Enhanced Recovery after Colorectal Surgery Pathway - West ...

Enhanced Recovery afterColorectal SurgeryPathwayEnhanced Recovery after Colorectal Surgery pathway is a programme of care aimedat reducing the physical trauma of surgery and achieving a complication-freerecovery, thereby shortening hospital stays for patients.Enhanced Recovery after Colorectal Surgery is a relatively new method of patientmanagement. It is a collection of strategies that combine in a structured pathwayallowing the surgical and anaesthetic teams to decrease the physical insult and aidrecovery enabling earlier discharge. This is achieved with fewer complications.While some of the following are active administrations of new modalities, there areothers that seek to reduce complications by minimising the effect of preparation forsurgery, and the surgery itself, on the gut. The 17 key elements included in theEnhanced Recovery after Colorectal Surgery Pathway are:1. Preoperative counselling2. Preoperative feeding (up to two hours prior to surgery)3. Reduced or No bowel preparation4. No premedication5. Fluid restriction (or at least optimisation)6. Perioperative high oxygen concentration7. Active prevention of hypothermia8. Epidural analgesia9. Laparoscopic or minimally-invasive incisions10. No routine use of NG tubes11. No routine use of drains12. Enforced postoperative mobilisation13. No systemic morphine use14. Standard laxatives15. Early removal of urinary catheters16. DVT prophylaxis17. Enhanced preoperative and postoperative nutrition via supplementsDeveloped with support from St Mark’s Hospital.Helen BroadwellEnhanced Recovery Nurse (Colorectal)July 2009

Patient addressograph / detailsName: ………………………………..……………………..D.O.B: ……………………………………………………...Hosp No: …………………………………………………...Consultant: …………………………………………………Signature SheetWard: ……………………………………………………….Date Print Name Signature ProfessionEnhanced Recovery for Colorectal Surgery. July 2009 v1 Page 2 of 13

Patient addressograph / detailsName: ………………………………..……………………..D.O.B: ……………………………………………………...Hosp No: …………………………………………………...Consultant: …………………………………………………Ward: ……………………………………………………….Patient reviewed by surgical doctorConsent signedPatient fully aware of planned surgeryInvestigations - Results availableBloods performed within the last 10-14 daysIf no must be repeated todayIf previously warfarinised check INRInform anaesthetist if INR >1.2X-ray and ECG availablePrescription chart writtenPre-Operation DayDate: …………………….Yes No n/aAdmission data: Yes No n/aPatient orientated to wardObservations - TPR,BP, SaO 2 and Pain scoreClexane prescribed and given at 18.00hrsAnti-embolism stockings given and appliedOrder pressure relieving equipment if appropriateCheck patient details and name bands insituBowel preparation as per protocolYes No n/aReferrals: Yes No n/aPain nursePhysiotherapistStoma nurseDieticianSocial workerAnaesthetic reviewNutrition: Yes No n/aNormal dietEnsure normal intake of oral fluidsPre-op drinks givenReferrals: Yes No n/aPain nursePhysiotherapistStoma nurseDieticianNurses Signature Day Shift Night ShiftPlease record any variancesTime Variance & Reason Action Taken SignatureEnhanced Recovery for Colorectal Surgery. July 2009 v1 Page 3 of 13

Patient addressograph / detailsName: ………………………………..……………………..D.O.B: ……………………………………………………...Hosp No: …………………………………………………...Consultant: …………………………………………………Ward: ……………………………………………………….Day of OperationDate: …………………….Ward: Yes No n/aNo food 6 hours before surgeryPre-op drinks and oral fluid up to 2 hours before surgeryTheatre preparation completedTED stockings insitu, if appropriate, observe heelsConfirm Clexane NOT given this amBowel preparation as per protocolPost-op Theatre / Recovery: Yes No n/aEpidural / PCA / painbuster insitu ... if no, record reasonObservations as per protocolUrine- minimum of 100mls over 4 hoursReport any abnormalities to anaesthetistPatient sat upPatient offered a drinkCheck Pressure Areas IntactTotal volume of IV fluid given in theatre =Estimated fluid loss in theatre =Nurses Signature Ward Nurse Recovery NursePlease record any variancesTime Variance & Reason Action Taken SignatureEnhanced Recovery for Colorectal Surgery. July 2009 v1 Page 4 of 13

Patient addressograph / detailsName: ………………………………..……………………..D.O.B: ……………………………………………………...Hosp No: …………………………………………………...Consultant: …………………………………………………Ward: ……………………………………………………….Post-Operation WardDate: …………………….Observations as per epidural / PCA / painbuster protocolMaintain fluid balance chartAdminister IV fluids and encourage oral intakeUrine output - ensure minimum output of 100mls over 4 hoursComplete stoma care plan if appropriateCheck pressure areas and record waterlow scoreMobility - ensure change of position- TED stockings insitu, if appropriate- refer to physio, if appropriate- 6hrs post surgery sit out for 2 hrs, if appropriateEncourage oral fluids, aim for 1000mlsHigh protein drinks x 2Check patient for gastric dilatation / paralytic ileus- patient feels unwell / nauseated- tachycardia >100- abdominal distensionPatient education - remind patient of programme requirementsYes No n/aNurses Signature Day Shift Night ShiftPlease record any variancesTime Variance & Reason Action Taken SignatureEnhanced Recovery for Colorectal Surgery. July 2009 v1 Page 5 of 13

Patient addressograph / detailsName: ………………………………..……………………..D.O.B: ……………………………………………………...Hosp No: …………………………………………………...Consultant: …………………………………………………Ward: ……………………………………………………….Post-Op Day 1Date: …………………….Observations as per epidural / PCA / painbuster protocolMaintain fluid balance chartDiscontinue IV fluidsUrine output- minimum of 100mls over 4hoursComplete stoma care plan ,if appropriateObserve woundCheck pressure areasMobility - out of bed for a total of 8hours- walks x 4 (aim for 60 metres each walk)- TED stockings insitu, if appropriate. Observe heels- promote deep breathing- refer to physio if appropriateEncourage oral fluids, at least 2000mlsHigh protein drinks - minimum of 2Light dietCheck patient to exclude gastric dilatation / paralytic ileus- patient feels unwell / nauseated- tachycardia >100- abdominal distensionPatient education - remind patient of programme requirementsBlood tests – FBC, U&E'S, LFTsDischarge planYes No n/aNurses Signature Day Shift Night ShiftPlease record any variancesTime Variance & Reason Action Taken SignatureEnhanced Recovery for Colorectal Surgery. July 2009 v1 Page 6 of 13

Patient addressograph / detailsName: ………………………………..……………………..D.O.B: ……………………………………………………...Hosp No: …………………………………………………...Consultant: …………………………………………………Ward: ……………………………………………………….Post-Op Day 2Date: …………………….Observations as per epidural / PCA / painbuster protocolMaintain fluid balance chartRecord any bowel motionWeigh patientRemove catheter - if remains state reasonDiscontinue epidural / PCA / painbuster, if appropriate- give oral analgesiaObserve wound - renew dressingHygiene needs metCheck pressure areasMobility - out of bed for a total of 8hours- walks x 4 (aim for 60 metres each walk)- TED stockings insitu, if appropriate. Observe heels- promote deep breathing- refer to physio if appropriateEncourage oral fluids, at least 2000mlsHigh protein drinks - minimum of 2Light / normal diet as toleratedCheck patient to exclude gastric dilatation / paralytic ileus- patient feels unwell / nauseated- tachycardia>100- abdominal distensionPatient education - remind patient of programme requirementsBlood tests - FBC and U&E'SDischarge planYes No n/aNurses Signature Day Shift Night ShiftPlease record any variancesTime Variance & Reason Action Taken SignatureEnhanced Recovery for Colorectal Surgery. July 2009 v1 Page 7 of 13

Patient addressograph / detailsName: ………………………………..……………………..D.O.B: ……………………………………………………...Hosp No: …………………………………………………...Consultant: …………………………………………………Ward: ……………………………………………………….Post-Op Day 3Date: …………………….Observations as per epidural / PCA / painbuster protocol- if epidural / PCA / painbuster down record 4 hourlyMaintain fluid balance chartRecord any bowel motionDiscontinue epidural / PCA / painbuster- give oral analgesiaIf catheter remains then state reasonComplete stoma care plan if appropriateObserve woundHygiene needs metCheck pressure areasMobility - out of bed for a total of 8hours- walks x 4 (aim for 60 metres each walk)- TED stockings insitu, if appropriate. Observe heels- promote deep breathing- refer to physio if appropriateEncourage oral fluids, aim for 2000mls- high protein drinks minimum of 2- normal dietCheck patient to exclude gastric dilatation / paralytic ileus- patient feels unwell / nauseated- tachycardia >100- abdominal distensionPatient education - remind patient of programme requirementsBlood tests - FBC and U&E'sDischarge planYes No n/aNurses Signature Day Shift Night ShiftPlease record any variancesTime Variance & Reason Action Taken SignatureEnhanced Recovery for Colorectal Surgery. July 2009 v1 Page 8 of 13

Patient addressograph / detailsName: ………………………………..……………………..D.O.B: ……………………………………………………...Hosp No: …………………………………………………...Consultant: …………………………………………………Ward: ……………………………………………………….Post-Op Day 4Date: …………………….Observations 4 hourlyMaintain fluid balance chartRecord any bowel motionWeigh patientIf catheter remains state reasonGive prescribed oral analgesiaComplete stoma care plan if appropriateObserve woundHygiene needs metCheck pressure areasMobility - out of bed for a total of 8hours- walks x 4 (aim for 60 metres each walk)- TED stockings insitu, if appropriate. Observe heels- promote deep breathing- refer to physio if appropriateEncourage oral fluids, aim for 2000mls- high protein drinks minimum of 2- normal dietCheck to exclude gastric dilatation / paralytic ileus- patient feels unwell / nauseated- tachycardia>100- abdominal distensionPatient education - remind patient of programme requirementsDischarge planYes No n/aNurses Signature Day Shift Night ShiftPlease record any variancesTime Variance & Reason Action Taken SignatureEnhanced Recovery for Colorectal Surgery. July 2009 v1 Page 9 of 13

Patient addressograph / detailsName: ………………………………..……………………..D.O.B: ……………………………………………………...Hosp No: …………………………………………………...Consultant: …………………………………………………Ward: ……………………………………………………….Post-Op Day 5Date: …………………….Observations 4 hourlyMaintain fluid balance chartRecord any bowel motionIf catheter remains state reasonObserve woundComplete stoma care plan if appropriateHygiene needs metCheck pressure areasMobility - out of bed for a total of 8hours- walks x 4 (aim for 60 metres each walk)- TED stockings insitu, if appropriate. Observe heels- promote deep breathingEncourage oral fluids, aim for 2000mls- high protein drinks minimum of 2- normal dietPatient education - remind patient of programme requirementsTTA's writtenDischarge planYes No n/aNurses Signature Day Shift Night ShiftPlease record any variancesTime Variance & Reason Action Taken SignatureEnhanced Recovery for Colorectal Surgery. July 2009 v1 Page 10 of 13

Patient addressograph / detailsName: ………………………………..……………………..D.O.B: ……………………………………………………...Hosp No: …………………………………………………...Discharge PlanConsultant: …………………………………………………Ward: ……………………………………………………….Patient fit for discharge.Yes No n/aNutrition: Yes No n/aAdvice on nutritional requirementsConsider giving high protein drinkEducation / Information: Yes No n/aPatient and carer preparedWritten information given to patientInformation leaflet discussedPatient has contact detailsWound Care: Yes No n/aDistrict / practice nurse letter givenDressings and staple remover suppliedMedications: Yes No n/aTTA's writtenTTA's given to patientOwn drugs returnedPatient understands about medications and regimeEnvironment Yes No n/aTransport homeTransport booked if requiredKeys to property availableDocumentation: Yes No n/aLetter to G.P.Out patients appointmentIf Stoma Present: Yes No n/aReviewed by stoma nurseProficient and confident in stoma careSupplies of appropriate applianceContact numbers for stoma nurseNurses SignatureDay ShiftEnhanced Recovery for Colorectal Surgery. July 2009 v1 Page 11 of 13

Patient addressograph / detailsName: ………………………………..……………………..D.O.B: ……………………………………………………...Hosp No: …………………………………………………...Consultant: …………………………………………………Ward: ……………………………………………………….Post-Op Day …..Date: …………………….Observations 4 hourlyMaintain fluid balance chartRecord any bowel motionIf catheter remains state reasonObserve woundComplete stoma care plan if appropriateHygiene needs metCheck pressure areasMobility - out of bed for a total of 8hours- walks x 4 (aim for 60 metres each walk)- TED stockings insitu, if appropriate. Observe heels- promote deep breathingEncourage oral fluids, aim for 2000mls- high protein drinks minimum of 2- normal dietPatient education - remind patient of programme requirementsTTA's writtenDischarge planYes No n/aNurses Signature Day Shift Night ShiftPlease record any variancesTime Variance & Reason Action Taken SignatureEnhanced Recovery for Colorectal Surgery. July 2009 v1 Page 12 of 13

Please record any variancesTime Variance & Reason Action Taken SignatureEnhanced Recovery for Colorectal Surgery. July 2009 v1 Page 13 of 13