Introduction of Enhanced Recovery After Surgery (ERAS) for cystectomy patients

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Background

Cystectomy is removal of the urinary bladder, performed at CGH in adults, usually to treatment bladder cancer. Following removal of the bladder, a segment of bowel is use to create a urinary stoma, which allows urine to drain from the kidneys to a bag on the abdominal wall. This is major surgery associated with a high risk of complications. Patients can expect a long post-operative hospital stay. Enhanced Recovery is now routine for patients undergoing other abdominal operations, such as colorectal surgery. It has been shown to reduce the length of stay and post-operative complications.

Aim

Following introduction of an Enhanced Recovery programme for adult patients undergoing cystectomy in The Trust, our primary aim was to reduce the length of stay by 20%. Secondary aims were to reduce the period of peri-operative fasting (i.e. restore normal diet sooner), reduce the period of immobility and produce a ‘shared care’ proforma to encourage MDT working.

Method

Our brief for the course was that it should be free, convenient (not requiring study leave) and open to all. The faculty for the course were the urology registrars providing training on 4 areas: simple/complex catheterisation, suprapubic catheterisation, haematuria/bladder washout & nephrostomy management. Equipment and facilities were provided by the Sandford Education Centre. Models were provided by Mediplus.

Results

We performed a literature review to help understand how other institutions introduced ERAS.

We met our stakeholders to ensure our proposed changes were achievable, likely to benefit patients and agreeable to stakeholder.

Based on these findings, we produced an Enhanced Recovery protocol, including a plan of care, daily ward round entry sheets and daily patient targets.

Introduced changes included:

• Improvement of pre-assessment to educate patients about ERAS.
• Providing patients with pre-operative carbohydrate drinks, and encouraging restoration of normal diet earlier than pre-ERAS, to reduced peri-operative fasting.
• Use of negative pressure suction dressings over the abdominal wound to reduce wound infection risk.
• Use of shorter drainage tubes to reduce restricted movement during the recovery period.
• Standardisation of the post-operative analgesia regime.
• Standardisation of post-operative daily goals for patients to adhere to (if able)
• ‘Prescribing’ patients daily targets to encourage earlier mobility, deep-breathing exercises to reduce risk of chest infection, self-injecting Fragmin to reduce VTE risk, independent stoma bag changes.
• Creation of a ‘SOS rescue plan’ for post-operative patients discharged home who need urgent advice.

Measured outcomes included:

• Length of stay
• Time to mobilise
• Time to eat a full diet
• Time to open pass wind/open bowels

Results:

Median length of stay was reduced from 13 to 7 days after introduction of ERAS.

Median time to pass wind reduced from 4 to 3 days.

There was no change in median time to open bowels (5 days)

Implications:

Reducing the peri-operative fasting state and encouraging earlier mobility seems to reduce overall length of stay. This may also reduce post-operative complications.

Next steps include formal printing of the ERAS protocol and pathway.

References

Dutton TJ et al. Implementation of the Exeter enhanced recovery programme for patients undergoing radical cystectomy. BJU Int. 2014; 113: 719-25

Smith J et al. Evolution of the Southampton enhanced recover programme for radical cystectomy and the aggregation of marginal gains. BJUI Int. 2014; 114: 375-383