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Problem
In 2011 a successful enhanced recovery (ER) programme for gynaecology was launched as a six month project in a NHS teaching hospital. Organisational restructure and staff changes in 2012 led to failure of the programme: ER post-operative goals were not achieved and length of stay increased. In 2013 an ER nurse was appointed to lead the programme.
Background
Enhanced recovery (ER) programmes aim to deliver an optimal surgical pathway designed to minimise the overall physiological and psychological impact of the surgical procedure helping patients recover sooner.[2,5,6]
An ER pathway can be divided into three main elements: pre-operative patient preparation; peri-operative interventions; and post-operative rehabilitation. Prior to the clinical education programme launch, pre-operative and peri-operative elements had been developed and introduced.[4] A generic patient information booklet covering the whole elective pathway was posted to all elective gynaecology surgery patients with their dates for pre-operative assessment clinic and surgery. In addition, the ER nurse trained all pre-operative assessment nurses to educate patients to assist in their own recovery and preparations for admission and discharge.
ER peri-operative practice successfully introduced in 2011 involves the patient meeting with their consultant surgeon on the morning of their surgery to confirm their consent for their procedure. Laparoscopic surgical interventions are used whenever possible, and no nasogastric tubes or abdominal drains are used routinely. Temperature is controlled and antiemetics, analgesia, and prophylactic antibiotics are administered. Goal directed fluid therapy is used in the major open cases and a zero balance is aimed for in laparoscopic cases.[1,4] Carbohydrate loading is not formally introduced, though patients are advised on minimum starvation times and that clear fluid energy drinks, Powerade or Gatorade, are beneficial to drink two hours before surgery.
The primary post-operative elements of ER are:
Early mobilisation
Early nutrition
Pro-active management of pain and nausea
Restricted intravenous fluid administration.[1,4,7]
A team approach to ER is essential to its sustainability and success. It cannot be implemented by an enthusiastic clinician alone but is reliant on clinical engagement from surgical, nursing, allied health professionals and anesthetic teams.[1] Even the simple changes in practice required to deliver the post-operative rehabilitation elements, is acknowledged [3] to represent a fundamental change in practice and can therefore be difficult to achieve. Central to the success of an...