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A new approach to major surgery is being introduced in two London hospital trusts, with the potential to reduce significantly the length of time patients stay in hospital. The approach combines better preoperative assessment, intraoperative monitoring, and postoperative recovery.
The enhanced surgical treatment and recovery programme (ESTREP) combines preoperative and postoperative aspects of other programmes that have previously been shown to improve the outcomes of surgery with an additional element of specialist anaesthetic monitoring and care during operations.
It has been developed by colorectal surgeons at University College London Hospitals NHS Foundation Trust, which will extend it to all colorectal surgery from next week, and from Guy's and St Thomas' NHS Foundation Trust, which has been using the programme for all patients undergoing elective colorectal surgery over the past six months. The results are being audited and the surgeons hope to publish their findings later in the year.
Andrew Williams, a consultant colorectal and general surgeon at Guy's and St Thomas' and one of the surgeons who developed the programme, said, “There have been a lot of advances over the last few years around the edges of performing surgery that we have brought together into an optimised care package. It combines lots of different elements that together provide the best standard of evidence based care for patients undergoing surgery.”
He added that the programme had been developed for use in patients undergoing complex surgery rather than just simple procedures.
Before their operation, patients are comprehensively prepared with a package of education about their “surgical journey” and an objective assessment of their fitness to undergo the operation they need. Previous research has shown that educating patients to expect to recover, mobilise, and eat early after surgery significantly improves their outcomes. Patients' nutrition is also optimised, with carbohydrate loading and minimising the “nil by mouth” period.
The London surgeons have added strategies during surgery designed to enhance patients' recovery still further, particularly in the more complex surgery that patients seen at teaching hospitals tend to undergo. They use minimally invasive surgical techniques and epidural anaesthesia wherever possible and precise cardiac and fluid monitoring during operations.
This specialist monitoring uses oesophageal Doppler monitoring, which monitors fluid output from the heart. The technique is considered best practice by the National Institute for Health and Clinical Excellence but is currently used in less than 5% of major operations in the United Kingdom.
Alastair Windsor, a consultant in colorectal surgery at University College London Hospitals, who helped to develop the programme, explained that more precise fluid monitoring during surgery can greatly improve outcomes. “If it is not used, fluid replacement tends to be done on a more ad hoc basis, depending on factors such as duration of surgery and blood loss. To be on the safe side, patients are often slightly overloaded with fluids, which can cause oedema and affect gut function.
“Using oesophageal Doppler monitoring provides very accurate and continuous measure of cardiac output, allowing very precise fluid balance. It can avoid the complications associated with overloading or underloading fluids—so allowing patients to recover from surgery more quickly.”
After their operation, patients follow a defined postoperative programme that includes rapid mobilisation and early return to eating and drinking, thus minimising surgical complications while encouraging recovery and discharge.
The new programme is nurse led and uses protocols to streamline its administration. Elements such as analgaesia and the need for intensive care are preplanned, on the basis of careful preoperative assessment of each patient. As long as patients meet the standards set out in the protocol they do not have to be seen by a doctor before discharge from the hospital, as is currently routinely required.
Mr Williams added: “The programme is a paradigm shift in how we deliver care. It traverses all specialties and budgets to optimise surgical care and changes a lot of preconceptions, such as the need for ‘nil by mouth,' bowel preps, and delayed mobilisation.”
The programme is expected to reduce the average stay in hospital for patients undergoing complex colorectal surgery from 12 days to eight days. Results so far have shown an average reduction in hospital stay of 1.5 days, but Mr Williams considered that staff were still getting used to the scheme, so this may reduce further. Each day in an NHS general or surgical ward currently costs up to £400 (€590; $800), depending on the additional care needed, so the scheme could achieve considerable savings. The Department of Health was supportive of the programme at a recent meeting.
Mr Windsor emphasised that the programme provides the best standard of care to patients, in addition to reducing hospital stays. “Patients recover more rapidly and are fit for discharge earlier, as opposed to being prematurely discharged to recover at home.”
The programme is initially being used for patients undergoing colorectal surgery but will be extended to other types of surgery, including vascular, gynaecological, and orthopaedic surgery, if the results are good.