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24th July 2024
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 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.
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.
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.
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.
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.
21st February 2023
This article discusses some of the enhanced recovery after surgery (ERAS) strategies that can be employed in optimising long-term conditions peri-operatively to achieve the best possible patient outcomes
The World Health Organization has estimated that approximately 234 million surgical procedures are performed worldwide each year.1
Although most of these procedures are uncomplicated, an increasing number of individuals are at risk of adverse outcomes because of comorbid conditions and poor functional capacity.
At age 65, some 50% of the UK population has multimorbidity, defined as two or more long-term conditions, and this proportion rises with age and deprivation.2
Complications that prolong length of stay occur after approximately 15% of inpatient operations, which can be mitigated by optimising patients for surgery.3
One of the key stages of enhanced recovery (ER) is optimising patients for surgery. The concept of ER was first pioneered in Denmark in the late 1990s for patients undergoing colorectal surgery.4
Since their introduction in the UK in the early 2000s, ER pathways have been successfully implemented within various surgical specialities in the UK, the primary aim being to reduce the length of stay while still providing a high-quality package of care.
Fundamental to all aspects of ER is that patients are ‘partners in their own care’ and are kept fully informed throughout their surgical journey.
It is crucial that assessment and preparation for surgery starts as soon as possible adopting a multi-modal, trans-disciplinary approach.2 Primary care physicians can play a major role in identifying the modifiable causes of increased morbidity; for example, smoking, reduced physical activity, excess alcohol and poor nutrition prior to referral for surgery.
Pre-assessment clinics (nurse-, anaesthetist- and pharmacist-led) are also crucial in identifying these ‘high-risk’ patients with multiple comorbidities at risk of post-operative complications: for example, pre-existing anaemia, diabetes, cardiovascular and respiratory disease.
In line with the ER initiative, a pharmacist-led Enhanced Surgical Medicines Optimisation Service (ESMOS) was implemented in a large 1200-bedded tertiary hospital in Central Manchester in September 2017 to mitigate the risks of post-operative complications and optimise post-operative care.5
The goals of the ESMOS service are to identify high-risk surgical patients once they are listed for surgery and get them in the best possible state for surgery by focusing on optimising their pre-existing comorbidities.
During the pre-operative phase, patients are reviewed in a virtual pharmacist clinic whereby patients’ pre-existing medical comorbidities are recorded by pharmacists along with any high-risk medication the patient is taking.6,7
The goal at this stage is to optimise long-term conditions prior to surgery. The ESMOS was initially rolled out to four main general surgical sub-specialties: hepato-pancreato-biliary (HPB); upper gastrointestinal (GI); lower GI; and vascular surgery.
The results of the 12-month follow up study following implementation of the ESMOS service demonstrated a significant reduction in length of stay and post-operative complications.6
Pharmacists can play a key role in identifying patients with co-morbid conditions and optimising these prior to surgery as time allows. Figure 1 summarises the key areas of optimisation.
Over the next section, strategies that can be employed in optimising these comorbid conditions are discussed in more detail.
Thorough assessment of cardiac morbidity is particularly important for high-risk surgical patients. The revised cardiac risk index is one of the most validated and widely used risk assessment tools for predicting peri-operative risk in patients with cardiac comorbidities.7
Hypertension alone is only a minor independent risk factor for adverse cardiac events in non-cardiac surgery.7 Postponement of planned surgical procedures due to elevated blood pressure is a common reason to cancel necessary surgery.
The Joint Guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society have produced a consensus statement stating patients with clinic blood pressures below 180mmHg systolic and 110mmHg diastolic should not have their surgical procedure delayed.8
Patients with stage 3 hypertension (BP >180mmHg systolic /110mmHg diastolic) should have their surgery delayed with BP optimisation and allowing a minimum of 4-6 weeks of treatment following the National Institute for Health and Care Excellence/British Heart Society CG127 algorithm.8
Patients presenting with stage 1 (BP 130–139mmHg systolic or 80–89mmHg diastolic) or stage 2 hypertension (BP >140mmHg systolic or 90mmHg diastolic) are considered safe to proceed to surgery.8
It should be noted that patients with diastolic pressure ≥110mmHg immediately before surgery have been shown to have increased risk of complications including myocardial infarction and renal failure.9
Heart failure is a global problem, with at least 26 million people affected.10 The prevalence of heart failure is also increasing as the population ages, and more patients with congestive heart failure will present for surgery.11
In patients with acutely decompensated heart failure (New York Heart Association class IV), surgery should be postponed, if possible, and the opinion of a cardiologist sought for titration of heart failure medication.7 Pharmacists can play a vital role in up-titration of heart failure medication in this crucial period.
Pre-operative optimisation of lung function helps to reduce post-operative pulmonary complications.12 Patients are advised to stop smoking for a period of four to six weeks. This reduces airway reactivity, improves mucociliary function and decreases carboxy-haemoglobin.12 Pharmacists can help promote smoking cessation advice to these ‘at-risk’ patients.
Incentive spirometry pre-operatively has also proved to be effective in reducing post-operative pulmonary complications.13
Pharmacists can further support patients by providing the appropriate counselling on correct inhaler technique and checking compliance. Patients with symptomatic asthma should have their treatment increased until symptom control is achieved.14
Approximately 4.5% of the UK population aged over 40 years are affected by chronic obstructive pulmonary disease (COPD).15
For the care of COPD, the updated National Institute for Health and Care Excellence (NICE) guidance emphasises ‘five fundamentals’ of chronic obstructive pulmonary disease care: offer treatment and support to stop smoking; offer pneumococcal and influenza vaccinations; offer pulmonary rehabilitation for people with COPD (if indicated); co-develop a personalised self-management plan; and optimise treatment of comorbidities.16 Postponement of surgery is advisable only after a recent exacerbation.13
Peri-operative hyperglycaemia, whether the cause is known diabetes, undiagnosed diabetes or stress hyperglycaemia, is a risk factor for harm, increased length of stay and death.17,18
The Centre for Peri-operative Care (CPOC) in the UK has published guidance on the peri-operative care for patients with diabetes mellitus undergoing elective and emergency surgery.19
Ideally, diabetic patients should be optimised at the time of referral from primary care.17 In situations where this is not possible, advice from the diabetes team should be sought as soon as possible to facilitate optimisation.
The key recommendations from the CPOC guideline are that pre-operative assessment clinics should refer all patients with a HbA1C of 69mmol/mol and above, an insulin pump or a continuous subcutaneous insulin infusion (CSII) to a specialist diabetes team for treatment optimisation.19
Another recommendation from this document is that pre-assessment clinics should work where possible, with the pharmacy team to ensure medicines reconciliation prior to admission to reduce medication errors including a system for patients to report changes to their medication between their pre-operative assessment and date of surgery.
Ideally, diabetic medication should be pre-prescribed prior to admission and for best practice rescue treatment should also be pre-prescribed for looming hypo- or hyperglycaemia.19
Pharmacists can use this vital time adequately to promote lifestyle interventions such as smoking cessation, lifestyle modification, reduction in alcohol intake, optimal nutrition and weight management.
It has been estimated that approximately 40% of patients presenting for surgery are anaemic.20 Pre-operative anaemia is associated with significantly higher rates of morbidity and mortality and increased need for blood transfusion.
Patients undergoing major surgery (defined as blood loss >500ml expected or possible) should be optimised if their haemoglobin concentration is less than 130g/l on screening.
Detection of pre-operative anaemia should be carried out as soon as possible, at least 14 days before elective surgery.21
Figure 2 suggests a treatment algorithm for different types of anaemia from diagnosis to surgery based on an international consensus statement as described by Munoz et al.22
Treatment of iron deficiency anaemia should be carried out with iron supplementation, and there is good evidence that this results in higher haemoglobin concentrations, lower transfusion rates and better quality of life.21 When the interval between investigation and surgery is sufficient (>6 weeks), oral iron treatment may be considered.21
Pharmacists can play a key role in optimising pre-operative anaemia by identifying affected patients in the first instance, interpreting laboratory results and working with the wider multi-disciplinary team to ensure a management plan is in place to correct the anaemia.
An increasing number of patients considered for surgery are on anticoagulants hence it is important that these are managed appropriately in the peri-operative period to reduce the incidence of thrombotic events.
The British Society of Haematology has published guidelines on the peri-operative management of anticoagulation.23 Pharmacists can support pre-assessment clinics by ensuring these patients have an appropriate management plan in place.
For those patients on warfarin, this should be stopped for five days prior to surgery and bridging-dose heparin should be considered in high-risk patients, with the last dose at least 24 hours prior to surgery for those on a once-daily regimen.
For patients on direct oral anticoagulants, the peri-operative management approach is based on an approximate calculation of the half-life of the drug and renal function. This is combined with consideration of the bleeding risk of the proposed procedure and a clinical evaluation of the patient’s individual risk factors for bleeding and thrombosis. Where available, local guidelines should be consulted and advise sought from specialist haematology teams in complex patients.
This article summarises some of the strategies that can be employed in this crucial pre-operative period to optimise patients for surgery to achieve the best possible patient outcomes. It is recognised that the surgery waiting lists in the UK already under pressure have been further increased by the COVID-19 pandemic. These waiting lists provide a unique opportunity for multidisciplinary teams to work collaboratively, further supporting the concept of enhanced recovery.
First published by our sister publication Hospital Pharmacy Europe.
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