Enhanced recovery (ER) has also been described as ‘fast-track’, ‘rapid’ or ‘accelerated’ recovery. In fact, the combination of evidenced based elements of care into a pathway (Figure 1) for elective surgery results in a reduction in the physiological stress response and organ dysfunction caused by surgery, which facilitates more rapid recovery, shortened length of stay,[1-3] and return to normal activity. The aim of the pathway is to optimise care, and the resulting reduction in the stress response to surgery can now be described as standard practice. At the time these pathways were described initially by Kehlet in Denmark in 1990s, for patients undergoing colorectal surgery, patients recovered more quickly, allowing discharge after 2–3 days at a time when the length of stay in UK hospitals for a colon resection was longer than 2 weeks. One of the key challenges to the implementation of these pathways is the dogma that accompanies many current surgical pathways based on familiarity rather than evidence.
It remains true that the bulk of the evidence for ER has been published for colorectal surgical pathways – two meta-analyses demonstrated the benefits of reduced length of stay, hospital morbidities and complication rates.[6, 7] A Cochrane review of ER in gynaecological cancer contained no randomised trials in ER, but non-randomised evidence in gynaecology and other specialties is building. Following the compelling evidence from colorectal surgery, and emerging evidence of benefit in gynaecology, current research is directed towards optimising elements of the pathways in gynaecology such as postoperative analgesia.
Gynaecology was included as one of four surgical specialties as part of the Enhanced Recovery Partnership Programme, from 2009 to 2011. An initiative between the Department of Health, the National Cancer Action Team, NHS Improvement and NHS Institute of Innovation and Improvement, only one procedure, hysterectomy, was included for gynaecology, and early work commenced in gynaecological oncology. Implementation and support for the development of enhanced recovery in gynaecology continues to be supported nationally by NHS Improving Quality.
As momentum builds, many bodies are supporting this approach. At the National Enhanced Recovery Summit in April 2012, a pan-specialty multidisciplinary consensus statement was signed by representatives of national bodies including the presidents of the Royal College of Obstetricians and Gynaecologists and the British Gynaecological Cancer Society:
‘The enhanced recovery approach to pre-operative, peri-operative and post-operative care has major benefits for many patients in relation to quicker recovery following major surgery. This facilitates shorter hospital stay with no increase in readmission rates. This has clear benefits for patients and their families and for the NHS.
‘Enhanced recovery is now being implemented across the NHS in patients undergoing elective procedures in four specialties: orthopaedics, colorectal, gynaecological and urological surgery. There is considerable scope to extend the relevant components of enhanced recovery to patients admitted as emergencies and to other specialties. We believe that enhanced recovery should now be considered as standard practice for most patients undergoing major surgery across a range of procedures and specialties.'
The RCOG Scientific Advisory Committee produces a range of Scientific Impact Papers providing up to date reviews of emerging scientific issues of relevance to obstetrics and gynaecology. Scientific Impact Paper No 36 “Enhanced recovery in gynaecology” was published in 2013 and, as the authors of that paper, we present the elements of enhanced recovery pathways described in it to further raise awareness of the approach. Some of the elements of enhanced recovery pathways, such as pre assessment clinics, antibiotic and thromboembolic prophylaxis, will be familiar elements of care, whilst others such as carbohydrate loading and individualised goal directed fluid therapy may not.
If possible, preoperative risk assessment of the patient's health and fitness for surgery should be organised so that any problems identified can be addressed in order to reduce complications and perioperative mortality. The process starts in primary care prior to GP referral. The use of formal pre-admission clinics is recommended. Verbal and written patient information ensures that patients understand their treatment pathway, and the active part they play in their care. Preoperative patient education can reduce the need for pain relief and improves patients' experience of the hospital admission. Procedure-specific information and consent can greatly aid the information-giving phase of the pre-admission process. The key role of specialist nurses in ER must be emphasised.
One of the key advantages of a standardised pathway for a surgical pathway is the ability to plan with accuracy the date of discharge from hospital. As part of the patient's responsibility for their care information about the anticipated length of stay and expected recovery for a particular procedure, so that they, together with carers, can ensure that the appropriate support is available on discharge.
Admission on the day of surgery has many advantages – these include reduction in preoperative bed usage. Dehydration is avoided by reducing the period of fluid fasting to 2 hours prior to anaesthetic, which has been shown to be safe without an increase the risk of aspiration. The use of complex carbohydrate drinks have been shown to be beneficial in colorectal surgery, reducing the length of stay and liked by patients. Mechanical bowel preparation can be associated with morbidity and there is no evidence that it improves the outcome for patients having elective rectal surgery, in whom bowel continuity is restored. The role of mechanical bowel preparation should therefore be investigated and generally avoided in patients undergoing gynaecological surgery. Long-acting sedative premedication can impair postoperative mobility. Antibiotics prior to incision and venous thromboembolic prophylaxis should be included as there is evidence for their benefit.[18, 19]
Enhanced recovery pathways advocate minimal access techniques.[20, 21] If considered necessary for the procedure to be performed safely, abdominal incisions should be as small as possible. Nasogastric, abdominal and vaginal drains have little benefit and should be avoided as they increase morbidity and prolong hospital stay.[22-24] The routine use of vaginal packs has been questioned, not only because they are uncomfortable for patients but also because they may hinder, if not prevent, mobilisation. However, because of the lack of evidence, a departmental approach for their use should be adopted to ensure consistency. This is another area for research.
Avoidance of intraoperative hypothermia has long been shown to reduce postoperative complications. In colorectal surgery, individualised goal-directed fluid therapy using stroke volume to guide intraoperative fluid management reduces peri-operative mortality and length of stay. The benefit of this approach relates to a reduction in the risk of bowel hypo-perfusion, but the role in gynaecological surgery is less clear. However, the use of intraoperative fluid management technologies is now recommended in patients undergoing major or high-risk surgery (including major surgery with an anticipated blood loss greater than 500 ml and major abdominal surgery) or high-risk patients (including patients aged over 80 years) undergoing intermediate-risk surgery.[27, 28]
Standardising anaesthetic protocols by focusing on the stress response to surgery, analgesia and fluid management improves patient outcomes and promotes patient safety.[29-32] A standard protocol to manage postoperative pain is required to reduce the adverse effects of the surgical stress response which can prolong recovery. Spinal, epidural and regional regimens can reduce opiate requirements, which in turn allows a more rapid return to oral fluid intake. In addition, there is evidence of improved patient satisfaction and an association with a rapid return to work.[30-32]
In routine surgery, early feeding and a reduction in the volume of routine intravenous fluids is a safe approach. Associated with a reduction in nausea, and higher patient satisfaction, this part of the pathway contributes to the shortened length of stay and higher patient satisfaction observed.[33, 34] Early mobilisation is key to ER and is achievable regardless of age with appropriate education and support. Encouraged by effective analgesia (in a protocol with reduced use of systemic opiates) early mobilisation reduces the risks of muscle loss and thromboembolism. Protocols should also include anti-emetics to manage postoperative nausea and vomiting, and laxatives to prevent constipation. Catheters, drains, vaginal packs and intravenous drips should be removed as soon as possible, to enable mobilisation and prevent developing associated secondary infections. Women are at risk of developing short-term voiding problems following pelvic surgery – after catheter removal voiding should be monitored using post-void residual checks. If necessary, it is safe for patients to be discharged with an indwelling catheter and to return for a trial without catheter as an outpatient.
Discharge for ER patients is criteria-based, and can effectively be nurse-led, once patients are mobilising, eating and drinking, passing flatus and their pain is controlled by oral analgesia. It is essential that patients are provided with written information on discharge that includes emergency contact information, practical advice to aid recovery and expected length of time until they return to normal function.
Models that have been applied for follow-up after initial discharge include: telephone calls to patients after 24/48 hours by nursing staff or patient-triggered follow-up contacting the ward with concerns or questions via a dedicated phone number.
Involving patients and their carers at every step of the process from decision to discharge in partnership with the clinical team is fundamental to ER. Empowering patients to take a significant role contrasts with the passive ‘sick' role patients play in traditional care pathways.
Crucial to a patient's psychological preparation is accurate and consistent information about ER. This starts in primary care at the time of referral, aligning their expectations with the expectations of the clinical team at the earliest stage. Shared decision making helps women take ownership over their decisions with respect to whether surgery is necessary or appropriate, through to how they want to be treated and to decisions around discharge. Informing patients and their carers about the ER pathway reduces the fear of the unknown and challenges preconceived ideas about the operation, pain, recovery and length of stay, that may be based on experiences of friends and family from a bygone era. My Role and Responsibilities in Helping to Improve My Recovery is a generic patient information leaflet produced by The Enhancing Patient Experience Working Group and promoted by NHS Improving Quality, that details the patient's role in their care. By taking an active role and responsibility for enhancing their own recovery, patients are involved, motivated and overall have an improved experience.[2, 30, 34]
Patients must receive the same messages about what to expect from all members of the multidisciplinary team, at all stages of the pathway. Some trusts have introduced new ways to educate patients, such as information evenings and DVDs. If patients require further information they need to know where to go for answers, advice or support.
Patient feedback from those who have used the service is key to maintaining and improving a quality service. Patients' experience may be very different than what was intended or assumed to have occurred. Formal evaluation is necessary to understand what does and does not work and what can be improved. This can be done using a variety of methods from questionnaires through to interviews and innovative ways such as patient parties.
Quality and cost
Patients on ER pathways recover more quickly and have shortened length of stay.[1-3, 38] Length of stay is taken as a surrogate marker for quality of care, as shorter stays suggest fewer complications. It is also used for inter-hospital comparison because it is readily available as Hospital Episode Statistics data. Complication rates are comparable to, or better than, those seen in the UK following conventional surgery. Typically, there is no increase in readmissions or postoperative work for primary care.[38, 39] In addition, ER pathways have better patient satisfaction, better nurse satisfaction and improved quality of life following surgery than traditional pathways. The costs and investment required for implementing ER varies depending on what infrastructure is currently in place. However, there are financial gains to be made by releasing beds for savings or increasing activity.
ER advocates to use the safest, most appropriate, least invasive procedure for each woman. Despite the development of minimal access techniques, an abdominal approach for hysterectomy was used in around 79% of benign cases in England (2010–2011 HES data) which does not compare favourably with other published national data (Finland 24%). There would be a significant benefit for patients and the UK health economy if there was a shift away from abdominal procedures to a minimal access approach.
Adopting ER challenges traditional practice – it can be difficult to persuade colleagues to adopt unfamiliar elements of a pathway such as carbohydrate loading, and further training may be required in laparoscopic surgical techniques. Successful implementation requires a commitment from all stakeholders in primary, secondary and social care, including high-level clinical and management teams within hospitals. Without this support, the change will not be sustainable. Experience in England over the past 4 years suggests that a core team of stakeholders should be identified – this comprises a surgeon, anaesthetist, specialist nurses and managers. Training is required to ensure that this core team understand the current service, and can then identify and implement improvements, measure the impact and feed back to the wider clinical team. A designated local ‘ER champion'can facilitate this work.
Education is fundamental to facilitating change. Locally agreed pathways and protocols, based on the ER Pathway documentation, must be developed to ensure local “ownership”. Unless these are advertised and promoted, staff may remain unaware of the changes or do not value their importance so do not change practice. All members of the multidisciplinary team need to understand the pathway and that their role is vital to its success.
Baseline and continuing data collection of both clinical and service evaluation outcomes is important to be able to demonstrate progress of implementing ER and its impact on the service. A national ER audit tool was developed to assist with this, which enabled benchmarking against other sites (see www.natcansatmicrosite.net/enhancedrecovery/Default.aspx). Dissemination of the results may help compliance with pathways and empower and inform frontline staff.
There is further support and information available to trusts considering implementation from NHS Improving Quality. Online resources remain available through the NHS Improving Quality website (www.improvement.nhs.uk/enhancedrecovery/) and from the document Delivering Enhanced Recovery published by the NHS Enhanced Recovery Partnership Programme.
In these times of financial pressure, commissioners want to commission cost-effective and high-quality services, which improve outcomes for patients. ER fulfils those criteria and aligns with the NHS Outcomes Framework Domains 3, 4 and 5. Commissioners have used contractual levers, such as Commissioning for Quality and Innovation payments and service specifications, to encourage providers to establish or further develop ER within their service. This has been seen in areas across the country for example, in London, the south east and south west.
Further research and developments
Randomised studies typically look at changes in components of care pathways. Some of the benefit of ER is a change of philosophy, putting the patient at the centre of the approach and developing and implementing an integrated care pathway that an entire multidisciplinary team has developed and signed up to. If one breaks down the pathway to evaluate individual components the key benefit of patient-centred care maybe lost.
Construction of a randomised controlled trial of a pathway containing no ER elements versus a fully implemented ER pathway, in a particular hospital would be difficult to carry out. For some elements such as early post operative feeding, there is strong evidence from randomised controlled trials. Other elements where evidence is lacking, for example, regarding the use of vaginal packs, are best evaluated by a randomised controlled trial.
The ER model offers the opportunity to improve the care of emergency admissions. Early work in obstetrics has begun in the pathway for elective caesarean section. To date there is little experience incorporating support of the newborn and the establishment of breastfeeding into ER. However, given the increasing numbers of elective and emergency caesarean sections, application of the ER principles could be of importance in obstetric care.
ER leads to improved patient satisfaction, less variation in patient care, shorter length of hospital stay, and a reduction in complications and re-admissions. There is a need for trusts to move forward using the ER principles for the benefit of the patients undergoing gynaecological surgery and for the NHS as a whole.
Disclosure of interests
All authors are also authors of the RCOG SAC paper on Enhanced Recovery for Gynaecology. NA is an advisor to NHS IQ and former member of the steering board for Enhanced Recovery (ERAS) UK and received a speaker fee from Baxter (UK) for a talk on Enhanced Recovery. NA and RC were previously national advisors to the Enhanced Recovery Partnership Programme, Department of Health. AN was an advisor to NHS Improvement.