Summary
Greater Manchester Medical Health aims to improve 5-year survival to 70% for all cancers, and has developed a new enhanced recovery surgery pathway aimed specifically at major cancer surgery patients. Developed by the ERAS+ team, it has been used over the last 12 months in more than 500 cancer patients and has demonstrated a substantial reduction in post-operative pulmonary complications in the major cancer surgical population in an acute NHS setting. This has major implications for cancer surgery and potentially 5-year survival. The team believes its toolset of innovations could be rapidly dispersed across the NHS.
Challenge
The World Health Organization has set the target of improving cancer survival by 25% by 2025. Greater Manchester Medical Health aims to improve 5-year survival to 70% for all cancer patients – and an important determinant of major cancer survival is the development of post-operative complications.
Objectives
To equip patients and their families with the tools to optimise patient preparation and recovery for surgery. To explain to patients how they can best prepare for their operation and how we plan to reduce their risk of pulmonary complications. To deliver a more patient- and family-focused pathway.
Solution
A multidisciplinary team incorporating the Trust’s key ERAS innovators developed a new major surgery pathway, ERAS+. This aimed to reduce complications following major surgery with a particular focus on reducing respiratory complications. This would reduce the period of time patients spent in hospital, and also improve both short- and long-term survival.
The ERAS+ team worked with the Boston Medical Centre (BMC) to produce ICOUGH UK. The BMC team had demonstrated that a low cost bundle of simple measures including pre-operative oral care, and incentive spirometry alongside early mobilisation could reduce the incidence of POPC by up to 50%. ICOUGH UK was bolstered with state-of-the-art anaesthetic elements of evidence-based respiratory best practice, and combined with the elements of ERAS aiming to provide inpatient stepped recovery. Using Quality improvement methodology, the ERAS+ICOUGH pathway was embedded within the critical care nursing and medical team structure to facilitate its use with surgical patients to ‘train’ them for their upcoming surgery. Preparation sessions were led by multidisciplinary ERAS+ teams, and supported by ICOUGH UK information videos and other multimedia support. Patients received instruction in what was expected of them before and after surgery, so they could feel empowered. Terminology included in discussion with patients and their families highlighted the benefit of patients being active and dynamic in their own recovery.
Results
Since September 2014, utilising ERAS+ in a major surgical population of more than 500 patients within a large NHS teaching hospital has resulted in a 40% reduction in pulmonary complications. Local baseline audit data confirmed that patients undergoing major cancer surgery confirmed a large group of high risk patients, with a PPC rate of 19-20%. Pathway innovation was supported by talking to patients and their relatives through sponsored listening sessions. ERAS+ developed through 2014 with staff education and training. Ward-based ERAS programmes dovetailed with the new ERAS+ within critical care, and helped support patient recovery.
Learnings
Minutes from the implementation and project steering group meetings were captured to ensure key learning points were collected. These learning points were collated and disseminated on a monthly basis to all staff involved with the project via multiple channels by the different ERAS leads within the Trust. We utilised monthly ERAS email updates, updates on departmental notice boards and at ward and departmental team meetings. Data and metrics that have been collected during the project were disseminated on a regular basis. As a group we have already developed expertise in carrying out large scale transformational change. ERAS+ group will continue in similar projects within the Trust and further afield thus ensuring that the skills and expertise developed are disseminated locally and nationally within the NHS and, potentially, internationally.Evaluation
Following what was thought to be a satisfactory period, ERAS+ was launched in September 2014 with a weekly Surgery School MDT session and data collection being achieved through an ERAS+ data collector which would come to form the Manchester Surgical Outcomes Project. All patients undergoing elective surgery requiring post-operative critical care admission were screened for the development of POPCs on days 1, 3, 5, 7 and 15 after surgery using standard definitions of POPC. ERAS+ champions appointed within critical care supported staff compliance with ICOUGH, which was measured in weekly audits. Further PDSA development generated ICOUGH prescription standing orders attached to drug charts to ensure all elements of the pathway were followed.
