Enhanced Care: Business Cases and SOPs

The Perioperative Medicine Service at York was set up in 2015 and comprises anaesthetists, Specialist Nurses, ward nurses and the wider multidisciplinary team. It primarily focuses on improving outcomes for patients undergoing major elective colorectal surgery.  The service has introduced pathways and treatment algorithms for the immediate postoperative management of these major surgical patients on a pre-existing Enhanced Care Unit- the ‘Nurse Enhanced Unit’.

Aims

Like many hospitals around the country York was struggling with day-of-surgery cancellations due to lack of critical care capacity. Our management plans and pathways were designed to move patients out of critical care and onto the 1:4 nursed, Nurse Enhanced Unit whilst still providing them with optimal postoperative care with regards haemodynamic and medical management.

The pathways essentially enabled postoperative goal directed fluid and vasopressor therapy in an enhanced ward setting, whilst ensuring appropriate escalation of the deteriorating patient when necessary.  We introduced arterial line monitoring, cardiac output monitors, vasopressor infusions and blood gas analysis to the ward staff in an area previously naive to these interventions. Details of the pathways, algorithms and the necessary training that went with them can be found on our website: www.yorkperioperativemedicine.nhs.uk

The website also contains information about how and why we set the service up as well as information for patients and professionals.

The main challenges we identified and sought to address

• Limited HDU access/high critical care occupancy rates/on day cancellations
• Delayed discharges and long length of stay
• Potential harm to patients with excessive fluid therapy in the perioperative period
• Junior staff managing patients at their most vulnerable point in the surgical journey and subsequent variation in post-operative management
• Failure to rescue deteriorating patients
• Postoperative functional decline/ increased dependency

We aimed to

• Reduce complication rates,
• Improve the utilisation of the resources already available to us including using the limited critical care resources for the acutely unwell patients.
• Prevent cancellations of surgery due to a lack of critical care beds.
• Reduce variation in practice.
• Provide goal directed fluid therapy and cardiac output monitoring to patients in the perioperative period.

We collected a lot of data to explore the impact of our service on patient outcomes.

Data were compared to a similar cohort who underwent surgery prior to introduction of this service. We have seen a steady reduction in length of stay, Critical Care utilisation and complication rates. Control Group data (Control, n=202) and data from the 3^rd year following introduction of the Perioperative Medicine Service (POM3, n=106).

• Length of hospital stay (mean)- Control 12.2 days; POM3 7.3 days
• Length of hospital stay (median)- Control 8 (6-12); POM3 5 (5-9)
• Reduced variation in length of stay e.g. interquartile ranges of length of stay: control group: 6-12 days, year 1: 5-8days, year 2: 5-8.5 days, year 3: 4-8 days
• Major Complications Control 22%, POM3 16.2%
• Minor Complications Control 39%, POM3 19.7%
• Post op pneumonia Control 6.1%; POM3 1.6%
• HDU admissions for respiratory failure Control 4.5% to POM3 0.5%

Feedback

Feedback from nursing staff and patients suggest that the introduction of the Perioperative Medicine Service has improved patient care throughout their surgical journey and recovery through more thorough and consistent reviews by senior Anaesthetists who rotate through a ‘POM Week’. Furthermore, when interviewed, ward nursing staff report feeling empowered by the protocols. They feel that they allow them to deal with post-operative hypotension and hypovolaemia autonomously and the incorporation of escalation plans into the protocols has facilitated swift access to Critical Care for the very few patients who have required it. 

Learning

Some of the pathways necessitated the introduction of arterial lines and vasopressors for the first time on the Enhanced Care Unit and the Perioperative Medicine Team was responsible for the training and assessment of competency for all the nursing staff across the Post Anaesthetic Care Unit and the Enhanced Care Unit. The training of staff was/is incredibly time consuming and is a challenge for the POM Specialist Nurses to keep a wide team up to date. To address this, we are developing an e-learning package, which will allow nurses to update their knowledge on an annual basis.

We now have an FY1 doctor attached to the team on a 6-week rotation to gain experience in the perioperative management of patients presenting for major surgery.

Funding

Funding for the project initially came from a £75,000 Health Foundation Innovation for Improvement Grant in July 2015. The results of the first year of activity of the POM Service allowed us to successfully bid for ongoing funding from our Trust to embed and expand the service.  A second business case is in place to expand the existing service and open a second enhanced care area for patients undergoing major vascular surgery.

In 2015 our Trust remodelled into a hub and spoke geography with a new central emergency care hospital at its core and 4 surrounding elective surgical/ medical step down hospitals. All acute services from the 4 ‘base sites’ were amalgamated at the new hospital including Emergency Department, critical care and transfusion services. With this major change, a 4 bedded ‘SERU (surgical enhanced recovery unit)’ was designed and set up at 1 of the 4 base sites to initially take higher risk orthopaedic and spinal patients.

Aims

Evidence supports good outcomes for patients undergoing care in specialist ‘high volume’ centres with standardised packages of care.  Transfers confer risk and increase morbidity for patients.  The aim of SERU was to allow for higher risk patients to be operated on within the same hospital, under specialist experienced teams and prevent and minimise predictable transfers.  It also paralleled the development of the Bone Infection Unit onsite.

How it works

The SERU allows for a higher nursing to patient ratio (2:1), continuous non-invasive monitoring and administration of peripheral vasopressors.

Admissions to the SERU can be planned or determined intra-operatively for the following reasons:

1. Surgical – more complex revision arthroplasty cases, peri-acetabular osteotomy work and instrumented spinal surgery
2. Medical – significant comorbidity, elderly/frailty (we tend to find that factors such as diabetes and hypertension (on multiple agents) and higher frailty scores leaves patients needing vasopressor support post procedure).
3. Anaesthetic – stable patients with labile blood pressure requiring vasopressor support, stable patients requiring closer monitoring

Patients may only go to SERU immediately following their surgery via recovery and for a maximum of 20 hours. Within this timeframe the patient is either ready for stepdown to the main elective orthopaedic ward or necessitates escalation to a higher level of care (i.e transfer out to the emergency care hospital).  SERU closes at 7am and provides a service Monday afternoon until Friday morning.

Medical care overnight on SERU is delivered onsite by nurse practitioners experienced in post-operative care of spinal and orthopaedic patients.  This level of enhanced care with experienced staff in these areas offers high quality standardised care to patients.  There is currently a developing program of competency training for all nursing staff on the orthopaedic and spinal unit covering all areas of care of which SERU forms one part.  Clear protocols are in place for escalation in the event of any deterioration and staff receive regular contact with critical care outreach and anaesthesia services to reinforce this crucial team safety aspect.    

Measures of success

In 2016 we found that transfers from Wansbeck theatres/recovery to NSECH for post-operative vasopressor had reduced after SERU had opened. Importantly, patients will still receive early physiotherapy and mobilisation on SERU if appropriate, all measures which facilitate recovery.  By the main ‘ownership’ of the unit being ward based and nurse led, a secondary but critical success has been SERU’s ability to minimise unnecessary interventions and push each patient’s mobilisation and ‘normalisation’ at the right time.  Having a higher level of care area and its pathways has also enhanced and encouraged communication with critical care and escalation processes as well as providing enhanced education and career opportunities for staff.

Further things we needed to consider/projects in hand included a nursing skills competency guide.

Concluding comments

SERU was setup with patient safety and high quality orthopaedic and spinal care the key factor.  It also benefits patient flow and efficiency underpinned with the ethos of ‘doing the simple things very well’.   Through increased staffing levels, their education, clear protocols and standardised processes, patient monitoring while minimising additional interventions we are able to provide safe and effective care to our patients.

PACU offers care equivalent to level 2 critical care for patients who have undergone a procedure in the central operating theatres. The care is delivered in the theatre recovery area. It is solely intended for patients with a planned duration of required escalated care of less than 24hours.

• Case selection:  Patients due to undergo surgery are assessed in the pre-assessment clinic (PAC), and a recommendation for post-operative destination made.
• This may include a bed in Intensive Care (level 3), High dependency (level 2), Post-operative Care Unit (PACU), ward, or day case discharge.
  • This recommendation is not a mandated action, and is based on a combination of population based, and individual patient information.
  • On admission, and during the course of surgery, this recommendation may be altered by an assessment of the individual patient’s clinical course & condition.
  • An updated decision made on the day by the intensive care, anaesthetic and surgical multi-disciplinary teams may result in either upgrading or downgrading of the actual post-operative destination compared with the PAC recommendation.

• After their planned surgical procedure the patient is taken to recovery as per routine theatre cases.
• The anaesthetist responsible for the case will continue responsibility until the end of their list as per routine patients in recovery.
• The on call anaesthetic and surgical teams will be responsible for patients in PACU out of hours or in case of emergency.
• A critical care admission document should be completed by the theatre anaesthetist for all patients admitted to PACU.  In the event of an unplanned admission to PACU the on-call team will complete an admission form.
• Handover from the list anaesthetist to the on-call team should be to one person minimum and preferably 1^st call +/- anaesthetic consultant.  It is then incumbent on the person who received the handover to update the others on the team. 
• It is expected that the anaesthetic on-call team will review the PACU patients Monday –Friday between 1700-2000 hrs, enabling comprehensive handover to the night team.
• The on-call surgical specialty registrar must be aware of any patient in PACU and will provide appropriate surgical advice/ review and assist with patient management if the anaesthetic junior staff are otherwise busy.
• Additional cover will be available from the Consultant surgeon on call for the relevant specialty.
• The hospital at night (H@N) team will not usually be involved in the care of these patients whilst they are in PACU.
• Ultimate responsibility for patients in PACU (along with admission and discharge rights) will belong to the on call consultant anaesthetist.

• Admission / discharge timing: It is not mandatory (unless otherwise stated by the responsible anaesthetist) for patients electively admitted to PACU during the day to stay overnight.  If reviewed by the appropriate anaesthetic staff and deemed fit for discharge to the ward then after the necessary documentation the patient may be discharged on the day of surgery before 22.00hrs.  Between the hours of 22.00hrs and 07.00hrs it is recommend that patients are not discharged to the ward from Critical care areas (PACU included) unless circumstances are extreme and that it would constitute a critical incident if discharge occurred.  In these circumstances an appropriate form would need to be completed and the patient reviewed the following morning by the Outreach team on the ward. Planned discharge time for overnight stays on PACU is between 07.30 and 08.00am.
• Physiological scoring for PACU patients as per the NEWS system should be performed a minimum of 3 times for patients staying overnight. This includes a mandatory record at around 6am prior to 2^nd call review.
• Between 06.30 and 07.00 am the anaesthetic second call or if necessary the first call should review any patient in PACU. They should do a physical assessment and chart review, record it on the medical record and state whether the patient is fit for discharge to the ward.
• The morning review for discharge can be the first call but the patient cannot be discharged before either the 2^nd call or consultant has reviewed/signed off the review.
• Patient needs to be handed over to a medical team, not just a nurse, in the morning.

• If the second call does not think the patient fit for ward discharge then they must inform the nurse in charge of ITU of a potential need for an HDU bed. They must then also pass this information to the anaesthetist coming on to start in emergency theatre that day.

• Any patients not discharged by 8am will be reviewed by the consultant on call for emergency theatre at 08:00 – 08:15. If the patient is not likely to be fit for discharge within 30 mins then the emergency theatre consultant should contact the Critical Care Consultant immediately so they are aware of the need for this patients’ HDU admission before giving the go ahead to that days’ elective surgery patients.

• Emergency surgical patients or elective surgical patients with an unanticipated need for PACU overnight may be admitted to the PACU beds if capacity is available and they meet the standard PACU criteria in particular the suitability for discharge by 8am. (Temporary admission to an available PACU bed or the emergency bed until ICCU bed availability is urgently arranged may be considered for patients needing higher or more prolonged level of care).
• No more than 4 patients can be cared for on PACU at any one time. If a non-electively-booked-PACU-suitable patient needs prolonged post-op close observation during the evening or overnight and all the PACU beds are occupied then they can be cared for in the “Emergency Recovery” bed as the fifth patient in recovery. However that precludes recovery staff from taking any further patients. As such any patients having emergency surgery overnight will have to be recovered by the emergency theatre staff as occurred prior to the 24 hour recovery system being introduced. This fifth patient should be treated as a Recovery patient and would be eligible for discharge to the ward during the night if they meet discharge criteria.
• In the case of a patient requiring barrier nursing the patient has to be considered level 3 and will need a dedicated nurse.  This will effectively cut the number of patients that can be admitted to PACU.  This should not routinely happen and must only take place after discussion between the critical care consultant and the infection control team.
• When the lack of a ward bed prevents a patient returning to the ward at 8am the patient will be monitored to the same standard as a ward patient.  The responsibility for the patient will remain with the anaesthetic on-call team until they leave the recovery area.