secondary care blend smoothly, we can imagine patients struggling at home, in pain, soiled with dirty dressings and missing medication a few days after surgery. The entire system, from admission to discharge, primary care and social support, must work comprehensively, or we will be doing our patients a disservice. This seems as far away as ever in the ongoing confusion following Liberating the NHS, so it is our responsibility as clinicians to ensure that ERPs are only introduced with appropriate governance and safeguards. We must also cater for the significant proportion of patients who do not want to go home – who value being in a hospital, surrounded by doctors and nurses, after a big operation. It is likely that these patients can still return home earlier but they will need temporary increases in community support.
One fundamental assumption, that ERPs can be introduced in a cost-neutral or even cost-negative fashion, remains. This is a complex issue and funding in the NHS is opaque on many levels. Funding for ERPs approaches public health proportions, since over 250 000 patients could be eligible annually [12, 14]. National Institute for Health and Clinical Excellence guidance advocates the use of oesophageal Doppler monitoring ; this will be associated with costs running to millions of pounds [24, 25]. Acute hospitals must have plans for how to translate real cost into savings. Several possibilities exist, from increasing productivity (unlikely in the current economic climate, with already low waiting times), reducing cancellations and 5-day wards, to closure of wards. System changes must come as a package to realise savings; ‘silo budgeting’ is a significant problem in the NHS (e.g. fluid management using oesophageal Doppler monitoring significantly affects the theatre budget but potentially reduces ward expenditure). Senior management and financial oversight are required to prevent incoherent decisions and the benefits of an ERP to individual (anaesthetic) departments cannot be assumed.
Are there any detrimental effects of an ERP? There are concerns that ERPs directly or indirectly could increase complications, e.g. anastamotic leaks or poor mobility of a joint replacement, or at least delay detection. Who in the multidisciplinary throng takes responsibility, and the governance implications overall, remain unclear. Whereas isolated centres report good results and maintained safety , it is acknowledged that: ‘Concern over increased readmission rates and the financial penalty that brings do however represent a real barrier …’ . Furthermore, if not all teams can achieve the same results as the ‘best in class’, just what standard of care are we providing? It is assumed that a stick coupled with a carrot (e.g. commissioners not reimbursing readmissions within 2 weeks) will ensure that standards are maintained. Any standard requires definition, so what is an ‘acceptable’ readmission rate following a colectomy, and would it be different between ‘best in class’ and ‘less than best’? And if these are different, how do we use national tariff structures, or present them in national league tables? Conversely, many developments have unexpected spin-offs or benefits. Preliminary data are suggesting that anaesthetic technique during a variety of types of cancer surgery may affect recurrence rates [27, 28]. If confirmed, ERPs may lead to a role for anaesthetists in preventing cancer recurrence , and some data are available to suggest that long-term outcome is being improved in colorectal cancer surgery .
So, it is highly likely an ERP will be arriving at a hospital near you – and the enthusiasm from certain quarters is palpable. Is it all bad? Far from it; much of it represents best practice. If the premise of enhanced recovery is ‘do everything better’, and the patient will recover sooner, then no-one can object. Is there a naked Emperor parading down the street? Perhaps, but the Emperor did need some new clothes. Should we be implementing ERPs? A more specific description of what that means would help. Will we all be ‘doing ERPs’ in 10 years’ time? Sick patients will certainly need operations and good anaesthetists will get them through it – whether we call this ‘good anaesthesia’ or an ERP is unclear. On balance, the term ERP, lacking a concise definition, may lack impact and merge into standard care, so if there is something in it we need to identify it and implement it soon.
SG is East Midlands Lead for Enhanced Recovery. No external funding declared.
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