ERAS

Dr fiona Carter bSc PhD, Manager of ERAS-UK Mrs Imogen fecher-Jones bSc MSc2 , ERAS facilitator Mrs Pat Darty2 , Conference co-ordinator Professor Michael Grocott bSc MbbS MD fRCA fRCP ffICM2 , Conference chairman Nader K francis MbbS PhD fRCS (Gen Surg)1, ERAS-UK Chairman

Affiliations 1 enhanced recovery After Surgery Society (UK) 2 University hospital Southampton nhS foundation trust

exPAnding the SCoPe And exPloring the JoUrney of enhAnCed reCoVery After SUrgery

Conference report: 4th Enhanced recovery after Surgery Uk at the Hub, City College, Southampton on 14th November 2014.

The Enhanced Recovery after Surgery Society (UK) was set up in 2010 with the aim of improving patient recovery after surgery by promoting knowledge, understanding and research regarding optimal outcomes. Each year, ERAS UK holds a national conference to highlight and share best practice and emerging techniques. This meeting provided a valuable opportunity for ERAS teams to network and discuss common challenges.

This year, our conference was co-hosted by a multi-disciplinary team from University Hospitals Southampton, led by Professor Michael Grocott. Held at the Hub, City College, Southampton, this event welcomed almost 200 participants from across the UK and beyond. The organising group had agreed on five main themes for the 2014 meeting: 1 Exploring transitions of care 2 Non-elective or non-surgical care 3 The impact of new technology or new techniques on ERAS 4 Measurement of ERAS outcomes 5 Tackling the challenges of sustainability

In addition to invited speakers, there were also 27 abstracts accepted for presentation, with seven of these given as oral presentations. In line with previous events, ERAS UK awarded prizes for the top three posters and oral presentations.

ExPLoRING TRANSITIoNS of CARE There is increasing awareness that much more work needs to be done to improve both the prehabilitation process and the longer recovery period after discharge. Dr Charles Alessi (Chairman of the National Association of Primary Care) set the scene for the day by describing the challenges of managing patients with multi-morbidity and the need to develop personalised care. Developing metrics that can reflect the activity across different sectors of healthcare will become increasingly important Developments in prehabilitation were highlighted by Mr Babu Naidu (Clinical Scientist, University of Birmingham) where rehabilitation pathways for Chronic Obstructive Pulmonary Disease patients have been adapted for the pre-operative period for lung cancer surgical patients. This involves pulmonary exercise classes, smoking cessation, patient education and assessment of nutrition, with dietary input if necessary. A patient story that highlights this approach is available online at http:// Vimeo.com/61707728. A reduction in pulmonary complications from 16 percent to nine percent, together with a reduction in readmission from 12 percent to four percent has been achieved through this approach. Dr Rachael Barlow, a Clinical Academic from Cardiff University, discussed the role of ERAS UK in research in the future and the formation of a research development group. A recent NIHR funded study highlighted the need for more multicentre randomised controlled trials and a greater focus on the evidence for cost-effectiveness for ERAS. The lengthy delays in essential treatment for cancer patients after discharge were highlighted by Mr Nader Francis (Consultant Colorectal Surgeon, Yeovil Dis-

trict Hospital & Chair of ERAS UK). In particular, this study detailed the significant variation in timing of chemotherapy for colorectal cancer patients after discharge, indicating that ERAS benefits do not extend beyond the hospital admission.

The final talk in this session was an abstract on ERAS ‘plus’ for frail elderly patients, from Dr Elizabeth MacDonald (NHS Lothian). This interdisciplinary project covers the patient journey from prehabilitation to discharge, with specific frailty markers embedded in the pathway. There was a significant percentage of frail surgical patients and that their needs were not always addressed by the conventional care pathways. Some aspects of frailty, such as comorbidity and polypharmacy, are more obvious than others (such as cognitive decline). Enhanced care can be targeted at the people who need it to provide better quality of care and improved outcomes for these frail elderly patients.

NoN-ELECTIvE oR NoN-SURGICAL CARE This session was opened by Dr Martin Kuper, Medical Director of Homerton Hospital, who described the process of setting up an enhanced recovery hospital. The conference chairman, Professor Michael Grocott, provided an overview of enhanced recovery following emergency laparotomy. Recent studies have shown impressive results, such as a reduction in 30-day mortality for the highest risk patients from 27 percent to 16 percent through use of these protocols. The national emergency laparotomy audit highlighted the lack of essential resources in some centres, such as lack of 24-hour access to emergency theatres, endoscopy or interventional radiology. Action plans and pathways form the best performing centres are being shared in an attempt to raise quality.

Professor Grocott then outlined the EPOCH study and explained the cluster approach of this research, which uses the National Laparotomy Audit data collection tool as a cost-effective means of measurement (find out more here: www.epochtrial.org/ epoch.php?page=about). He concluded with the important point that the principles of enhanced recovery (multi-disciplinary collaboration, measurement of interventions and continuous improvement) can be applied to almost any aspect of healthcare.

The ambitious project of redesigning pathways across a whole health board in Wales was described by Dr Rachel Barlow, who emphasised that ERAS should be seen as a quality initiative which opens up capacity and improves cost effectiveness. One of the major issues is that staff often do not realise the part that they play within ERAS pathways and this lack of awareness must be challenged by local ERAS leads and champions.

Mr Tim Batchelor (Bristol Royal Infirmary) presented his initiatives in using ERAS for non-elective thoracic surgery patients, who are disadvantaged by the lack of access of the pre-operative ERAS pathways and undergo a functional decline as a result of prolonged hospitalisation and waiting for transfer to his tertiary centre for treatment. Ensuring that these patients are encouraged to follow a multidisciplinary pathway before surgery should result in improved post-operative outcomes.

Two oral abstract presentations closed this session, with the first from Mr Tom Wainwright (Bournemouth University), who discussed the huge potential impact of applying enhanced recovery to fractured neck of femur patients nationally. Applying modelling to data extracted from Hospital Episode Statistics, Tom predicted that over 86,000 bed days could be saved if all centres could reduce their length of stay to the current national mean (19.6 days).

The second abstract presentation was delivered jointly by Josie Caffrey and Rachel Thomas (Royal Berkshire NHS FT), who described the implementation of an elderly care pathway across five wards. They demonstrate an improvement in patient experience, staff attitudes and team working.

THE IMPACT of NEW TECHNoLoGy oR NEW TECHNIqUES oN ERAS Our third session was opened by Dr William Fawcett (Royal Surrey County Hospital) who provided an update on analgesia techniques that are relevant for enhanced recovery. He began by emphasising the importance of good analgesia in peroperative care in that it can allow earlier mobilisation, reduced organ dysfunction and stress response, earlier return to normal eating and drinking and faster discharge. This is largely achieved by multimodal analgesia and avoidance of opioids.

Mr Tom Wainwright then presented his second abstract of the day, on a novel device (gekoTM) to reduce post-operative oedema. This device works by stimulating the extensor muscles in the calf and results in increased venous return. Use of the gekoTM as opposed the conventional TED stockings resulted

in a significant reduction in lower limb volume in the postoperative period.

The impact of technology on colorectal surgery was discussed by Professor David Jayne (Leeds Teaching Hospitals), starting with the introduction of laparoscopic surgery in the 1990s which significantly reduced post-operative pain, increased mobilisation and more rapid return to normal activity. These benefits, when combined with ERAS protocols have been examined in two RCTs (LAFA study: www.ncbi.nlm.nih. gov/pubmed/21597360, ENROL trial: http:// jco.ascopubs.org/content/early/2014/05/05/ JCO.2013.54.3694). Professor Jayne described the increasing use of robotic surgery, particularly for rectal cancer resections, where the surgeon’s control of the operative image and greater precision of the instrumentation reduce the likelihood of conversion to open surgery. Newer developments, such as single port surgery, may confer cosmetic benefits to the patient, but currently have no demonstrable benefits on outcomes. Professor Jayne closed by looking to the future technologies, in particular endoluminal or trans-anal surgery, which will be important as patient demographics change in the coming years.

Ms Marielle Nobbenhuis (Royal Marsden Hospital) and Mr Anthony Koupparis (Southmead Hospital) both gave excellent talks on the impact of robotics on gynaecological oncology surgery and urology surgery respectively.

MEASUREMENT of ERAS oUTCoMES Vaneesha Short (University of Bristol) started this session with an abstract presentation on a qualitative study of perioperative nutrition in patients undergoing colorectal surgery. The outcomes of this study could identify potential barriers and facilitators to feeding during the colorectal patient journey. Use of ERAS in patients having liver resection was the next abstract presented by Charlotte Hitchens (Derriford Hospital), reported a reduction in length of stay by two days for this group of patients. The final abstract presentation of the day was from Jennifer Mason (Yeovil District Hospital) about the factors that can predict 30-day readmission after colorectal surgery. It was interesting to note that poor compliance with the post-operative elements of the ERAS pathway significantly increased the likelihood of readmission.

The current progress with widespread implementation of ERAS in Wales, together with national reporting systems was set out by Dr Rachael Barlow and this was then followed by an update on the Scottish national data collection programme by Mr David McDonald (Scottish Government). Mr Nader Francis presented the last talk in this session with a brief overview of a recent survey of ERAS UK members looking at what aspects of ERAS are being measured locally and what sort of tools are used to do this. Whilst a majority of centres are recording compliance with specific ERAS elements, most teams are using local databases or spreadsheets for this purpose, making benchmarking virtually impossible.

TACKLING THE CHALLENGES of SUSTAINAbILITy The final session commenced with a debate on the topic: ‘What is delaying recovery?’ with Dr Mike Scott (Royal Surrey County Hospital) arguing that poor individualised fluid management is the main culprit. Mr Julian Smith (University Hospitals Southampton) presented his views that the culture of care was the main cause for delay and Mrs Imogen Fecher-Jones concluded the debate with her views that support at weekends, issues in critical care and challenges with patient’s social circumstances were the main barriers to recovery.

Fiona Dalton, Chief Executive of University Hospitals Southampton gave the final address of the conference, with a powerful overview of the challenges facing the NHS and some insight into future directions for sustaining ERAS.

In summary, the 4th National ERAS UK conference was very positively perceived by the feedback from the delegates, faculty and the 12 industrial sponsors. The full conference programme and many of the presentations are available to view on ERAS UK website (www.erasuk. net). The 5th ERAS UK conference will be held in Scotland on 6th November. Suggestions for content are very welcome and you can get involved via the website.

Acknowledgements ERAS UK is grateful to the following companies who kindly provided financial support for this event: BBraun, Convatec, Deltex, Edwards, Halyard Health, Lidco, Massimo, MSD, Napp, Nutricia, Smith & Nephew and Vitaflo. In addition, ERAS UK would like to thank all the members of the organising committee and staff from the UHS service improvement department for their support on the day.