Jason Ali is a consultant cardiothoracic surgeon at Royal Papworth Hospital and the surgical clinical lead for the hospital’s new ‘Enhanced Recovery Unit’. Together with consultant intensivist Dr Mike Hoy and lead nurses Michelle Barfoot and Jonee Doronila, he has overseen the development and implementation of this new initiative aimed at improving the flow and experience of cardiac surgical patients in the early postoperative period.
Royal Papworth Hospital in Cambridge, UK, has a highly specialised intensive care unit (ITU) with many competing demands. In addition to cardiac surgery, there are patients requiring cardiothoracic transplant and mechanical circulatory support, respiratory extracorporeal membrane oxygenation (ECMO) and various cardiology procedures.
We have recently had challenges with cardiac surgical operations being cancelled due to a lack of ITU capacity, which needed resolving. The cardiothoracic surgery ‘Getting It Right First Time’ (GIRFT) report recommended ‘ring-fencing’ intensive care beds for cardiac surgery as a means of improving throughput and reducing cancellations.
The Enhanced Recovery Unit (ERU) was developed with this in mind – both offering the ability to ring-fence ITU beds for cardiac surgery and an opportunity for quality improvement by looking to enhance patients early postoperative recovery. It was hoped that this would improve the flow of cardiac surgical patients through the ITU – and the hospital – which should allow the team to limit cancellations and reduce waiting lists.
The ERU model and team structure
The ERU has been created as a new, standalone unit occupying a section of our original ITU. It has been established as a new business unit within the Trust, with separate clinical governance processes and directorate accountability.
The ERU model is a short-stay level 3 (intensive care) unit, with a maximum length of stay of 48 hours to maximise patient flow. If patients require ongoing level 3 care beyond 48 hours, they will be transferred to our adjacent ITU for ongoing management.
We are proud that the ERU is nurse-led. The unit leadership structure comprises two lead nurses, Michelle Barfoot and Jonee Doronila, with support from a dedicated lead intensivist Dr Mike Hoy and myself as lead surgeon.
On each shift there is a ‘cardiac surgical specialist’ nurse, who is a band 6 or 7, and has undergone specific training and ongoing assessment in managing immediate post cardiac surgical patients. They lead a team of bedside nurses, managing postoperative patients, with the aim of early extubation and early mobilisation – key components of enhancing recovery.
They are trained to manage common problems encountered in this patient population and are supported by surgical and anaesthetic doctors. Their aim is to have all patients sitting in their chair eating breakfast by the first post-operative morning, preferably drain free, ready to be transferred to our surgical ward.
Patient selection and enhancing outcomes
We currently have only five beds in the ERU. To maintain patient flow, we are restricting admission to cardiac surgical patients who we predict will be admitted for less than 24 hours based on complexity of their surgery and how unwell the patient is preoperatively. Patients who are unlikely to be discharged within 24 hours, or who will require more advanced organ support, continue to be admitted to our ITU.
In time, we aim to expand the number of beds, and this will allow for relaxing of our selection criteria to those likely to require admission for less than 48 hours, meaning that a greater proportion of our surgical patients can benefit from the enhanced immediate postoperative care offered by our unit.
We hope that implementation of the ERU will improve our patients’ experience and lead to a reduction in the length of our waiting lists. We anticipate this will be achieved by reducing the length of stay of our surgical patients and by improving patient flow through the hospital, which will reduce cancellations.
We also see that there are significant benefits for our nursing staff, and we are confident that the ERU will have a really positive impact on nursing recruitment and retention. This is because the nurse-led nature of the ERU offers excellent opportunities for nursing staff progression and empowerment. There will be ample opportunities for learning and development with promotion into cardiac surgical specialist roles.
We hope that the smaller ERU team will allow for enhanced support of our nursing staff, offering a greater sense of belonging and improving staff wellbeing and morale.
Reception and feedback
Implementation of the ERU has been a great success so far. There is widespread recognition throughout the hospital of the positive impact the unit has been having on patient flow. In the first four weeks of opening, we admitted 101 patients, with 89% being transferred to the surgical ward within 48 hours.
It is not unusual to walk through the unit first thing in the morning and see all five patients sitting in their chair eating breakfast, which is an excellent achievement, and a major advancement on the care we were providing our postoperative patients previously. As a result, the feedback from surgeons and the patients has been very good.
There is a real sense of positivity in the unit from the nursing team, who are proud of the work they are doing and these early achievements. The unit is evolving, but so far so good.
Replicating this ERU model in other hospitals
Cardiac centres in the UK vary a lot in their practice. Unlike Royal Papworth Hospital, which is a dedicated tertiary cardiothoracic centre, some hospitals share critical care units with other surgical specialties, which brings its own challenges. There are cardiac centres in the UK that have recovery units and others that have high-dependency units for the early postoperative management of cardiac surgical patients. We are not aware if these have a similar nurse-led model for the care provided in these units.
Although it is early days in our experience, the positive impact of the ERU has already been felt – both with patient flow and with morale of the nurses working in the unit. We would strongly recommend other cardiac surgical centres to consider the nurse-led model for early postoperative management of cardiac surgical patients, especially as the unit offers the opportunity to truly ring-fence beds from competing demands.
The success of our implementation came from early collaboration between intensive care physicians, surgeons and senior nurses working together with hospital management to design the unit and define the protocol to be followed when managing patients.
Looking to the future
We hope that the ERU will allow us to reduce our waiting lists for cardiac surgery at Royal Papworth Hospital, which have been growing in recent years since the Covid-19 pandemic. We believe that streamlining the immediate postoperative recovery of patients will have a positive impact and improve their experience.
We anticipate that the ERU is just the start of a larger project looking to enhance patients’ recovery following cardiac surgery at our centre and we will be reviewing each step of a patient’s journey, looking to implement changes that promote enhanced recovery.
With time, we are planning on expanding the unit to 10 beds, which will allow for the desired relaxing of the patient selection criteria. Expanding slowly will allow appropriate time for the confidence and expertise of the team to develop, which is important in building a successful department.
We hope that this will ultimately allow us to expand the number of operations we do a year, allowing us to maintain our position as one of the largest cardiothoracic centres in the UK.
This article is part of our Clinical Excellence series, which offers valuable first-hand insights into how experts from renowned Centres of Excellence are pursuing innovative approaches to optimise patient care across the UK and Europe.
