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

THE APPLICATION OF THE ENHANCED RECOVERY AFTER SURGERY SYSTEM TO REAL LIFE CASES: AN ANALYTICAL REVIEW Contents Contents 2 Introduction 3 Central Case 3 General Framework of Work 4 Contemporary Practice Pathway 4 Intraoperative Processes 6 6 Technical Concerns Prior to Surgery 6 Postoperative Issues 7 Stress Reduction 7 Pain Relief after Procedures 7 Proactive Mobilisation for Complications 8 Early Oral Feeding and Dietary Supplementation 8 Strategic Analysis & Justification of the Chosen Pathway 8 Biological Analysis 9 Psychological Analysis 10 Social Analysis 11 Conclusion 12 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 Joan is a 30-year old Caucasian lady of Anglo-Saxon origins married with two children aged between 3 and 5. She is an administrator at one of UK’s financial service entities. Joan has to go through a surgical operation for Appendicitis in a middle-sized medical hospital in South London. Joan has been told she will be discharged after 1 to 3 days and it will take 1 week to 1 month for the wounds to be healed fully and totally so she can return to normal life. Joan smokes one to three sticks of cigarettes a day and drinks alcohol occasionally. General Framework of Work The standardised procedure for dealing with Enhanced Recovery After Surgery is steeped in the process of the ERAS society which asserts that a nurse or healthcare practitioner should do three main things as a general framework: 1. Gather patient data; 2. Analyse and share information; 3. Adjust and improve practice based on known facts during and after the procedure (ERAS Society, UK, 2013) These important information forms the basis for the evaluation and conduct of the operation. However, after the operation, there is the need for various degrees of the management of the impact of the operation through a given framework. The important elements and aspects of the post-operative management include amongst other things: 1. Immediate Pain Management (Pucher, 2013); 2. Care in Post-Operative Period (Malhothra, Puri, & Malhothra, 2013); 3. Proactive Review of Complications of the Case (Leaper & Whitaker, 2010) This means that the broad framework of the strategy to be used will be one that will relieve the immediate pain and complications of the cuts in the surgical process (Ropper, 2010). It will focus on providing post-anaesthetic care and get Joan to be ushered into an era of recovery. 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, within that one week that Joan will remain in hospital, there is the need for the provision of aided medication and treatments to ensure that she recovers appropriately (Cohn & Dolich, 2014). Contemporary Practice Pathway Operative systems and processes require three main phases within which Jane’s cooperation and participation will be essential and necessary. Also, other members of the surgical and health team will need to play various roles in helping Jane to recover and deal with relevant complications that might come up. The ERAS framework of promoting post-surgery healing has elements that go back to the days before the surgery, this is classified as the preoperative matters within the ERAS framework. Jane 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). Another important part of this phase include prehabilitation (European Association of Urology, 2013) which include getting Jane to exercise in order to boost the healing process (University of Virginia Health System, 2013). This will strenghten her muscles and promote fitness during and after the process (Cabilan, Hines, & Munday, 2013). Also, alcohol usage and smoking cessation are essential for Joan 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 Joan 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 Joan must be made to go through that (Burden, Todd, Hill, & Lal, 2012). Intraoperative Processes 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 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. Technical Concerns Prior to Surgery Care must be taken when administering the technical elements of the surgery to avoid complications. This include prophylaxis antibiotics over a 5-day period to avoid fungal and bacterial infections and this must be done at least 24 hours before the actual surgery (Department of Surgical Education, Orlando Regional Medical Center, 2012). Perioperative oxygen therapy and anaesthetic estimations must be done by measuring a standard level of oxygen administration and anaesthetics during and after the surgery (Qadan, Akca, Mahid, Hornung, & Polk, 2009 ; Vallet & Futier, 2010). Minimally invasive procedures form an important part of the ERAS framework and involves the support of local and regional anaesthetics (Botta, et al., 2013). This prevents the possibility of major issues and problems like the risks of infection and enhances the possibility of an early recovery. There must be high oxygen concentration and normothermia with the view of limiting peri-operative fluid overload (Ned & Albayati, 2011). Perioperative hypothermia is associated with poor outcomes for patients, hence there is the need to maintain normothermia throughout the process as a means of reducing risks and enhancing recovery after the operation (Bernard, 2013). The surgery of Jane must also involve a close monitoring of her condition for pharmacological modifiers in the process. This is because there could be some changes that could cause complications. Also, introperative fluids must be monitored to ensure that the right dosage of fluids is administered to keep Jane stable throughout the process. Finally, there is the need to reduce the use of drains and nasogastric tubes. Postoperative Issues 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. Stress Reduction There is the need for Joan to be made to de-stress and not feel the challenges and anxiety that will come with a first timer going through surgery (Scott, 2009). This will include various activities like counselling and an attempt to understand all her concerns so that she can be re-assured before technical processes can be done and conducted. Pain Relief after Procedures 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 Joan from having a negative experience whilst trying to recover after the surgery. Proactive Mobilisation for Complications There is the need for the healthcare professionals of the South London hospital to be on the lookout for complications that 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. Hence, Joan will have to be examined regularly on several occasions during to day for any evidence of complications that might need prompt attention. Early Oral Feeding and Dietary Supplementation Oral feeding must be carried out quickly to get Joan’s body to adjust to the circumstances and changes in digesting normal food. Oral feeding at the early stages of a postoperative surgery enhances the recovery of the patient and also prevents postoperative nausea since the body adjusts quickly and is put to work quickly (Zargar-Shoshtari & Hill, 2008). The diet has to be appropriate and it must be jelly or puree in texture to enable a quick absorption into the body (Alvarez-Falcon & Ruiz-Santana, 2013). This will enable the patient’s body to adjust to food and begin to function normally without issues and matters. Also, supplements must be given to the patient so she can recover quickly and get her systems and processes to commence functioning as quickly as possible. There should also be less reliance on tubes, drains and catheters which will slow down the recovery process. Strategic Analysis & Justification of the Chosen Pathway Basically, the case of Joan indicates that there is the need for some technical and social elements to be integrated into the procedure of treating patients who go through surgery and will need to apply the ERAS framework. There are numerous reasons that call for the preoperative, intraoperative and postoperative systems that have been chosen above. Biological Analysis The body reacts in various ways and manners in surgeries. Hence, there are two main considerations that must be put into account to enhance the recovery process. 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. In complementing the case of Joan, we could think of the case of a delicate patient called Marilyn who is a sickly person with so many complications in her health life. Marilyn is a delicate person who is allergic to many issues and is on medication all the time. In this case, the demands might not be as straightforward as Joan’s case which requires nothing more than cessation of some kinds of actions and normal bowel emptying. There will be the need for some extra care. 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 South London 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 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. Psychological Analysis 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. A hypothetical case that can be used is the case of Fred who lost his mother at an early age through a surgery. At the age of 45, the same age at which he lost his mother, he is diagnosed of a similar complication that requires him to go through a surgery similar like his mother’s surgery. Fred also has three young children and is divorced from his wife who is out of the UK. 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). It is therefore imperative on the South London 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. 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. Social Analysis 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. 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 Alio-Sanz, J. L., & Azar, D. T. (2009). Management of Complications in Refractive Surgery. London: Springer. Alvarez-Falcon, A., & Ruiz-Santana, S. (2013). Oral Feeding. World Review of Nutritional Diet , 43-39. Bernard, H. (2013). Patient Warming in Surgery and Enhanced Recovery. British Journal of Nursing Vol 22(6) , 319-325. Botta, L., Cannata, A., Bruschi, G., Fratto, P., Taglieri, C., Russo, C. F., et al. (2013). Minimally invasive approach for redo mitral valve surgery. Journal of Thoracic Disease 16(5) , 1439-1452. Braga, M., Ljungqvist, O., Soeters, P., Fearon, K., Weimann, A., & Bozzetti, F. (2009). ESPEN Guidelines on Parenternal Nutrition: Surgery. European Society for Clinical Nutrition and Metabolism , 378-386. Burden, S., Todd, C., Hill, J., & Lal, S. (2012). Pre-operative nutrition support in patients undergoing gastrointestinal surgery. Cochrane Database System Review , 1858-1872. Burke, J. P. (2011). Maximizing Appropriate Antibiotic Prophylaxis for Surgical Patients. Clinical Surgical Dis , 78-83. Cabilan, C. J., Hines, S., & Munday, J. (2013). Prehabilitation for Surgical Patients: A Systematic Review Protocol. Home Vol 11(5) , 219-233. Cohn, S. M., & Dolich, M. O. (2014). Complications in Surgery and Trauma. New York: CRC Press. Department of Surgical Education, Orlando Regional Medical Center. (2012, June 10). Antibiotic Prophylaxis in Surgery. Retrieved July 24, 2014, from Orlando Regional Medical Center: http://www.surgicalcriticalcare.net/Guidelines/antibiotic_prophylaxis.pdf ERAS Society, UK. (2013, December 9). ERAS Care - General Overview. Retrieved July 23, 2014, from ERAS Society Official Website: http://www.erassociety.org/index.php/eras-care-system/general-overview European Association of Urology. (2013, November 14). Exercise training as prehabilitation before surgery. Retrieved July 24, 2014, from Science Daily: www.sciencedaily.com/releases/2013/11/131114193241.htm Hagget, E. (2010). The Human Rights Act 1998 and the Access to NHS Care. School of Public Policy: The Constitution School , 1-39. Holt, J., & Convey, H. (2012). Ethical Practice in Nursing Care. Nursing Standard 27(1) , 51-56. Lassen, K., Coolsen, M. E., Slim, K., Carli, F., De Aguilar-Nascimento, J. E., Shaefer, M., et al. (2012). Guidelines for Perioperative Care for pancreaticoduodenectomy: Enhanced Recovery After Surgery Recommendation. Clinical Nutrition 31 , 817-830. Leaper, D., & Whitaker, I. (2010). Post Operative Complications. Oxford: Oxford University Press. Malhothra, N., Puri, R., & Malhothra, S. (2013). Operative Obstetrics and Gynaecology. London: JP Medical Limited. Melnyk, M., Casey, R. G., Black, P., & Koupparis, A. J. (2011). Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Canadian Urological Association 5(5) , 342-348. Ned, A., & Albayati, S. (2011). Enhanced Recovery after Surgery Programs Hasten Recovery after Colorectal Resections. World Journal of Gastrointestinal Surgery , 1-6. Nurses and Midwifery Council. (2013, December 12). The Code Standards of Conduct, Performance and Ethics for Nurses and Midwifes. Retrieved July 24, 2014, from NMC Website: http://www.nmc-uk.org/Documents/Standards/nmcTheCodeStandardsofConductPerformanceAndEthicsForNursesAndMidwives_LargePrintVersion.PDF Pucher, R. (2013). Nursing the Surgery Patient. London: Elsevier Health Sciences. Qadan, M., Akca, O., Mahid, S. S., Hornung, C. A., & Polk, H. C. (2009 ). Perioperative supplemental oxygen therapy and surgical site infection: a meta-analysis of randomized controlled trials. Archives of Surgery 144(4) , 359-366. Ramírez, J. M., Blasco, J. A., Roig, J. V., Maeso-Martínez, C. S., J, E., Esteban, F., et al. (2011). Enhanced recovery in colorectal surgery: a multicentre study. BMC Surgery 11:9 , 867-891. Ropper, A. H. (2010). Neurological And Neurosurgical Intensive Care. Amsterdam: Wolters Kluver. Scott, E. (2009, June 4). Surgery Stress Relieve Techniques. Retrieved July 25, 2014, from About.Com Stress Management: https://www.google.co.za/search?q=nutritional+support+prior+to+surgery&ie=utf-8&oe=utf-8&aq=t&rls=org.mozilla:en-US:official&client=firefox-a&channel=fflb&gfe_rd=cr&ei=NS_SU7rFIafd8gfVqoBY#channel=fflb&q=stress+reduction+in+surgery&rls=org.mozilla:en-US:o The Royal College of Surgeons. (2009). Brief Review: Fast-Track Surgery and Enhanced Recovery after Surgery. Sydney: Royal Australian College of Surgeons. Tønnesen, H., Faurschou, P., Ralov, H., Mølgaard-Nielsen, D., Thomas, G., & Backer, V. (2010). Risk reduction before surgery. The role of the primary care provider in preoperative smoking and alcohol cessation. BMC Health Service Res , 123-131. Tonnesen, H., Nielsen, P. R., Lauritzen, J. B., & Moller, A. M. (2009). Smoking and Alcohol Intervention Before Surgery: Evidence for Best Practice. British Journal of Anaesthetics , 297-306. University of Virginia Health System. (2013, October 17). Helping abdominal surgery patients recover sooner. Retrieved July 25, 2014, from Science Daily: www.sciencedaily.com/releases/2013/10/131017093501.htm Vallet, B., & Futier, E. (2010). Perioperative Oxygen Therapy and Oxygen Utilization. Current Opinion on Critical Care 16(4) , 359-364. Zargar-Shoshtari, K., & Hill, A. C. (2008). Optimisation of Postoperative Care for Colonic Surgery: A Review of the Evidence. ANZ Journal of Surgery 78 , 13-23. Read More