The Application of the Enhanced Recovery after Surgery System to Real Life Cases - Case Study Example

 THE APPLICATION OF THE ENHANCED RECOVERY AFTER SURGERY SYSTEM TO REAL LIFE CASES: AN ANALYTICAL REVIEW Cont Introduction 2 Central Case 2 Hip Replacement Surgeries in the UK 3 General Framework of ERAS 4 Rationale for Choice of ERAS Pathway 5 Biological Analysis 6 Psychological Analysis 9 Social Analysis 11 Conclusion 13 Bibliography 14 Introduction The project will examine the most appropriate pathway for Enhanced Recovery After Surgery (ERAS) in order to deal with post-operative recovery and management complications. This paper will examine hypothetical cases of three patients who have various post-surgury issues that need to be handled. The paper will utilise the ERAS Framework as well as elements from the Human Rights Act (1998) as well as rules from the Nurses and Midwifes Council, UK (NMC) and the Royal College of Nurses (RCN). The central focus of the paper is to use various level of specialised care to prevent complications and ensure the full recovery of the patients after surgery. The paper will be focused on two main parts. The first part will focus on a central patient in the central case. The second part, focusing on the justification of the methods will examine two different cases involve biological, psycholical and social factors relevant to ensuring the success of the ERAS framework. Central Case The research work is being conducted on teh basis of three patients the writer encountered in her local trust who underwent hip replacement surgeries and needed to go through Enhanced Recovery After Surgery Procedures. The patients are as follows: Joan A 30-year old Caucasian lady of Anglo-Saxon origins married with two children aged between 3 and 5. Joan needed to get a hip replacement because she has an issue with osteoarthritis which is caused by the fact that the bones in her hips are worn away and they are rubbing against each other[NHS14]. This procedure is estimated to take about a week of preoperative care and three weeks of post-operative recovery. Marilyn A feeble and sickly person with so many complications in her health life. Marilyn is 19 and is a delicate person who is allergic to many issues and is on regular medication. There was the need for some extra care in her hip replacement operation. Marilyn had an issue with rheumatoid arthritis and this is due to her immune system mistakenly attacking the lining of the joint, resulting in pain and stiffness[NHS14]. Fred He lost his mother at an early age through a hip replacement surgery. At the age of 45, the same age at which he lost his mother, he was involved in an accident recently and has a hip fracture which requires a hip replacement surgery. Fred also has three young children and is divorced from his wife who is out of the UK. Hip Replacement Surgeries in the UK “Hip replacement surgeries have the potential to transform a patient’s life by relieving the pain, disability or deformity that prompt the surgical intervention and in its ability to restore independent freedom” (Hukkanen, Polak, & Hughes, 2012, p178). There were 71,000 hip replacement surgeries that were carried out in the UK in the year 2010, and out of this, 10% of the replacements were revsion surgeries where replacement hips were removed and refixed[Bro10]. Hip replacement surgeries are about the replacement of the ends of both bones at the joint in order to create a new joint surface (Poinier & Koval, 2013). This includes the use of materials like metal, plastic and ceramic to replace the ball at the femur in order to create a different surface that in the pelvic bone (Poinier & Koval, 2013). There are two types of hip replacement surgeries. First of all, the cemented joints are created through the use of some kind of glue or cement in order to artificially join the bones at the hip joint. Uncemented joints are attached through the use of a porous coating that allows the bones to adhere to the artificial joint. With time, a new bone will grow to fill the gap between the two bones. There are general anesthesia processes that are somewhat comprehensive whilst there are regional anesthesia cases (Poinier & Koval, 2013). This implies that the processes vary in several ways and forms. General Framework of ERAS The ERAS framework brings together Biological, Psychological and Social factors that are important and vital for the rapid healing and improvement of the lives of patients after a surgery (ERAS Society, UK, 2013). The biological aspects tackles pain management and the handling of the procedures of the hip replacement surgery (Pucher, 2013). The psychological aspects of ERAS have to do with sharing information and conditioning the mind of the patient before, during and after a surgery (Malhothra, Puri, & Malhothra, 2013). Finally, the social aspects include nutrition and merger of the recovery process to the patient’s normal life and interaction with society (Leaper & Whitaker, 2010). This means that the broad framework of the strategy to be used is one that will relieve the immediate pain and complications of the cuts in the surgical process and also ensure that the healing process is shortened significantly (Ropper, 2010). ERAS focuses on providing post-anaesthetic care to aid the recovery of the patients. Once the operation is done, there must be regular checks for complications that might need to be dealt with as a peculiar case relating to the patient (Alio-Sanz & Azar, 2009). Finally, for hip replacements, there is the need for patients to be up and doing within an average of a one week after the surgery, Hence, there is the need for the provision of aided medication and treatments to ensure that she recovers appropriately (Cohn & Dolich, 2014). Rationale for Choice of ERAS Pathway The fundamental reason for choosing the ERAS framework of promoting post-surgery healing is to promote rapid and effective healing of patients that go through surgery like our three paitents. ERAS has elements that go back to the days before the surgery and last from the surgery to the healing phase of the surgery. First of all, the hip replacement patients will need to get some kind of guidance and counselling within the context of informed consent because sharing information about the patient’s situation is vital in ensuring that she gives an informed consent, which is her fundamental right as a person (The Royal College of Surgeons, 2009). This is in sync with the Human Rights Act 1998. However, the central focus of the ERAS framework relates to the postoperative practices that ensure that a patient gets healed rapidly and the patient gets a thorough recovery that ensures optimum quality of life at the shortest possible time. Biological Analysis “Valid and reliable assessment of pain is essential for both clinical trials and effective pain management.”[Bre08]. Therefore, there is the need to examine and assess the way in which the bodies of the patients react to the various processes of the hip replacement surgeries. Pain Management Pain management of the patients in the three patients has to be done by finding a way of documenting and evaluating pains and the challenges that patients are likely to go through during the hip replacement surgeries (Breivik, et al., 2008). Hence, there are two main considerations that were taken into account to enhance the recovery process of our three patients[Dep12]. The first is the case of healing and natural processes of the body. This involves the ability of the body to react to certain things and perform in a certain way. Secondly, there is the issue of the impact of foreign microorganisms that could potentially cause the healing process to encounter complications. These two factors inform practice and helps to deal with the recovery process. Pain management is also an essential aspect of the ERAS process. This can be done through the examination of where the pain is, the intensity of the pain and its effects (Breivik, et al., 2008). There are various forms of questionnaires that can be given to the patients and they must be made to provide information and feedback about their feelings. From there, the appropriate forms of treatment can be given to the patients to enable them to overcome these pains. This is done by examining the intensity and finding solution to the issues. The benefit of this procedure is that it will help to study the patients and find out what is wrong with them at any point in time and then get them to react and change their ways where necessary. This will prevent pain through a proactive approach and the management of pain will also aid quick healing. Therefore there is a general trend towards the treatment of these patients which are steeped in promoting the best practices within the ERAS framework[Zar08]. For each of the patients, there was the need for thorough diagnosis and evaluation of their current statuses in order to deduce what their bodily functions are, and how they are potentially going to react to the surgery and recovery processes[Ned11]. This Prehabilitation is vital and there is the need for each patient to be examined in the physical sense[Bot13]. Fred and Joan are patients who work out regularly, hence, there is little that ought to be done to them but to keep them on the normal track of exercising to remain fit at the time of the hip replacement survey. However, Marilyn is a sickly individual and will need some kind of guidance and an exercise routine. And this must be instituted a few days before the operation and the patients must go through them[Qad44]. Healing Process After the operation, there is the need for the utilisation of various processes to hasten the recovery process. This will include various actions that will be conducted on Joan to ensure that the period between 1 and 3 weeks, she will be given the best treatment so she could recover fully and get back to her work. Fred must be given some kind of attention to identify if there are any genetic conditions that can cause him to suffer a fate similar to his mother. Marilyn might need closer attention to ensure that she is not going through any complications that could harm her negatively. The ethical requirements of the Royal College of Nursing indicates that the nurse should use the best principles and practices to provide the best level of care and service to patients who need it (Holt & Convey, 2012). Therefore, Marilyn, in her fundamental state needs to be given the most appropriate and the best process that is necessary to deal with her surgery and recovery based on her requirements. She will therefore need to have a critical examination and an evaluation of her patient profile and needs from previous GP so that the local trust hospital can get guidelines on her background and case history. Based on the information about Marilyn, the operation process can be evaluated and estimation of risks relating to her reactions can be documented in the preoperative stage. This will enable her to get at least a week of preparation to ensure that she gets the right prehabilitation to adjust her body for the operation. During her operation, there is the need for the intraoperative team to monitor Marilyn much closely in order to examine issues and matters and deal with them so that complications relating to her bodily functions or other external organisms can be identified and handled in order to prevent complications. Biological Risk Analysis Biological analysis therefore requires the healing process to be estimated and all biological risks in the environment to be realistically assessed and reviewed to provide technical and expert support before, during and after the operation so that the elements of the enhanced recovery after surgery (ERAS) can be integrated and implemented on a patient based on her specific needs and challenges. During the operation, there is the need for certain things to be done with the view of ensuring that complications are avoided so that Joan and Fred can recover quickly within the normal timeframe. In cases complications are encountered, there is the need to identify them and deal with them during the post operative period. Psychological AnalysisThere is the need for all the three patients to be made to de-stress and not feel the challenges and anxiety that will come with a first timer going through surgery as the case may be for Joan and Fred (Scott, 2009). This will include various activities like counselling and an attempt to understand all their concerns so that they can be re-assured before technical processes can be done and conducted. The mindset of a patient is important and this can play a significant role in the recovery process and hence, it is vital to the ERAS framework and process that will be used by a healthcare facility (Braga, Ljungqvist, Soeters, Fearon, Weimann, & Bozzetti, 2009). This implies that the mind of the patient is important in ensuring that the patient goes through the body and his or her functions are all optimal in order to ensure that she goes through the processes. In such a situation, a professional nurse will need to identify that Fred has a major psychological challenge which is so fundamental that the success of the ERAS process as applied upon Joan will depend largely on what he thinks during the process. This is because due to fear, panic and distress, Fred’s bodily functions might be affected adversely and this will mean that the ERAS process might not function appropriately due to the mindset of Fred (Lassen, et al., 2012). The main approach that can be applied to the process include the national early warnings sign (NEWS) which include the examination of the physiological measures that observe and provide predications of what ought to be changed. This include the six main pointers: 1. Respiratory rate; 2. Oxygen saturations; 3. Temperature; 4. Systolic blood pressure; 5. Pulse rates and 6. Level of consciousness (Royal College of Physicians, 2012) The biological reaction of the patients, particulary Marily who has a history of medical challenges must be examined closely and any abnormalities that will be identified must be handled immediately. This will inform conduct and get the team to change its approaches and methods quickly. It is therefore imperative on the local trust medical facility to spend time to condition Fred’s mind and cause him to relax. There are many things Fred will need to know that might not be necessary in the case of Joan. This can be done through the observation of the respiration, bodily features, blood pressure and others. This should be documented for action to be taken quickly to ensure that the patients’ psychological features can be deduced and dealt with. For instance, there is the need to reassure Fred on several occasions that the surgery of his mother over 30 years ago has gone through a lot of changes and his chances of survival are much higher than it was in his mother’s day. He must also be assured that his children will be given proper care as he is going through the surgery (Ramírez, et al., 2011). The healthcare facility ought to go the extra mile to ensure that Fred is made to relax before, during and after the process. This will aid his healing process and also enable him to cooperate more for the best of results. Reassurance is important and fundamental in the process of treating the three patients. There must be an effective approach for pain relief after the operation is over. This will include the examination of important issues and matters that come up and based on Joan’s complaints after the procedure. Antibiotics must be administered after the process to prevent exposures and other bacterial and fungal infections that might cause complications that will be problematic (Melnyk, Casey, Black, & Koupparis, 2011). Prophylaxis must be administered to prevent nausea and also promote quick healing (Burke, 2011). This will prevent the patients from having a negative experience whilst trying to recover after the surgery. There is the need for the healthcare professionals of the local trust hospital to be on the lookout for complications that could occur. This is because in cases where complications are identified, they can be dealt with in a relatively quicker timeframe than those that go undetected. The patients must be told about this from the onset so they can get some kind of reassurance in the process. Social Analysis Another important part of this ERAS framework includes prehabilitation (European Association of Urology, 2013). Prehabilitation is about getting the patients to exercise in order to boost the healing process (University of Virginia Health System, 2013). This will strenghten their muscles and promote fitness during and after the process (Cabilan, Hines, & Munday, 2013). Also, substance abuse, including alcohol usage and smoking cessation are essential for the patients because these substances can intervene in the medication during the surgery (Tønnesen, Faurschou, Ralov, Mølgaard-Nielsen, Thomas, & Backer, 2010). This should be over a period of about 3 to 8 weeks before the process (Tonnesen, Nielsen, Lauritzen, & Moller, 2009). Mechnical bowel preparations and adjustments to the environment are essential and a nurse on the team will have to assist the hip replacement through the process. This is because the NMC framework seeks to promote and safeguard the wellbeing of patients and their quality of life (Nurses and Midwifery Council, 2013). Finally, carbohyderate loading and oral feeding 24 hours before the procedure are central aspects of the ERAS framework so the patients must be made to go through that (Burden, Todd, Hill, & Lal, 2012). Healthcare in the UK went through major changes with the introduction of the Human Rights Act in 1998 (Hagget, 2010). This law has created a framework within which previous issues that were covered under tort and often overlooked by the court can be insisted upon in courts. The national early warning system involves the examination of the “track and trigger” system through which patients developing acute sicknesses can get their cases evaluated and analysed before the cases get extreme[Roy12]. This must provide signs and triggers that will help to skew the system of care into a way and manner that will detect and deal with issues and problems much earlier. Additionally, eating habits and bodily features of the patients ought to be examined critically and thoroughly by using the malnutrition universal screening tool (MUST) will inform the changes and modifications that have occurred in patients. This will include evaluating the height and weight of the patient, the percentage of weight loss, effects of a disease or weight loss processes and the integration of relevant scores into perspective and processes. Basically, the right to autonomy that was something that came with so many limits can be insisted upon strongly. This has to do with the area of consent and confidentiality in the treatment of patients. There is the need for patients to be given information about the process that they are going through. They will have to be told about the ERAS framework and what it is aimed at and get the patient to voluntarily authorise the treatment. Therefore, in the case of Joan, Marilyn and Fred there is the need for them to be told about what the ERAS framework will be about and why it is being used. This is necessary because it forms a significant part of NMC Regulations and RNC Ethics. Therefore, the facility and any nurse or medical practitioner must ensure that this is attained. Secondly, there is the need for confidentiality to be guaranteed in the ERAS process. Information about any of the three patients studied in this case are to be kept securely by the nurses and staff members of the South London medical facility. And the distribution of this information must comply with the Data Protection Act of 1998. This prevents the unauthorised transfer of any of the patients’ information save for a situation where their lives are at stake or their best interest is sought. Otherwise, any transfer of personal information about the patients must only be transferred by the expressed authorisation of the patient. Conclusion The ERAS framework is a modern approach to the conduct of surgery to ensure quick and speedy recovery of patients with minimal risks of complications. The research studied the case of a hypothetical patient, Joan and it indicated that Joan had to go through the use of specialised ERAS techniques in the preoperative, intraoperative and postoperative phases of her treatment. This is to take into account her biological conditions, social and psychological status. Extreme cases of social and psychological cases of two other patients, Marilyn and Fred were examined. And it indicated that nurses and healthcare practitioners have the obligation to ensure that the biological needs of patients are diagnosed before being subjected to the ERAS process . Also, in cases of trauma or psychological challenges, patients must be given counselling and necessary psychological procedures so the process goes without complications. Also, there is the need for nurses to be sensitive to ethical rules of the NMC and RCN which relate to confidentiality and informed consent. The human rights of patients must be taken into account during treatments within the ERAS framework. Bibliography NHS14: , (NHS Choices, 2014), Bro10: , (Brooks, 2010), Bre08: , (Breivik, et al., 2008, p. 17), Dep12: , (Department of Surgical Education, Orlando Regional Medical Center, 2012), Zar08: , (Zargar-Shoshtari & Hill, 2008), Ned11: , (Ned & Albayati, 2011; Bernard, 2013), Bot13: , (Botta, et al., 2013), Qad44: , (Qadan, Akca, Mahid, Hornung, & Polk, 2009 ; Vallet & Futier, 2010), Roy12: , (Royal College of Physicians, 2012), Read More