Want to get out of hospital in record time ? Scoff yourself
Date Posted: 04.09.2012
Having an operation?
For decades, this has meant nil by mouth for at least eight hours before surgery, no food for several days afterwards, lots of bed rest and a hospital stay of up to two weeks. But over the past three years the rulebook appears to have been ripped up.
Enhanced recovery — also known as fast-track recovery — is a new system that’s quietly revolutionising hospital care.
It involves feeding up or ‘carb-loading’ patients with high-calorie snacks and drinks just before and after surgery, getting them up and walking about as soon as possible afterwards and more localised pain relief. It sounds controversial, but the system has seen a fall in complication rates, and inpatient stays dramatically reduced by 50 per cent in most cases.
First introduced for colorectal patients, then orthopaedics, gynaecology and urology, the programme is being rapidly extended to other specialities. The theory is that if patients are well fed they won’t lose weight, meaning they’ll get better quicker and up and about sooner, so they don’t lose muscle strength. This, in turn, means they leave hospital sooner and are less prone to complications and infections.
In just under three years, the number of hospitals offering enhanced recovery has mushroomed from fewer than 50 hospitals in 2009 to 86 per cent of all NHS hospitals implementing it in at least one speciality, according to Department of Health estimates. ‘Enhanced recovery isn’t about the NHS pushing people out of hospital before they’re ready,’ says Professor Mike Richards, National Cancer Director and chairman of the Enhanced Recovery Partnership, an NHS/Department of Health umbrella group.
‘These patients are as well when they are discharged as they would have been had they had a much longer hospital stay — they are just getting better quicker. ‘And readmission rates for complications have not risen. 'Patients like it, too — given the choice, most of us would prefer to recover in the comfort of our own homes.’
The enhanced recovery approach was pioneered in Denmark by Professor Henrik Kehlet in 1997 — he didn’t think it made sense to starve patients before and after surgery when they needed their strength for recovery. His revolutionary approach was brought to Britain in 2002 by colorectal surgeons and by 2009 the Department of Health backed a national programme to spread good practice to other specialities.
The approach varies according to the problem — to speed recovery, some patients are given less invasive keyhole surgery techniques or localised pain injections rather than epidurals and ultrasound monitoring of hydration levels. And the method seems to be working: at St Mark’s Hospital in North London, bowel surgery patients who would have previously spent two or three weeks in hospital are fit to go home after three to five days, thanks to an enhanced recovery programme.
Meanwhile, at Poole General Hospital the length of hospital stays for hip and knee replacements fell by half after the new principles were applied.
Surgeons are even applying enhanced recovery to one of the most complicated cancer operations.
At the Royal Surrey County Hospital, Guildford, surgeon Shaun Preston and his team have more than halved inpatient stays for patients undergoing surgery for oesophageal cancer from 16 to seven days and reduced complication rates by 35 per cent. ‘When we first talked about enhanced recovery for these patients, no one believed they could get better so quickly after such radical surgery,’ says Mr Preston.
Then in 2007 he read that it was being used by a team in Seattle with extraordinary success. He flew out for a week to observe them and came back with a plan to introduce it for British patients.
‘These operations take six to ten hours to perform; we have to open the chest and the abdomen and sometimes collapse a lung to get access to the oesophagus. ‘We then have to move the stomach into the chest to make a new oesophagus before joining it to the remaining oesophagus high in the chest or neck — it’s major trauma to the body. ‘We didn’t change any of the surgical or anaesthetic procedures. It was more a case of changing the patient’s expectations — we told them we would sit them up in bed for four hours after surgery.
At 7am the next day they would be sat up in bed ready for the physiotherapists. They would walk or march on the spot, and walk every day thereafter with increasing frequency.’ To stop patients losing too much weight because of not being able to eat properly after surgery, they are fitted with feeding tubes during the operation and gradually reintroduced to solid food.
Other simple changes included starting surgery at 6.30am instead of 9am or 10am. ‘This meant patients were leaving theatre late in the afternoon rather than the evening, allowing us to start the patient’s recovery plan on the day of surgery rather than the following day,’ says Mr Preston. ‘This meant, for instance, breathing tubes were removed sooner rather than keeping patients on a ventilator overnight. ‘What we’ve achieved here is mind-blowing. ‘This is one of the most high-risk, complicated types of surgery — if you can introduce enhanced recovery for this, you can more or less do it for any operation.’
Indeed, the principles are being used to offer day surgery for breast cancer patients. And at St George’s Hospital, Tooting, gynaecologist Hugh Byrne has introduced an enhanced recovery programme for women undergoing hysterectomies, reducing the hospital stay from up to five days to just one night. It includes admitting patients only two hours before their operation and giving women a specially formulated high-calorie drink before their surgery.
Surgeons also use less invasive keyhole surgery techniques so there is less trauma to the body and a localised pain-killing injection in the abdominal wall for pain relief rather than an epidural so patients can walk about sooner after surgery.
‘These patients are sitting up in bed eating toast and drinking tea minutes after their operations. In the old days, they could have waited for two days until they were given the go ahead to eat and drink,’ says Mr Byrne. St George’s is extending enhanced recovery for women undergoing caesarean sections.
‘Women can have blood tests for anaemia the week before the operation which means they can come into hospital just a few hours before their scheduled slot and they could be ready to go home within a day,’ explains Mr Byrne. ‘The same sort of approach is also going to be applied to urology cases — kidney surgery for example — and even major heart surgery.’ The biggest challenge, says Mr Byrne, is changing ideas about needing to be in hospital for a long time.
‘Usually when patients are going in for an op they buy a new dressing gown and pack a big suitcase as they expect to be in hospital for an extended time. ‘But now we know that lying in a hospital bed is not good for recovery — and they could be out in a matter of days.’