Jo Hartley

Promoting enhanced recovery after surgery following coronary artery bypass grafting and minimal access cardiac valve surgery

Background 

Enhanced recovery after surgery (ERAS) is a multi-modal, post-operative pathway established into practice for many routine surgeries, e.g. colorectal resections and orthopaedic hip and knee replacement surgeries. 

The aim of this project was to assess, implement and evaluate enhanced recovery after surgery principles for patients post coronary artery bypass surgery (CABG).

Quality of care, patient experience and increased patient participation in decision making processes were evaluated. The ERAS team expected a CABG ERAS programme to reduce hospital length of stay and facilitate appropriate and timely patient discharge from hospital. It was anticipated that patients having access to specialist ERAS pathways and team would improve post discharge support, preventing avoidable hospital readmission.  

 

Prior to this project, patient recovery after coronary artery bypass surgery was doctor led, leaving patient progression reliant on medical reviews. Since the project, patients meeting agreed criteria have nurse led care

  

As one of the leading trusts in the UK to implement a CABG ERAS programme the ERAS team were pivotal in developing a pathway.  With a multidisciplinary approach, a nurse led pathway for patients undergoing CABG surgery and latterly minimal access valve surgery was developed.  

Appropriate individualised patient care was at the forefront of this development. Prior to this project, patient recovery after CABG was doctor led, leaving patient progression reliant on medical reviews. Since the project, patients meeting agreed criteria have nurse led care. Care is now progressed according to patient recovery. Decisions regarding patient extubation, central/intravenous line, drain and pacing wire removal are incorporated into the pathway, meaning intensive care unit nurses decide care according to patient recovery. ERAS principles of early mobilisation, eating, drinking, and patient involvement are promoted to enable individualised and progressive care.                              

Aims and objectives  

  • Increase physiotherapy cover to seven days a week
  • Facilitate patient review and treatment by physiotherapists twice a day for patients on the ERAS ‘CABG pathway’
  • Extend ERAS ‘CABG pathway’ to patients under one of three participating consultants to seven days a week
  • Enable post discharge support for patients on the pathway through phone or video follow up
  • Initiate an ERAS pathway for patients undergoing minimal access valve surgery 
elderly lady exercising with nurse

Activity to date

Due to a lack of physiotherapy support, the ERAS ‘CABG pathway’ required a business case. This was written and presented to the trust board to gain financial agreement and uplift in physiotherapy cover was funded in September 2017. This allowed the ERAS team to effectively manage patients on the ERAS ‘CABG pathway’ for patients under the care of the three participating consultants, seven days a week. 

ERAS nurses review the patients daily, encouraging them to complete their patient diaries. The ERAS nurse undertook the patient assessment and initiated plans and targets for the next twenty-four hours. Patients are actively involved in setting targets and therefore a high proportion of the ERAS nurses’ time is spent educating, discussing issues and negotiating plans with patients and their relatives/carers. 

 

ERAS nurses review the patients daily, encouraging them to complete their patient diaries

 checking-male-patient-heart

One of the ERAS nurses completed the non-medical prescribing (NMP) course which enabled the team to develop the role through daily prescription reviews. Any necessary medication changes were promptly made rather than having to wait for a doctor. This has had a positive effect upon patient care during the post-operative period. Prompt and effective management of post-operative pain, the management of analgesic side effects enables patient’s progression on the pathway.  NMP is now an essential part to the ERAS role. 

 

The ERAS nurses set up a phone follow up clinic for all patients on the pathway in order to support their discharge and ensure effective and timely tracking of readmissions

 

Successful early patient discharge requires additional support. The cardiac centre is a large tertiary centre serving wide geographical area. Patient readmission to referring hospitals have a delay in information being passed to Blackpool Teaching Hospitals (BTH) surgeons.

The ERAS nurses set up a phone follow up clinic for all patients on the pathway in order to support their discharge and ensure effective and timely tracking of readmissions. They established whether any readmission was appropriate. ERAS nurses act as a direct point of contact for patients without waiting for the booked appointment if necessary. 

Initially patients were phoned 24 hours and 3 days post discharge. This service has now developed and if patients have access to IT equipment that enable video calls we now video call them. If they don’t have access to the equipment then we revert to phone calls. 

It has allowed the ERAS nurses to review patients and wounds without any need for patients to leave their home

 

Video calls are carried out via the hospital IT system and as such are secure. It has allowed the ERAS nurses to review patients and wounds without any need for patients to leave their home. Any concerns were identified and required intervention sign posted by the ERAS nurse to the appropriate service (e.g. liaising with GPs, arranging patients review at hospital or GP clinic and admission to local hospitals or intra-hospital transfer to BTH). This has prevented all unnecessary readmissions for patients on this pathway. 

As the pathway for patients undergoing minimal access valve surgery only began in October 2017 the ERAS team are in the process of collating the first three months data. It is anticipated this will demonstrate a reduction in length of hospital stay.

Outputs to date

110 patients followed the pathway in 2017, these were a mixture of elective surgeries that were mainly admitted on the day of surgery and scheduled inpatient surgeries. 

Jo Hartley project

*N.B. ‘Days’ relates to length of hospital stay.

Lessons learned

  • ERAS pathways can be successfully implemented post-cardiac surgery, enhancing the patient experience 
  • Hospital length of stay can be safely reduced with no increase with the readmission rate
  • Supporting patients post discharge with phone or video calls prevents hospital readmissions

We were unable to implement the ERAS pathway to all consultants, due to a lack of resource in the ERAS nursing and cardiac physiotherapy team. Further financial support is required to facilitate every patient been reviewed and treated twice a day. Incorporating all consultants is required to ensure there is equality within the service.

open book

Reflections on impact

Contemporaneous data was collected on all ERAS and a matched EuroSCORE cohort of non-ERAS patients. 
Inclusions in data collected were:

  • Time to extubation
  • Time to mobilisation
  • Complications experienced
  • Pain and nausea scores
  • Length of stay
  • Hospital readmissions within thirty days 

A patient satisfaction survey at the point of discharge and a friends and family survey were arranged and showed an increased sense of involvement in care. Patient-controlled analgesia was not well received in the survey, therefore fentanyl patches and intrathecal morphine was introduced. Relative praised the post-operative support provided.

The way forward

The internet video calls have had a positive effect upon patient’s care, prior to this initiative patients would have attended an advanced nurse practitioners clinic. The video calls have allowed practitioners the ability to visualise patients, assess patients and review wounds without the patient needing to travel. This has also enabled improved utilisation of the advanced nurse practitioners clinics to review patients who need a hospital appointment. There is also a tariff attached to the virtual appointments and as such this initiative has also been an income generator for the trust.

 

The video calls have allowed practitioners the ability to visualise patients, assess patients and review wounds without the patient needing to travel

 

The video calls have enabled the triaging of patients to appropriate practitioners for interventions when red flags have been identified and as such have ensured that only appropriate hospital discharges have occurred. 

The roll out of this service to all ERAS patients on other pathways within the trust may enable stream lining of post-operative clinical appointments whilst allowing patients to be visually assessed. In order to allow this, we would need to write a business case for the financial investment needed from the trust to ensure IT support for this initiative.

Sustain momentum embed the project 

Stakeholder involvement is key to the on-going success of the project, enabling a multi-disciplinary approach and promotes ownership of the project therefore increasing the success of the project. Regular analysis of the data and its presentation to the stakeholders ensures that the project remains at the forefront of service development.

Continual analysis of the project and feedback from the patients has identified areas of practice for future development.

Two areas identified by patients or their relatives are:

  1. Inpatients waiting for surgery have identified that they would like a pathway to follow while they are waiting for surgery and we are looking at developing a prehabilitation pathway for these patients and elective admissions. This may help address issues relating to pre-operative length of stay for urgent inpatient referrals highlighted as part of the cardiac surgical “Get it right first time” report.
  2. Patients’ relatives have expressed how daunting the prospect of taking their relative home so soon after surgery is. As such we are planning to involve relatives with the prehabilitation programme and discuss the discharge requirements as part of the preoperative meeting for elective patients. This will help to increase patient education, a sense of involvement, develop effective communication pathways and trusting therapeutic relations between patients and the ERAS team.