Chiaramente, ogni formato ha i propri vantaggi e svantaggi comprare doxycycline senza ricetta per effettuare un acquisto, non è necessario fornire la prescrizione medica.

Microsoft word - a blueprint for surgical optimization resource manual

Jocelyn Reimer-Kent, RN, MN Clinical Nurse Specialist Cardiac Program Fraser Health – Royal Columbian Hospital Rapid Surgical Recovery Architect/Consultant Adjunct Professor, University of British Columbia School of Nursing Table of Contents
Acknowledgement and Team Credit . i
Rapid Surgical Recovery Champion / Leader Contact Information . ii
Chapter 1: Rapid Surgical Recovery: The Fraser Health Experience. 1
Background: Fraser Health's Experience With Rapid Surgical Recovery . 2 What is Rapid Surgical Recovery . 3 Why is Rapid Surgical Recovery Important . 3 Theories/Conceptual Frameworks/Models That Support Rapid Surgical Recovery . 4 Reimer-Kent's Postoperative Wellness Model . 4 Kehlet's Fast Track Surgery Principles . 5 A Comprehensive Surgical Optimization Framework . 6 Chapter 2: Rapid Surgical Recovery: A Change Package . 7
A Change Package to Support Rapid Surgical Recovery . 8 AIM Statement Definition . 8 Example of a Rapid Surgical Recovery AIM Statement . 8 A Change Package for Preventing Pain . 9 Examples of Postoperative Pain Management Orders for Major General Surgery and Cardiac Surgery . 11 A Change Package for Preventing Delirium . 11 Examples of Postoperative Delirium Management Orders for Major General Surgery and Cardiac Surgery . 12 A Change Package for Normalizing Gastrointestinal (GI) Function – Preventing Postoperative Nausea and Vomiting (PONV) . 13 Examples of Liberalized Fasting and Thirsting Orders for Major General Surgery and Cardiac Surgery . 14 Examples of Early Postoperative Feeding Orders for Major General Surgery and Cardiac Surgery . 16 Examples of Postoperative GI Upset/Distress Orders for Major General Surgery and Cardiac Surgery . 16 A Change Package for Preventing Normalizing GI Function – Preventing Postoperative Constipation . 17 Examples of Postoperative Constipation Management Orders for Major General Surgery and Cardiac Surgery . 17 A Change Package for Preventing Postoperative Immobility . 18 Examples of Postoperative Mobilization Orders for Major General Surgery and Cardiac Surgery . 19 A Change Package for Preventing Postoperative Respiratory Compromise . 20 Examples of Postoperative Venous Thromboembolism (VTE) Prophylaxis Orders for Major General Surgery and Cardiac Surgery . 21 Other Components to a Rapid Surgical Recovery Program . 21 A Change Package for Improving Access and Flow . 21 Examples of Targeted Length of Stay For Cardiac Surgery and General Surgery by Major / Minor / Day Category . 22 Examples of Discharge Criteria For Cardiac Surgery and General Surgery by Major / Minor / Day Category . 23 Practice Support Tools for Rapid Surgical Recovery . 24 Pre-printed Doctor's Orders . 24 Clinical Pathway . 24 Patient Teaching Material . 24 Recovery After Heart Surgery: In Hospital and At Home – Patient & Family Information . 25 Major General Surgery: Rapid Surgical Recovery – Patient & Family Information. 26 Minor General Surgery: Rapid Surgical Recovery – Patient & Family Information. 27 Day General Surgery: Rapid Surgical Recovery – Patient & Family Information . 28 Recovery After General Surgery – Patient & Family Information . 29 Chapter 3: Rapid Surgical Recovery: Pre-Implementation Activities . 30
Suggested Pre-Work Activities for Implementing Rapid Surgical Recovery . 31 Pre-work Activities Checklist . 31 Forming the Team . 32 Chapter 4: Rapid Surgical Recovery: A Measurement Strategy . 35
A Measurement Strategy for Generating Rapid Surgical Recovery Evidence. 36 Example of How Data Could Be Displayed . 36 Example of Pre- and Post-Implementation Data Collection Tool for Major General Surgery . 38 Rapid Surgical Recovery Results For Cardiac Surgery – CABG and General Surgery – Colon Resection . 40 Chapter 5: Rapid Surgical Recovery: A Charter . 41
Example of a Rapid Surgical Recovery Charter . 42 Rapid Surgical Recovery: Literature Reviewed . 48
Reference List. 49 Rapid surgical recovery is not the work of an individual as it truly takes a team effort to embed best and promising practices into patient care. Just like it takes a village to raise a child it takes an inter-professional team unified in purpose and plan to optimize the surgical outcome of each and every patient and to support them through a safe, efficient and effective surgical journey. There would be no dramatic before and after findings if there had not been surgeons, anesthetists, nurses and allied health care professionals willing to review and change practice and culture to sustain new standards of care within their programs. Without this support rapid surgical recovery would be just a great but untried idea for surgical optimization. Grateful thanks is extended to the Fraser Health (FH) Cardiac Surgery Program at the Royal Columbian Hospital (RCH), the RCH and Eagle Ridge Hospital (ERH) Department of General Surgery, and the RCH and ERH Department of Anesthesia and the inter-professional teams who were early adopters, motivators, and continuous champions for rapid surgical recovery. Implementing rapid surgical recovery in these programs within FH's current Program Management Model is truly an example of intra-program collaboration and cooperation. Rapid Surgical Recovery Champion / Leader Contact Information
The following practitioners/clinicans were extremely helpful in implementing, sustaining and
spreading Rapid Surgical Recovery in cardiac and general surgery at the Royal Columbian Hospital
• Jocelyn Reimer-Kent, RN, BN, MN
Cardiac Surgery Clinical Nurse Specialist & Rapid Surgical Recovery Architect/Consultant Fraser Health (FH) –Cardiac Program Adjunct Professor, University of British Columbia School of Nursing jocelyn.reimer-kent@fraserhealth.ca 604-520-4369 or 604-613-5268 • Jenny Misar, RN, BSN, MSN Practice Consultant FH Professional Practice & Integration (Former FH Clinical Nurse Educator for Rapid Surgical Recovery) Jenny.misar@fraserhealth.ca 604-613-7991 Cardiac Surgeons (Office # 604-522-6800) • General Surgeons • Dr. Robert Hayden, MD, CM, FRCS(C)  Dr. Peter Blair, MD, FRCSC, FACS FH Program Medical Director for Surgery & • Dr. Shahzad Karim, MD, FRCS(C) – FH Clinical Professor of Surgery, University of Regional Division Head for Cardiac Surgery British Columbia Peter.blair@fraserhealth.ca shahzadk4775@gmail.com • Dr. Tim Latham, MD, FRCS(C) tbl@telus.net  Dr. Laurence Turner, MA, MB, BS, FRCSC • Dr. Derek Gunning, MD, FRCS(C) FH Regional Division Head General Surgery derek.gunning@gmail.com ljturn@shaw.ca 604-526-3721  Dr. Dave Konkin, MD, FRCSC, FACS Head Department of Surgery ERH • Dr. Richard N Merchant, MD FRCPC – Chair Dave.Konkin@fraserhealth.ca 604-526-2440 of Canadian Anesthesiology Society Standards Committee richard.merchant@ubc.ca 604-524-2357 Advanced Practice Nurses • Lori Hughes, RN, MSN • Brenda Poulton, RN, MSN, ACNP FH General Surgery Clinical Nurse Specialist FH Pain Nurse Practitioner Lori.Hughes@fraserhealth.ca 604-807-8467 brenda.poulton@fraserhealth.ca 604-520-4988 • Dianne Obal, RN, BSN – Cardiac Surgery • Elaine McGlenister, RN, BSN – General Surgery Dianne.Obal@fraserhealth.ca 604-520-4526 Elaine.Mcglenister@fraserhealth.ca 604-520-4362 Clinical Nurse Educators • Kate Martin or Barbara Hall – Cardiac Surgery • Elizabeth Tompkins – General Surgery Barbara.Hall@fraserhealth.ca 604-520-4986 Physiotherapists • Colleen Confrey – General Surgery • Laurie Parrent or Lori Roy – Cardiac Surgery Colleen.Confrey@fraserhealth.ca 604-520-4672 Laurie.Parrent@fraserhealth.ca lori.roy@fraserhealth.ca 604-520-4672 • Lysa Wone – General Surgery • Alysone Martel – Cardiac Surgery Lysa.Wone@fraserhealth.ca 604-520-4381 Alysone.Martel@fraserhealth.ca 604-520-4690 Chapter 1 – Rapid Surgical Recovery: The Fraser Health Experience This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Background
Fraser Health's Experience With Rapid Surgical Recovery

Since 1996 rapid surgical recovery has been a cornerstone within the Fraser Health (FH) cardiac surgery
program at the Royal Columbian Hospital (RCH). This effort started with the implementation of the Reimer-Kent
Postoperative Wellness Model, a conceptual framework for rapid surgical recovery, which was spearheaded by
the need to reduce postoperative length of stay (LOS) and address access for those on the surgical waitlist.
The approach needed to maintain or improve high quality care and patient safety/satisfaction. This synergistic,
clinical care model is designed to proactively address anticipated postoperative dysfunction such as pain,
nausea, constipation, immobility, and respiratory compromise.153,155 Each concept is operationalized through
evidence-informed best/promising multimodal treatment and medication strategies. Addressing common and
expected surgical issues in a preventive manner is important as there is mounting evidence that merely
reacting jeopardizes patient safety, contributes to morbidity and mortality, decreases quality of life and prolongs
LOS.8,13,15,16,18,21,34,40,73,76,92,98,160,183,202 Surgical outcome directly impacts patient flow, throughput and access,
and access impacts wait times.29,32
With rapid surgical recovery, clearly established goals that span the surgical trajectory (pre-admission to
targeted discharge) help patients/families traverse the surgical course. Patients free of pain, nausea, and
constipation have stated how remarkably well they feel soon after surgery and have demonstrated that they are
more likely to tolerate earlier feeding, an accelerated activity plan and aggressive respiratory care. With this
feeling of wellness and knowledge of the daily recovery goals, patients are also more likely to actively
participate in their recovery and discharge process. Within the FH cardiac surgery program it became
immediately evident that returning patients to their functional baseline by reducing or eliminating anticipated
postoperative dysfunction improved surgical outcome, decreased LOS, and increased access to
care.74,126,127,141-157 There was also evidence that post-discharge convalescence was enhanced and hastened.65
Reimer-Kent's Postoperative Wellness Model is also a practical way in which to address patient safety due to
the manner in which it focuses on prevention. One of the rules for patient safety outlined in the Institute of
Medicine's Committee for Quality Health Care in America document Crossing the Quality Chasm: A New Health
System for the 21st Century
states that "Patients' needs should be, as much as possible, anticipated and not
treated in a reactive manner".40 This principle applies to all facets of health care, including routine postoperative
management. Yet despite evidence-based recommendations that would change reactive care to preventive
care; multimodal strategies to optimize surgical outcome remain underutilized.1,4,9,10,11,44,45,59,75,77,78,80,84-
Rapid surgical recovery is also an example of how a team can transform care at the bedside65 and is a healthcare innovation that is appropriate for desimmination17 diffusion162 and spread.16,68 As the concepts in Reimer-Kent's Postoperative Wellness Model are generalizable beyond the cardiac surgery patient population rapid surgical recovery was spread within FH to general surgery at RCH and Eagle Ridge Hospital (ERH) in 2006.74,99,151-153,155-157 By this time a growing world-wide movement to reform surgical care had surfaced led in large part by Dr. Henrik Kehlet, from Hvidovre University Hospital, Denmark. Kehlet is known as the father of Fast Track Surgery. Analogous terms include ‘accelerated recovery', multimodal rehabilitation', and ‘enhanced recovery' and many of the principles within these frameworks support and are congruent with rapid surgical recovery as they all address surgical optimization through multimodal rather than unimodal strategies that enhance and hasten recovery and convalescence.78-91 The RCH/ERH general surgery work started with just the colon resection patients but due to the positive results quickly spread to include all general surgery patients.74,99,155 Instead of developing pathways, pre-printed orders, and patient teaching material for each surgical procedure the general surgery team chose to create these practice support tools to reflect surgical categories, i.e., major, minor, and day general surgery procedures. In FH the cardiac surgery program at RCH and the general surgery program at RCH/ERH are using the rapid surgical recovery methodology as outlined in this document. Chapter 1 – Rapid Surgical Recovery: The Fraser Health Experience This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. This surgical optimization work received the 2008 FH Above and Beyond Award for Evidence-Based Practice
and in 2010 the surveyors for Accreditation Canada recommended that rapid surgical recovery be deemed a
leading Canadian practice.

What is Rapid Surgical Recovery?
Rapid surgical recovery, also known in the world wide literature as ‘fast-track surgery', ‘accelerated recovery',
‘multimodal rehabilitation', and ‘enhanced recovery' is a bundle of multimodal, preventive, best/promising
practices based on available evidence that simplify care and treatment processes, and when performed together
have real potential for improving patient safety, quality care, and access.34,66,104 It is an aggressive patient care
approach that seeks to rapidly return patients to their functional baseline through humanizing, normalizing,
preventive, and restorative strategies designed to make patients feel remarkably well, remarkably soon after
surgery. Reimer-Kent's Postoperative Wellness Model developed within FH is a conceptual framework that
provides strong support for attaining rapid surgical recovery.74,99,126,127,141-157
What sets rapid surgical recovery apart is that it is a very specific patient management methodology that is goal-
directed and outcome-driven. The strategies are designed to help the patient win the surgical recovery race ---
fondly referred to as the amazing race. In FH it fits well with each strategic imperative and with many current
initiatives, like: the American College of Surgeons National Surgical Quality Improvement Program (ACS
NSQIP); ALOS/350 Challenge; Home First; Front-line Leaders Enabling Care; Care Planning; 48/6 which
includes assessing for pain, nutrition, hydration, elimination, functional status, and medications within 48 hours
of admission to hospital.
Rapid surgical recovery is not unique to any one patient population.85,90,91,99,141-157 While the principles remain
solid the practices get adjusted to best suit the situation and circumstances (different hospitals and different
patient populations) making it an ideal cornerstone for any surgical optimization work.

Why is Rapid Surgical Recovery Important?

• Surgical care uses an appreciative amount of the available healthcare resources.91 • Despite advances to reduce hospitalization and overall costs, a significant portion of surgical patients still suffer from an undesirable outcome (morbidity/mortality).8,13,15,91 • Recent studies have found many traditional methods wanting – unnecessary – harmful – and not in accordance with evidence.86,91,112,177,178,182 There is a worldwide movement to improve health care9,16,18,27,34,64,67,108,135,137 and make it safer33,40,98,102,121,130,140,160,183,202 by reforming surgical care and implementing multimodal rehabilitation programs, like rapid surgical recovery that combine unimodal evidence-based principles of care into a multimodal effort to optimize, enhance, and hasten surgical recovery. There is a growing body of evidence that has found the following:74,85,90-93,96,97,99,138,155,175,179,191,196,203 • Supported as safe. • Reduced risk of a medical complication. • Reduced hospital stay. • Reduced readmission rate. • Reduced convalescence time. • Reduced costs (needs further economic analysis) – Transfer costs to another facility; Early postoperative period more expensive than later postoperative period; Opportunity costs of having additional beds. Chapter 1 – Rapid Surgical Recovery: The Fraser Health Experience This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Theories/Conceptual Frameworks/Models That Support Rapid Surgical Recovery
All clinical pathways, pre-printed doctors' orders, and patient teaching material would benefit from being framed on a model that clearly articulates to the team why and what they are implementing. Models provide practitioners with a framework to assess need, set goals, implement, and evaluate care. It promotes evidence-informed practices by helping to infuse research into practice.90,125 Within the scientific method, theories are formed from concepts --- e.g., rapid surgical recovery will be attainable if patients are rapidly returned to their functional baseline and made to feel well. Concepts are abstract notions or ideas --- e.g., postoperative wellness will be derived from the concepts of preventing pain, nausea, constipation, immobility, and respiratory compromise. The variables are the characteristics that change or vary --- e.g., each concept is operationally defined through treatment and medication strategies designed to rapidly return patients to their functional baseline and in order to reach the patient are translated through clinical pathways, pre-printed orders, and patient teaching material. While the theory and model remain firm the content of these tools change as new evidence becomes available. Although inflexible on the core concept of PREVENTION, this clinical care model is flexible enough for participating teams to "re-invent" as they implement the change. Prevention is a key to improving health care quality and safety.18,31,34,40,57,62,73,90,91,98,99, Examples of rapid surgical recovery models/principles are Reimer-Kent's Postoperative Wellness Mode155l and Kehlet's Fast Track Surgery Principles.78,91 Both need to be viewed as part of a comprehensive surgical optimization framework. Reimer-Kent's Postoperative Wellness Model 32,74,99,105,122,126,127,137,141-157,200
An innovative proactive, preventive-focused, patient-centered model that supports rapid surgical recovery as it is designed to accomplish the following: • Optimize surgical outcome by preventing or minimizing anticipated postoperative problems such as: Nausea/vomiting. Respiratory compromise. • Support rapid surgical recovery by: Seeing surgical recovery in a wellness rather than an illness paradigm for all patients. Architecting care so that patients are able to rapidly return to their functional baseline. Implementing humanizing, normalizing, preventive and restorative medication and treatment strategies designed to make patients feel remarkably well, remarkably soon after surgery. Encouraging a natural engagement in active rather than passive recovery by the patient. o Demonstrating the importance of going beyond just LOS as a measure of success and measuring the pyramid of indicators that address rapid surgical recovery and which would provide clinical teams with data on the success of their practices.
Chapter 1 – Rapid Surgical Recovery: The Fraser Health Experience This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Model developed in 1995 by Jocelyn Reimer-Kent, RN, MN, Clinical Nurse Specialist Cardiac Program, Fraser Health -- Royal Columbian Hospital Reimer-Kent, J. (2012). Creating a Postoperative Wellness Model to Optimize and Enhance Rapid Surgical Recovery. Canadian Journal of Cardiovascular Nursing, 22(2), 7–14 http://www.cccn.ca/media.php?mid=241 Kehlet's Fast Track Surgery Principles
Kehlet's Fast Track Surgery Principles were first reported in 1997 to support an enhanced and hastened recovery and convalescence.2,10,11,20,22,62,63,75,78-91,115128,132,134,189,194,197 More and more surgical programs around the world are redesigning their approach to the surgical experience using Kehlet's principles. The theory behind Kehlet's principles: • Single modal therapy for a multimodal problem is futile. • Multimodal evidence-based care within the fast-track methodology significantly enhances postoperative recovery and reduces morbidity, and should therefore be more widely adopted. • Optimize perioperative care by reducing the expected stress response with tissue catabolism and known organ dysfunction associated with surgery and this will shorten recovery time and convalescence. • Reduce the time needed for full recover by having an inter-professional team pay attention to the following postoperative issues: Nausea/vomiting/paralytic ileus. Timely removal of drains/lines/tubes. Sleep disturbances. Chapter 1 – Rapid Surgical Recovery: The Fraser Health Experience This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Kehlet's principles include the following and a schemata of a Fast Track Surgery algorithm197 is available at: Wilmore, D.W. & Kehlet, H. BMJ 2001;322:473-476 http://www.bmj.com/content/322/7284/473.full • Fast Track Surgery will results from the following: Staff training/reorganization and procedure specific care plans is imperative. Information and optimization of organ function preoperatively is emphasized. Mitigating the surgical stress response with:  Regional anesthesia.  Minimally invasive operations.  Pharmacological modifiers. Effective pain relief and prophylaxis for nausea/vomiting are essential. Modification of perioperative care is a requirement and needs to address the following:  Early mobilization.  Minimal use of tubes, drains, and catheters.
A Comprehensive Surgical Optimization Framework

There are several phases to the surgical experience (preoperative, intraoperative, postoperative, and post-
discharge/follow-up) and there needs to be continuity and consistency within and between each phase for the
patient to have a seamless journey. The surgical experience can be viewed as an umbrella that covers the
patient as they move through each phase, which should be seen as a continuum ranging from evaluating and
preparing patients for surgery, to minimizing the surgical stress response, to promoting the rapid return to health
and wellness after surgery.46,51,78,83,91,101,153 The patient is the handle and the cloth covering the surgical phases
There is synergy in this framework as what happens within each phase will ultimately affect the total experience
and outcome. The problem of perioperative risk may not be solved by preoperative optimization.91 Gains made
in each phase may not be fully realized if the patient is then exposed to outdated, traditional practices.
Evidence-informed best/promising practices carefully integrated into a multimodal rehabilitation program such as
those within rapid surgical recovery need to be embedded within each phase so that the true benefit of a
comprehensive surgical optimization framework can be realized.
Chapter 1 – Rapid Surgical Recovery: The Fraser Health Experience This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. A Change Package to Support Rapid Surgical Recovery
A ‘change package' is a collection of concepts and corresponding ideas for how to change current practice.
Change is inherent to the improvement process,6,16,17,21,27,34,35,40,64-72,95,98,100,108,130,135,140 yet health care has been
noted as an industry with an aversion for change16,27,35,135 at times even if there is a perceived benefit to the
change.17 There is often fear and resistance to changing the status quo95 and spreading good ideas and
innovations within health care organizations can be extremely slow.121,130,160 However, care needs to be
customized to truly meet the needs of patients/families.109 Just developing a protocol for rapid surgical recovery
will not suffice as it takes a team to understand the fundamental principles behind the protocol and a willingness
to change practice.115 It takes time to infuse practice changes into long-term improvements and reinfusion over
time as to why the practice changed needs to be part of the sustainability plan.101,177
Change is often easier to implement if there is a perceived benefit and rapid surgical recovery would be ideal for
an initiative such as pay-for-performance.166
To ensure that changes lead to improvements there need to be checks and balances in place. For example
decreasing postoperative LOS only to see increasing readmission rates would not be an improvement. Having a
team know what they are aiming for is fundamental to changing the practice and culture that will support rapid
surgical recovery. Essential to the process is a willingness of the team to reconsider and revise the use and
necessity of traditional postoperative care principles.90,101,115
AIM Statement Definition

An AIM statement69 clearly defines what the team is going to accomplish. It is part of the Model for Process
Improvement developed by Associates in Process Improvement and is a powerful tool in addressing system
redesign.6,67-72
Example of a Rapid Surgical Recovery AIM Statement
The Department of Surgery at Hospital will address surgical access, patient safety and quality care by implementing an evidenced-based rapid surgical recovery program based on Reimer-Kent's Postoperative Wellness Model and Kehlet's Fast Track Surgery principles which will address the following care issues: • Preventing/minimizing pain and suffering – A prerequisite for achieving rapid surgical recovery. Using opioid-sparing, multimodal balanced analgesia. • Preventing/minimizing nausea/vomiting and constipation – A prerequisite for achieving rapid surgical Liberalizing preoperative fasting and thirsting and feeding early post-surgery. Normalizing GI function and elimination patterns. • Preventing/minimizing immobility/inactivity – A prerequisite for achieving rapid surgical recovery. Following an aggressive mobilization plan and resuming activities of daily living and self-care early after surgery. Discontinuing attached lines, tubes and/or drains early after surgery. • Preventing/minimizing respiratory compromise/hypoxemia – A prerequisite for achieving rapid surgical Following an aggressive respiratory plan and discontinuing supplemental oxygen as soon as possible. • Increasing access to care – A benefit of achieving rapid surgical recovery. Ensuring a timely and appropriate discharge according to clearly set discharge criteria. Aiming for discharge home. Avoiding needless readmission especially from ineffective pain relief and/or nausea/vomiting. Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. The following ‘change package' includes suggested practice changes that relate to
surgical care processes and are designed to optimize outcome by
preventing/minimizing postoperative dysfunction and rapidly returning patients to
their functional baseline.
A Change Package for
Preventing Postoperative Pain
NO Pain – GREAT Gain
Prevent/minimize pain and suffering in all surgical patients as it is a prerequisite for optimal outcome and rapid return to baseline or better function.10-12,23,37,49,51,73,78-91,99,101,126,127,134,146,147,149-155,157,169,174,189,192,193,197 All patients experience postoperative pain, most often at moderate to severe levels,5,73,78,79,113,118 which is often undertreated leaving patients with ineffective pain relief.5,90,169 Yet even patients with moderate to severe pain may report being satisfied with their pain management.39 Unrelieved postoperative pain must be viewed and treated as a complication or risk, not as an acceptable consequence of surgery as unrelieved acute and prolonged postoperative pain can result in:5,88,120,134,174 • Negative physiological effects such as: Hematologic, immune, hormonal systems – clotting, impaired wound healing. Cardio-respiratory systems – hemodynamic compromise, atelectasis/pneumonia. Musculoskeletal system – immobility. Central nervous system – delirium, chronic pain as persistent pain can cause changes in the nervous system and become a distinct chronic disease. • Negative psycho-social-spiritual effects. Include all strategies outlined in the postoperative wellness model to garner the synergistic effect of all its multimodal strategies so that pain arising from retching/straining/stiff or sore muscles/coughing can be also be prevented.153 Provide optimal, dynamic, PREVENTIVE pain relief10-12,22,23,37,49,51,63,73,78-82,87-,91,101,113,145-155,157,169,174,189,192-194,197 that is simple and safe,113 started as soon as possible in the perioperative period, used concomitantly with any other pain management approach,23,113,147,153 and extended well into the postoperative period (e.g., a minimum of the first week after major surgery).12,147,153,174 This will significantly improve postoperative recovery.1,37,87,90,147,153,174,192 Avoid having day surgery patients fall into a quality/safety chasm as they recover out of sight and possibly out of mind especially in regards to duration and severity of pain.12,50,90,170,192, 193 As postoperative pain should wane over time it is important to assess any patient with severe pain at 72 hours for the possibility of a complication.97,153 By this time surgical pain should be diminishing and escalating pain often accompanies a complication such as a deep wound infection. Set a pain management/comfort goal (e.g., 3 or less on a 0 to 10 verbal pain rating scale or mild).113,147,150,153,185 Assess pain regularly (at a minimum as the 5th Vital Sign) at rest and with moving/coughing. 49,53,56,113,147,150,174,185 Patients may have pre-existing chronic pain issues and it may not be possible to get their pain rating at 3 or less. Consider other pain assessment parameters for these patients such as: patient's stated comfort goal; ability to sleep, eat, perform required activities, deep breathe and cough, and move/ambulate; and satisfaction with pain relief. Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Establish an opioid-sparing multimodal/balanced analgesic pain management plan for all surgical procedures day, minor, and major. Such a plan will have an additive or synergistic effect. It will also have a concomitant effect of lowering side effects of single agents.90,97,147,174 Non-opioids have a significant opioid-sparing effect and will decrease the incidence of opioid-induced side-effects such as: sedation; respiratory depression; postoperative nausea/vomiting (PONV), and postoperative ileus (POI); urinary retention; pruritus; and nightmares, hallucinations, and panic attacks.23,49,77,82,147,193 Preventing postoperative pain will also do the following:5,63,90,147,149,189,193 • Improve clinical outcomes and recovery – starting early postoperative feeding; starting early postoperative mobilization; avoiding the development of chronic pain; avoiding clinical complications and reducing morbidity. • Improve quality of life and functionality that may otherwise persist for weeks after an elective operation. • Save health care resources. Please note there are advantages and disadvantages to all non-opioids, especially
NSAIDs so each team will need to determine which if any they will use.14,19,147,153,167,174

Use the oral route for all analgesics as soon as possible (e.g., by postoperative day 1 or 2).113,147,150,153,174 Use an appropriate alternate route (e.g., parenteral, rectal, etc.) if the oral route is inappropriate53,147,150,174 but avoid intra-muscular injections for delivering analgesics as it is a painful way to deliver pain relief and there can be medication absorption issues.49,147,150 Discontinue infused analgesics (epidural, PCA, nurse-controlled) as soon as the patient has effective pain relief with oral analgesics (e.g., by postoperative day 2).1,97,99,157 Move to a non-opioid based postoperative pain management plan with an occasional opioid. Relying excessively on opioid analgesics will lead to increased morbidity and mortality193 as often patients will experience negative analgesic side effects from opioids, especially PONV, constipation, POI, and respiratory compromise.5,43 Give around-the-clock (ATC) non-opioids [using both acetaminophen and a non-steroidal anti-inflammatory drug (NSAID)].36,37,39,53,82,147,150,153,178 These non-opioids are opioid-sparing, and will reduce opioid side effects and hasten recovery.23,90,97,147,153,158 Administer when due, whether pain is present or absent.5,147,150,153 Use the non-opioid analgesic acetaminophen regularly to maximal recommended doses ATC as a 'background' medication for all acute pain problems, unless there is a clear contraindication.14,113,114,147,150,153, 174,193 Use a non-opioid analgesic(s) within the class of NSAIDs regularly to maximal recommended doses114 ATC as a 'background' medication for all acute pain problems unless there is a clear contraindication. NSAIDs have both beneficial (powerful opioid-sparing effect, which may reduce PONV and POI90) and harmful effects (e.g., renal toxicity) and should to be assessed for each patient before they are prescribed.14,90,113,114,147,150,153,174,193 Avoid medications that combine a non-opioid with an opioid, [e.g., acetaminophen with codeine (Tylenol® #3), acetaminophen with oxycodone (Percocet), etc.].5,56,147,150,153 This will allow better ATC dosing with non-opioids. Also most pain management plans with combination medications are likely to leave the patient undertreated as the patient would only intermittently get the non-opioid and only when their pain warranted the opioid. Give an immediate release PRN opioid on demand as rescue medication to treat breakthrough pain. This is any pain rated at more than mild or above comfort goal. Use also as a pre-procedural analgesia, regardless of pain rating. 23,39,53,56,113,147,150,153,174 Administer opioids to effect as they do not have the ceiling on dosage that exists with non-opioids. Use only one opioid to encourage familiarity and reduce risk and medication error.81,113,147,150,153,169 Avoid codeine (due to its poor pain relief profile and the potential lack of the enzyme CYP2D6 in some patients which is required to convert codeine into morphine, and its harsh GI side effects).110,147,150,153 Also avoid meperidine due to its toxic metabolites.81,113,147,150,153,169,174 Yet acetaminophen with codeine (Tylenol#3) is still the most commonly prescribed postoperative analgesic despite codeine's harsh side effects (especially PONV and constipation) and poor pain relief profile.5,147,150,169 Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Examples of Postoperative Pain Management Orders
For Major General Surgery and Cardiac Surgery
Please note as this is continuous quality improvement work, medications and
treatments strategies may change over time as new evidence and effectiveness data
emerges – what well not change is that medication and treatment strategies need to
support the PREVENTION of postoperative pain.
Major General Surgery
Cardiac Surgery
ACETAMINOPHEN 650 mg PO/PR
For ALL NSAIDs – HOLD if eGFR is less than 60
mL/min or if patient has a history of peptic ulcer Goal for ALL patients – Pain rating at 3 or less on a 0- disease or an ASA allergy: 10 pain rating scale and patient able to deep breathe • NAPROXEN 500mg PO/PR
and cough, move and ambulate, and satisfied with pain management • If pain rated at greater than 3 & as a pre- Goal for ALL patients – Able to deep breathe and procedural analgesic (regardless of pain rating), cough, move and ambulate, and patient satisfied with MORphine 1 to 4 mg IV q5minutes PRN or 5 to 10
mg PO or NG q30 minutes PRN For Patients on APS – Follow APS orders
ACETAMINPOHEN SUPP 1300 mg times one
For Patients NOT on APS
dose in operating room at the end of the case
followed by ACETAMINPOHEN SUPP 650 mg or
OXYCODONE 5 to 10 mg PO q4h PRN or
1000 mg PO or NG qid, for 7 days, then qid PRN MORphine 5 to 10 mg subcutaneous q4h PRN
(use only if NPO or unable to tolerate PO)
HOLD ALL NSAIDs if eGFR is less than 60 mL/min &
there has been a 25% decrease in baseline serum
ACETAMINOPHEN 650 mg PO/PR q6h for 5
days, then q6h PRN  INDOMETHACIN SUPP 100 mg one dose in
HOLD ALL NSAIDs if eGFR is less than 60 mL/min or
operating room at the end of the case followed by if patient has a history of peptic ulcer disease or an INDOMETHACIN SUPP 100 mg per rectum q12h,
for 2 days then IBUPROFEN 400 mg PO qid with
Use one of the following: food, times 4 days; then qid PRN with food  NAPROXEN  250 mg or  500 mg PO/PR bid
 CELECOXIB  200 mg or  100 mg
(contraindicated if SULFA allergy/breast feeding) PO bid for 4 days  KETOROLAC 10 mg IV q6h times 4 days
A Change Package for Preventing Postoperative Delirium
Prevent/minimize delirium22,33,124,161 in all surgical patients as it is a prerequisite for optimal outcome and rapid return to baseline or better function. Include all strategies outlined in the postoperative wellness model to garner the synergistic effect of all its multimodal strategies153 so that all patients have optimal cognitive functioning.188 Many patients following major surgery develop postoperative delirium. This acute confusional state causes a temporary global disorder in cognition. Delirium is deemed a major complication as it is known to increase morbidity and mortality, increase LOS, decrease quality of life (patient/family distress and caregiver burden), and potentiate the need for a new admission to long-term care. Delirium is a multifactoral problem and has not been linked with any one risk factor.22,33,124161 However, delirium has been associated with inadequate postoperative pain relief.161 Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Use opioid-sparing analgesia and prevent PONV as this should increase the likelihood of starting early postoperative feeding --- a strategy correlated with reduced morbidity including delirium.22,33,124,161 Administer analgesics (especially non-opioids ATC) during any periods of delirium.22,147,150,153,161,165 Assess patients regularly for delirium using the Confusion Assessment Method Instrument (CAMI). This widely used assessment tool will help with early recognition and lead to prompt treatment, which in-turn will help reduce the severity and duration of delirium.22,124 Examples of Postoperative Delirium Management Orders
For Major General Surgery and Cardiac Surgery
Please note as this is continuous quality improvement work, medications and
treatments strategies may change over time as new evidence and effectiveness data
emerges – what well not change is that medication and treatment strategies need to
support the PREVENTION of postoperative delirium.
Major General Surgery
Cardiac Surgery
Delirium Management Delirium Management Delirium Assessment qshift & PRN [see Confusion Delirium Assessment qshift & PRN [see Confusion Assessment Method Instrument (CAMI) back of order Assessment Method Instrument (CAMI) back of order • If patient meets CAMI criteria for Delirium notify • If patient meets CAMI criteria for Delirium give: General Surgery House Staff and inquire re • HALOPERIDOL 1 to 5 mg IV PRN (Maximum
referral to Psychiatry and give: 5 mg IV in 15 minutes) or 2 to 10 mg PO PRN • LOXAPINE 10 mg PO or subcutaneous at hs
(Maximum 10 mg PO in 15 minutes) – and q1h PRN – Maximum total daily combined MAXIMUM combined IV/PO Dose 50 mg in 24 HS and PRN LOXAPINE dose = 100 mg hours – until other Delirium Management Orders written by physician • Continue with pain management as outlined in this order set including Epidural • Continue with pain management as outlined in • STOP PCA and contact APS Check If Appropriate:  Consult Psychiatry Confusion Assessment Method Instrument (CAMI) Delirium Watch
The diagnosis of delirium by CAMI
Features
requires the presence of features
1 and 2 + either 3 or 4
1. Acute onset & fluctuating course Does the abnormal behaviour: Increase or decrease in severity 2. Inattention Does the patient: Have difficulty focusing attention Become easily distracted Have difficulty following conversation 3. Disorganized thinking Is the patient's thinking: Does the patient have: Illogical flow of ideas 4. Altered level of consciousness What is the patient's level of consciousness: Agitated (hyper) Lethargic (drowsy but easily roused) Stupor (difficult to arouse) Comatose (unable to arouse) Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. A Change Package for
Normalizing Gastrointestinal (GI)
Function
Preventing Postoperative Nausea
and Vomiting (PONV)
Normalize GI function and prevent PONV in all surgical patients as it is a prerequisite for optimal outcome and rapid return to baseline or better function. Include all strategies outlined in the postoperative wellness model to garner the synergistic effect of all its multimodal strategies.153 Provide optimal, dynamic, PREVENTIVE PONV management and work to normalize GI function. PONV has been called the little big problem as it is a common postoperative complication that increases LOS, increases cost of care, and prolongs recovery.54,55,90,101 PONV may be one of the greatest stressors for patients109 more stressful than pain.101 PONV is a common occurrence in ambulatory patients, often not present prior to discharge.55 To reduce gastric distress administer gastric motility agents ATC and a proton-pump inhibitor (PPI) ATC especially to all patients receiving NSAIDs.14,135,146,149 Administer antiemetic prophylaxis as well as for breakthrough PONV.10,11,54,55,78,80,84,85,90,91 Think of ‘food as medicine' both preoperatively and postoperatively. Prepare patients appropriately for surgery, which is like a cellular marathon, a race that needs to start with
adequate nutrition and hydration. Many health care practitioners still hold onto the deeply rooted directive of Nil
per os or NPO after midnight. Despite world-wide efforts to implement best practice guidelines that liberalize the
duration of preoperative fasting and thirsting, actually changing practice remains a challenge. NPO is often
unquestioned and rarely individualized even though prolonged fasting and thirsting is known to have detrimental
effects such as the following:1,20,22,24,25,28,41,42,54,55,60,61,90,97,101,106,107,111,112,116,117,122,133,136,176,180,181,186,195,200
• ↑ pre-op discomfort and gastric volumes. What to do about
fasting and

• ↑ time to full post-op recovery thirsting?
↑ rate of PONV Why it is important • ↑ dizziness, irritability, headache, anxiety, discomfort, delirium.
to stop the
automatic NPO

• ↑ hunger and dehydration. after midnight
• ↓ absorption of glucose and amino acids. directive.

• ↓ body's ability to cope with stressors (blood loss, infection) due to depressed immune • ↓ muscle strength (weakness, deconditioning, falls) and lean body mass. • ↑ post-op insulin resistance and electrolyte imbalance. • ↑ cardiovascular compromise and need for inotropic support. • May ↑ ventilator associated pneumonia (VAP). Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Please note liberalized fasting and thirsting (e.g., clear fluids until 2 hours before
surgery) has NOT been linked to postoperative morbidity (e.g., aspiration rate).97,101,168
Although pulmonary aspiration can occur during the perioperative period187 it is
deemed largely preventable with improved more aggressive reflux prophylaxis and/or
airway control strategies.168

Follow the latest Canadian Anesthesiology Society (CAS) Guidelines on Fasting/Thirsting.28,119,180 These
guidelines stipulate that before elective procedures, for patients with normal digestion who are not at high risk
for aspiration (e.g., gastric pathology, obesity, pregnancy and recent narcotic use), the minimum duration of
fasting/thirsting should be:
• 8 hours after a meal that includes meat, fried or fatty foods. • 6 hours after a light meal (such as toast and a clear fluid), or after ingestion of infant formula or • 4 hours after ingestion of breast milk. • 2 hours after clear fluids. Move to having a hydrated and carbohydrate fed patient entering the operating room.1,54,55,61,90,97,106,107,168,200 Develop a nutritional prep that treats solid food and fluid as distinctly different. Preoperative starvation is often longer than NPO after midnight as usually patients do not eat after their supper. Start with an evening snack, then NPO for solid food and end with the patient drinking clear fluids other than water within a 2-3 hour window before their surgery. Ensure that patients will eat and drink as instructed before surgery as patients, even those who comprehend instructions, may for various reasons fast longer than instructed.90,94,103,111,112,186 Monitor, evaluate, and educate regarding liberalized fasting/thirsting as even with achieving consensus on liberalized guidelines, there remains a professional practice gap in implementation.122 Examples of Liberalized Fasting and Thirsting Orders
For Major General Surgery and Cardiac Surgery
Please note as this is continuous quality improvement work there may be further
enhancements in minimizing the time a patient needs to starve before surgery.
Major General Surgery
Cardiac Surgery
• Eat an evening snack then NO solid food after • Eat an evening snack then NO solid food after midnight and continue clear fluids midnight and continue clear fluids • Drink 1 to 2 glasses (up to 500 mL) of apple or • Drink 1 to 2 glasses (up to 500 mL) of apple or cranberry juice 3 hours prior to surgery – Wake cranberry juice 3 hours prior to surgery – Wake patient if necessary, then NPO patient if necessary, then NPO • For morning and afternoon cases drink 1 to 2 glasses (up to 500 mL) of apple or cranberry juice at 0500 hours – Wake patient if necessary, then NPO for the morning case and the afternoon case to repeat 1 to 2 glasses of apple or cranberry juice at 0800, then NPO Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. EXCEPTIONS to this nutritional prep
• If a bowel prep was used then clear fluids only after bowel prep – NO solid food but still drink 3 hours prior • Pregnant. • Narcotic use in past 12 hours. • Trauma. • Gastric surgery. • Diagnosed Gastroesophageal reflux disease (GERD). • Diagnosed diabetic gastroparesis. Avoid routine mechanical bowel preparation.1,26,52,58,91,101,138 This is a controversial practice but its avoidance may be valuable in reducing postoperative morbidity such as: postoperative ileus (POI), dehydration, perioperative fluid management challenges, and PONV.1,24,28,52,54,55,58,60,86,91,97,101,112,138 Avoid routine nasogastric (NG) decompression.86,91,97,101,184 NG tubes may actually hinder recovery by prolonging POI and predispose the patient to pulmonary aspiration.97,184 If an NG is placed during surgery to evacuate stomach air from ventilation aim to remove before reversal of anesthesia.101 Avoid an analgesic plan that is primarily opioid-based as this will prolong POI. Most bowel surgery patients will develop a POI, which will delay gastric emptying and reduce gastric motility.7,43,62,86 This complication negatively affects upper GI (intolerance of solid food) and lower GI (constipation) recovery. It also results in increase health care resource utilization and postoperative LOS.7,43,62,86
What to do about postoperative feeding?
Why it is important to stop postoperative starvation and start early postoperative feeding.

Feed all patients as soon as possible after surgery (e.g., major general surgery a full-fluid diet postoperative day 0 and regular diet by postoperative day 2 or sooner; cardiac surgery regular diet by postoperative day 1 or sooner).1,3,77-80,86,90,91,153,175,195,199 Early postoperative feeding is deemed safe and more importantly beneficial even after colonic surgery with bowel anastomoses.90,97,101,173,177 Avoid a clear fluid diet and provide normal food as soon as possible.3,10,45,47,153 The ingestion/digestion of normal food will: reduce malnutrition; improve GI motility; decrease insulin resistance; improve muscle function; promote healing; avert postoperative fatigue, muscle wasting and morbidity (e.g., infections from reduced gut permeability/bacterial translocation), and shorten LOS.3,47,63,86,90,97,101 Feed even with PONV or a POI as these conditions should be pharmacologically treated.90 Feed even if bowel sounds have not been heard. Keeping patients NPO after surgery until bowel sounds/flatus return is considered an archaic practice as bowel sounds may or may not be present with either bowel activity or inactivity and this should not delay early postoperative feeding.173,197 Protect and enhance meal time (no interruptions during meal time, no eating in bed, ensuring patient has hand hygiene, cleared and cleaned tray top, etc). Minimize the interruption in chronic medication administration to treat pre-existing conditions (e.g., antihypertensives, antidepressants) to avoid abstinence syndrome deemed as serious as a complication.11,80,90,128,,191 Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Examples of Postoperative Early Feeding Orders
For Major General Surgery and Cardiac Surgery
Please note as this is continuous quality improvement work there may be further
enhancements in minimizing the time a patient needs to starve after surgery.
Major General Surgery
Cardiac Surgery
Post-op Day 0 full fluids Post-op Day #0 post-extubation start feeding as soon as able with a General non-cardiac diet as tolerated – Start Post-op Day 2 general diet as tolerated (if Diabetic diet if patient on diabetic diet pre-op diabetic – diabetic medium and if new ileostomy – fibre restricted) Examples of Postoperative GI Upset/Distress Orders
For Major General Surgery and Cardiac Surgery
Please note as this is continuous quality improvement work, medications and
treatments strategies may change over time as new evidence and effectiveness data
emerges – what well not change is that medication and treatment strategies need to
support the PREVENTION of postoperative GI upset/distress.
Major General Surgery
Cardiac Surgery
PANTOPRAZOLE 40 mg IV at 2200 hours OR
METOCLOPRAMIDE 10 mg IV or PO qid, times
ESOMEPRAZOLE 40 mg PO at 2200 hours times
48 hours then qid PRN (purpose gastric motility 5 days (PPI purpose prevent gastric distress agent) HOLD if patient has diarrhea associated with NSAIDs) • ESOMEPRAZOLE 40 mg PO hs, times 7 days
METOCLOPRAMIDE 10 mg IV or PO qid times 48
(PPI purpose prevent gastric distress associated hours, then qid PRN (purpose gastric motility agent) HOLD if patient has diarrhea &/or has an • dimenhyDRINATE 12.5 to 25 mg IV or 25 to 50
mg PO or NG q6h PRN – DO NOT give as a sleep • ONDansetron 4 mg IV q8h PRN if ineffective in
aid and HOLD if patient has delirium, 30 to 45 minutes administer dimenhyDRINATE
dimenhyDRINATE 10 to 25 mg IV q15 minutes
PRN to a maximum of 50 mg in four hours or 25 to 50 mg PO q6h PRN • ALUMINUM HYDROXIDE/MAGNESIUM
HYDROXIDE SUSPENSION 10 to 20 mL PO qid
PRN – Maximum 80 mL in 24 hours
Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. A Change Package for
Normalizing GI Function
Preventing Postoperative
Respiratory
Normalize GI function and prevent postoperative constipation and POI in all surgical patients as it is a prerequisite for optimal outcome and rapid return to baseline or better function. Constipation is often a result of surgery (anesthesia, opioid analgesia, dehydration, malnutrition, etc.). Include all strategies outlined in the postoperative wellness model to garner the synergistic effect of all its multimodal strategies.153 Provide optimal, dynamic, PREVENTIVE constipation management so that patients will have a first defecation by their 3rd postoperative day86,99,153 through strategies that will aid in the defecation process such as the following: • Liberalizing preoperative fasting/thirsting and starting early postoperative feeding with normal food. • Using opioid-sparing analgesia and avoiding codeine. • Re-evaluating the effectiveness of stool softeners and their delayed onset of action, and whether they are required in a rapid surgical recovery bowel care plan. • Using gastric motility agents for the purpose of aiding in gastric emptying. • Knowing that analgesic suppositories (if part of the pain management plan) may cause rectal stimulation. • Having the patient use the toilet in the bathroom with their feet on the floor and privacy. • Monitoring and tracking the occurrence of postoperative defecation and administering time specific bowel care agents to all eligible patients. Many rapid surgical recovery patients defecate without any additional medication/bowel care.147,153 Examples of Postoperative Constipation Management Orders
For Major General Surgery and Cardiac Surgery
Please note as this is continuous quality improvement work, medications and
treatments strategies may change over time as new evidence and effectiveness data
emerges – what well not change is that medication and treatment strategies need to
support the PREVENTION of postoperative constipation.
Major General Surgery
Cardiac Surgery
Start Post-op Day 2 – if no bowel movement since • Post-op day 2, if no BM since surgery give surgery and NO diarrhea or ileostomy MAGNOLAX 30 to 60 mL PO hs, times one dose
MAGNESIUM HYDROXIDE 30mL PO and repeat
• Post-op day 3, if no BM since surgery give PRN daily until first post-operative bowel BISACODYL SUPP 10 mg PR at 1000 hours,
• Post-op day 3, if AM BISACODYL SUPP ineffective repeat BISACODYL SUPP at 1800
hours, times one dose
Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. • Post-op day 4, if no BM since surgery & if eGFR is greater or equal to 50, give SODIUM
PHOSPHATE
enema at 1000 hours, times one
dose, if ineffective notify physician
• For LOS greater than 4 days start post-op day 5, give GENERAL BOWEL PROTOCOL
A Change Package for
Preventing Postoperative Immobility
Prevent postoperative immobility and balance sleep and rest in all surgical patients as it is a prerequisite for optimal outcome and rapid return to baseline or better function. It is imperative that patients are able to mobilize and benefit from the restorative properties of sleep.164,165 Include all strategies outlined in the postoperative wellness model to garner the synergistic effect of all its multimodal strategies.153 Provide optimal, dynamic, PREVENTIVE immobility management and institute an escalating and accelerated mobilization/activity plan (e.g., formalized exercise classes and/or walking sessions).91,101,153 Work to return patients to their baseline mobility level, through strategies such as the following: • Having patients ambulate early and avoid bed rest (e.g., independent mobilization by postoperative day 2, eat all meals out of bed,91,101,153 etc.), as bed rest causes the following:10,45,90,97,101 ↑ insulin resistance. ↑ muscle loss. ↓ muscle strength leading to weakness. ↓ pulmonary function and tissue oxygenation leading to pulmonary complications. Predisposes to thromboembolic complications and orthostatic intolerance. • Setting a target for the removal of all routine drains/lines/tubes (e.g., urinary catheter < 48 hours; chest tubes < 24 hours, etc.).10,90,91,97,101,153 Having a continuous epidural infusion is not an indication for bladder drainage beyond 24 hours.90 • Encouraging self-care and the resumption of activities of daily living – hygiene and toileting in • Avoiding the use of urinals or bedpan as this is a good reason to mobilize.153 • Balancing sleep and rest with activity as sleep disturbances may contribute to poor postoperative outcome such as the following:164,165 Early postoperative fatigue Episodic hypoxemia Hemodynamic instability Altered mental status Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. • Implementing sleep hygiene strategies such as the following: Giving patients an uninterrupted and protected (no visitors, no physician visits, no tests, etc) afternoon (2 hour) rest period. This will address early fatigue and provide the opportunity to complete a full sleep cycle.153 Administering HS sedation only to patients who have insomnia.153 Eliminating sleep disturbing factors encourage ear plugs, lower the nursing unit noise level, e.g., alarms, phones, pagers, etc.78-80,87,90,153,164,165 Mobilization Time Adds Up
Time in minutes Activity 180 3 meals in chair 60 Voiding in BR x6 Examples of Postoperative Mobilization Orders
For Major General Surgery and Cardiac Surgery
Major General Surgery
Cardiac Surgery
• Post-op Day 0 – 10 to15 minutes or greater (e.g., • Post-op day 1, total activity 1 to 3 hours or greater high fowlers, dangle at bedside, up in chair) (i.e., chair for every meal, up to bathroom, walk in hallway) • Post-op Day 1 – 1 to 3 hours or greater (e.g., up in chair for all meals, up to bathroom, walk in • Post-op day 2, total activity 4 hours or greater (i.e., chair for every meal, up to bathroom, walk in hallway, attend exercise class) and start to shower • Post-op Day 2 – 4 hours or greater and start to with stand-by assistance & on telemetry shower – If NO epidural monitoring – If patient has pacer wires ensure they • Post-op Day 3 and beyond – 5 hours or greater are capped and covered with waterproof dressing • Post-op day 3, total activity 5 hours or greater (i.e., chair for every meal, up to bathroom, walk in hallway, attend exercise class, climb 1 flight of stairs) • Post-op day 4 and beyond, total activity 5 hours or greater (i.e., chair for every meal, up to bathroom, walk in hallway, attend exercise class, climb 2 flight of stairs) Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. A Change Package for
Preventing Postoperative
Respiratory Compromise
Respiratory
Prevent postoperative respiratory compromise in all surgical patients as it is a prerequisite for optimal outcome and rapid return to baseline or better function. Include all strategies outlined in the postoperative wellness model to garner the synergistic effect of all its multimodal strategies.153 Atelectasis forms within minutes after the induction of anesthesia, and causes intraoperative gas exchange abnormalities and postoperative pulmonary dysfunction. This may persist especially in the elderly and in those without effective pain relief resulting in the following:171,201 Decrease in the FRC. Impairment of VC. Rapid and shallow breathing pattern. Increased work of breathing. Ineffective cough. Provide optimal, dynamic, PREVENTIVE respiratory management and institute an aggressive respiratory care plan as hypoxemia has been linked with postoperative problems ranging from sleep disturbances to acute myocardial infarction.90 Include in this plan strategies such as the following: • Extubating as soon as possible (e.g., cardiac surgery within 6 hours or sooner).153 • Starting DB&C and use of incentive spirometer q1h and PRN while awake as soon as possible.78, • Setting targets for weaning and discontinuing supplemental oxygen (e.g., for major surgery by postoperative day 2 or sooner).90, 99,153 • Averting hypoxemia and having the patient maintain SpO2 at 93% or greater at all times.90, 153 • Making SpO2 measurement part of vital signs. • Maintaining adequate hydration intraoperatively to prevent respiratory compromise by allowing airway secretions to mobilize.168 • Assessing all patients for venous thromboembolism (VTE) risk and providing appropriate VTE prophylaxis.57,76,90,91,101 Surgery causes a coagulation/fibrinolytic imbalance and anticoagulation is needed to prevent deep venous and pulmonary thromboembolism.90 • Using LMWH concomitantly with NSAIDs as it is considered safe.101 • Rethinking the need for Sequential Compression Devices (SCDs) and anti-embolism stockings as they are not routinely warranted57,90,101 and may limit mobilization, which is a major activity to also prevent VTE.90 Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Examples of Postoperative VTE Prophylaxis Orders
For Major General Surgery and Cardiac Surgery
Please note as this is continuous quality improvement work, medications and
treatments strategies may change over time as new evidence and effectiveness data
emerges – what well not change is that medication and treatment strategies need to
support the PREVENTION of postoperative VTE.
Major General Surgery
Cardiac Surgery
HEPARIN 5000 units subcutaneous on call to the
ALL patients MUST be assessed for VTE risk • Start post-op day 1, HEPARIN 5000 units or
 DALTEPARIN 5000 units subcutaneous daily until
_ units subcutaneous q12h until • Mechanical Prophylaxis only if anticoagulant prophylaxis contraindicated – Reassess daily to start anticoagulation prophylaxis when contraindication resolves Other Components of a Rapid Surgical Recovery Program
Rapid surgical recovery also applies other evidence-based surgical optimization principles into its multimodal rehabilitation program such as the following:1,4,78,79-86,90,101,139,172,175,177,191,197,203 • Optimizing Fluid Status – avoiding hypovolemia/crystalloid excess. • Preventing Surgical Site infections – Prophylactic antibiotics and nasal and skin decontamination. • Preventing Intraoperative Hypothermia. • Preventing Blood Loss and Need for Transfusions. Home First
A Change Package for
Improving Access and Flow
Expedite rapid return to baseline (normal) function for all surgical patients. Prevent lengthy hospitalization, especially from ineffective pain management and/or PONV/constipation.74,99,147,153 Educate the entire care team (including patients and their support person) about the practice changes related to rapid surgical recovery.90, 97,101,153 Debunk the myth that the patient is too old and/or too sick to receive or benefit from preventive postoperative care.44,47,144,153,171,172,188 Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Incorporate all strategies outlined in the postoperative wellness model as it has the potential to have a significant positive effect on LOS without increasing readmission or burdening community healthcare resources.74,99,147,153 Plan care so that the patient will be ready for a timely and appropriate discharge back to their pre-hospital living situation or better (e.g., Home First) and thereby creating access for patients waiting for surgery.29 At each stage of the surgical experience rapid surgical recovery is a pull strategy and in keeping with the current FH definition that a pull strategy aims to make transitions between programs smoother, faster, with fewer hassles and bottlenecks, resulting in a better patient experience – patients are pulled from the waitlist into surgery and from surgical recovery back into their homes. Avert adverse events, which are the unintended injuries or complications that can result from how patients are managed by the health care team.8,13,15,76 Complications are a major contributor to postoperative morbidity and mortality and consume considerable health care resources.92 Prevention-based care such as designed through the postoperative wellness model helps with the early recognition and prompt treatment of any postoperative complications.4, 92,153 Consider rapid surgical recovery for exceedingly high-risk patients, including those requiring emergency surgery as these patients are expected to benefit greatly have this approach to care.91,153 Conduct daily inter-professional rounds, re-evaluate discharge plan daily and make timely referrals to continuing care, social work, etc.153 Develop discharge criteria and a careful, detailed discharge plan that starts before an elective or in-hospital waiting patient goes for surgery or as soon as possible after emergency surgery.153 Target postoperative LOS at or below national average and develop a LOS tracking system. Reduce the need for new institutionalization and/or transfer to post-acute convalescent or rehabilitation services or care facility.4,153 Prevent re-admission, especially from uncontrolled pain, PONV, and/or constipation.2,38,54,55,153,192 Ensure a triplicate prescription is written for an appropriate opioid for any patient receiving breakthrough pain analgesia at time of discharge.153 Avoid prescribing acetaminophen with codeine as a discharge analgesic.110,153 Ensure discharge information includes the importance of ongoing pain prevention and the continuation (if major surgery patient discharged < 5 to 7 days) of ATC doses of non-opioids before switching to PRN doses.153 Also include the importance of bowel care should the patient receive a prescription for acetaminophen with codeine.153 Examples of Targeted Length of Stay
For Cardiac Surgery and General Surgery by Major / Minor / Day Category
Cardiac Surgery Procedure
Post-operative Length of Stay
Coronary artery bypass graft Major General Surgery Procedure
Post-operative Length of Stay
Appendectomy (perforated) Bowel resection (without ostomy) Bowel resection (with ostomy) Bowel surgery (ostomy closure) Cholecystectomy (open approach) Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Esophagectomy (partial and total) Gastrectomy (partial) Gastrectomy (total) Hepatectomy (partial) Hernia (open approach) Nissen Fundoplication Minor General Surgery Procedure
Post-operative Length of Stay
Appendectomy (non-perforated) Day General Surgery Procedure
Post-operative Length of Stay
Inguinal Hernia Repair- laparoscopic Umbilical Hernia Repair Cholecystectomy - laparoscopic Breast Biopsy/Lumpectomy Peritoneal Dialysis Catheter Example of Discharge Criteria
For Cardiac Surgery and General Surgery by Major / Minor / Day Category

Aim to send patient home when the following discharge criteria have been met

Effective pain relief with oral analgesics not required for Day Surgery as LOS may be too short to meet this target. • Tolerates regular diet not required for Day Surgery as LOS may be too short to meet this target. • Assess need for homecare follow-up for wound care according to the FH Home Health Service Referral Pathway Tool For RCH Short-Stay Surgical Inpatient Requiring Home Care Nursing for Wound Care. • No nausea or vomiting. • Defecation has occurred not required for Minor or Day Surgery as LOS may too short to meet this target. • Independent mobilization and able to get self in and out of bed or back to pre-operative functional level not required for Day Surgery as LOS may be too short to meet this target. Resumption of Activities of Daily Living (ADL) not required for Day Surgery as LOS may be too short to meet this target. • Has an identified support person who will be available to assist as needed. • Discharge teaching completed and recovery booklet provided: Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption.









Provide patient and support person with written instructions related to prevention of pain, nausea, constipation, respiratory compromise and immobility and review other post-operative care requirements. Drain/dressing care teaching as appropriate (see FH Home Health Service Referral Pathway Tool). Instruct patient to call family doctor for follow-up appointment in one week and to call surgeon for follow-up appointment as necessary. • Discharge prescription written including: Medications as per current MAR as appropriate. Medications for pre-existing conditions as appropriate. Triplicate prescription for MORphine or OXYCODONE as needed. • If discharge home criteria not met for day surgery patients, notify surgeon, and refer to transfer criteria (per Practice Support Tools for Rapid Surgical Recovery

Pre-printed Doctor's Orders
• Create pre-printed orders (PPO) for the selected patient population that incorporates multimodal strategies to optimize surgical outcome and enhance and hasten recovery.153 • PPOs bring the desired medications and treatments to the inter- professional team for implementation. • PPOs should standardize and integrate the care and can be altered or changed as patient circumstances dictate. • PPOs for day, minor and major general surgery and for cardiac surgery are available from the FH print shop, FH Forms on Demand, or on request. Clinical Pathway
• Create a clinical pathway for the selected patient population that incorporates multimodal strategies to optimize surgical outcome and enhance and hasten recovery.153 • Clinical pathways also lessen the chance of human error in ensuring that treatment plans and goals, targets and expected outcomes are clearly delineated.140,160,183 • Clinical pathways, provided they are rigorously reviewed and evidence-based can help infuse research into practice, and promote quality care and standardization.183
Patient Teaching Material

• Prevent anxiety by having patients attend a pre-admission clinic for assessments and teaching (verbal and written) about the surgical Cardiac Surgery Rapid Surgical Recovery procedure and the rapid surgical recovery rehabilitation program. Daily Goals – Posted on bathroom door in Include the expected length of stay and daily milestones for each patient room • Create a patient pathway, information pamphlets and discharge • Update printed patient education material to reflect changes in • Ensure timely and complete discharge teaching. • Include patient's family/support person in all teaching sessions. • Patient teaching booklets that include the clinical pathway for day, minor and major general surgery and for cardiac surgery are available from the FH print shop, FH intranet, or on request Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. http://fhpulse/clinical_programs/surgical_services/resources/Documents/Recovery%20after%20Heart%20
Surgery%20In%20Hospital%20%20At%20Home%20%20Patient%20%20Family%20Information%20Apr%20
16%2708.pdf or from the Fraser Health PRINT SHOP # 383 or on request

Recovery After
Heart Surgery:
In Hospital & At Home
Patient and Family Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. http://fhpulse/clinical_programs/surgical_services/resources/Documents/RapidSurgicalRecovery/Major%
20General%20Surgery%20Patient%20and%20Family%20Information.pdf or from the Fraser Health PRINT
SHOP #255732 or on request

Major General Surgery
Rapid Surgical Recovery
Patient and Family
Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. http://fhpulse/clinical_programs/surgical_services/resources/Documents/RapidSurgicalRecovery/Minor%
20General%20Surgery%20Patient%20and%20Family%20Information.pdf or from the Fraser Health PRINT
SHOP #
255731 or on request

Minor General Surgery
Rapid Surgical Recovery
Patient and Family
Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption.
http://fhpulse/clinical_programs/surgical_services/resources/Documents/RapidSurgicalRecovery/Day%2
0General%20Surgery%20Patient%20and%20Family%20Information.pdf or from Fraser Health PRINT
SHOP #
256284 or on request

Day General Surgery
Rapid Surgical Recovery
Patient and Family
Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. http://fhpulse/clinical_programs/surgical_services/resources/Documents/RapidSurgicalRecovery/General
%20Surgery%20Going%20Home%20Information.pdf or from Fraser Health PRINT SHOP # 254474or on
request

Recovery After
GENERAL SURGERY
Patient and Family Chapter 2 – Rapid Surgical Recovery: A Change Package This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has. (Margaret Mead) Chapter 3 – Rapid Surgical Recovery: Pre-Implementation Activities This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Suggested Pre-Work Activities for Implementing Rapid Surgical Recovery
To change the practices and often the culture to implement rapid surgical recovery requires the cooperation and collaboration of an inter-professional team.64,72,74,85,91,97,101,153,198 This effort is a prime example of the power of team work and of continuous quality improvement. This work is a dynamic process involving a myriad of changes. It is about building teams and consensus, collaborating, providing patient-centered care, avoiding premature discharge, and avoiding needless readmissions (especially from pain/PONV). It will require that the leaders have a comfort level and clear understanding of what the aim of this work is so that they can allay the unease and fear this work may evoke Participating in this work is an opportunity to: • Improve patient safety and quality care by: Implementing multimodal ‘best practices' based on available evidence that simplify care and treatment processes and that are designed to control anticipated postoperative dysfunction and geared to returning patients rapidly to their functional baseline and optimizing surgical outcome. • Increase access to surgical care by: Improving patient flow and throughput. Decreasing length of stay. Before proceeding, please ensure that the following aim aligns with the strategic imperatives of your organization. • The Department of Surgery at Hospital will address surgical access, patient safety and quality care by implementing an evidenced-based rapid surgical recovery program based on Reimer-Kent's Postoperative Wellness Model and Kehlet's Fast Track Surgery principles which will address the following care issues: • Preventing/minimizing pain and suffering – A prerequisite for achieving rapid surgical recovery. • Preventing nausea/vomiting and constipation – A prerequisite for achieving rapid surgical recovery. Normalizing GI Function Minimizing preoperative starvation Feeding postoperatively ASAP • Preventing immobility – A prerequisite for achieving rapid surgical recovery. Discontinuing attached lines, tubes &/or drains ASAP Promoting self-care • Preventing respiratory compromise – A prerequisite for achieving rapid surgical recovery. • Increasing access to care – A benefit of achieving rapid surgical recovery.
Pre-work Activities Checklist
To prepare for this task the following pre-work activities are highly recommended.
Please use the following checklist as a guide.

 Specify which patient population will receive rapid surgical recovery:
 State current anticipated postoperative LOS for specified patient population: Chapter 3 – Rapid Surgical Recovery: Pre-Implementation Activities This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption.  Hire/delegate a Rapid Surgical Recovery (RSR) Coordinator – Someone who understands the project and the processes of care, has a good working relationship with colleagues, oversees data collection, and drives the project on a daily basis. Forming Teams

Leadership Team – Elevate the importance of this work by forming a team that includes senior leaders who
will support and ensure the necessary resources are available to be successful. Suggested composition: Position
Executive Director Medical Director Program Director Head of Anesthesia  Set date for first meeting: _
Core Inter-professional Team – Group that will meet regularly (weekly or every other week), work
collaboratively on changing the systems and processes related to making rapid surgical recovery a reality, and report progress to the Leadership Team. Suggested composition: Position
Acute Pain Service Surgical Ward Nurse Chapter 3 – Rapid Surgical Recovery: Pre-Implementation Activities This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. ET Nurse (if applicable)
 Set date for first meeting: _
Ad Hoc Team – Identify people from other departments and work areas that will be affected by the changes
and who may need to be included as either member(s) of the Core Inter-professional Team or as ad hoc team members. Where these individuals fit will depend on the issues being addressed. It is important that these departments/areas understand the who, what, where, when, why and how postoperative care is being redesigned so that they can buy-in to making, maintaining and sustaining the practice changes that impact their department/area. Check all those that apply:  Health Records  Patient Safety/QI Consultant  Research/Ethics  Epidemiologist/Statistician  Library Services  Unit Clerks/Care Aides  Pharmacy (Pre-printed orders/MAR)  Print Shop (Revised documents, patient teaching material)  Family Physicians  Hospitalists/Clinical Associates  Discharge planning coordinators  Surgeons' MOA's  OR Slate Surgical/Bed Booking  Volunteer Services  Respiratory Therapist  Infection Control  Addictions Medicine  Communications (publicity) Chapter 3 – Rapid Surgical Recovery: Pre-Implementation Activities This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption.  Housekeeping (high flow area/bed turnaround)  Other (please state) _  Review current documentation to ensure that information is charted in a manner that pre- and post-data can be retrieved, e.g., pain ratings, defecations, diet progression, etc.  Describe current practice and include clinical outcome targets if available  Pain Management Plan – Describe your current practice and clinical targets: Include all types and routes of analgesics, pain assessment routine, pain assessment tools, etc.  GI Management Plan – Describe your current practice and clinical targets: Include NPO restrictions, Bowel Prep, NG tube, Nausea/Vomiting, Bowel Care, Type of Diet, etc.  Activity Plan and Self-Care Expectations – Describe your current practice and clinical targets: Include level of daily activity/duration/level/type of assistance, VTE prophylaxis, use of SCDs, TEDs, hygiene plan, use of urinal/bedpan/commode, where meals are taken, etc.  Lines, Drains, and Tubes – Describe current practice and clinical targets: Include Urinary Catheter, NG Tubes, O2, etc.  Postoperative Sleep and Rest Management – Describe current practice and clinical targets: Include HS sedation, sleep aides, protected rest periods, etc.  Compile all clinical pathways, pre-printed doctor's orders, and patient teaching material related to selected patient population  Complete the ethical approval process at your institution to collect data from patient charts and permission to present and publish.  Collect baseline data  Retrospective chart reviews using the Rapid Surgical Recovery data collection form (see page xx)  Set date for Kick-off Session to introduce staff to the Initiative: Chapter 3 – Rapid Surgical Recovery: Pre-Implementation Activities This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Chapter 4 – Rapid Surgical Recovery: A Measurement Strategy This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. A Measurement Strategy for Generating Rapid Surgical Recovery Evidence
Measurement is a critical part of testing and implementing changes. Results tell a team whether the changes they are making actually led to improvements. Measurement for improvement is about bringing new knowledge and research/evidence into practice.71 Not all clinical data needs to come from randomized trials of A versus B.9 In fact with the level of evidence already available to support suggested surgical reform some trials may be unethical. All too often in health care what is not asked after isn't done and what isn't measured isn't valued. This is especially true when it comes to changing practice and culture which requires system redesign to improve quality and patient safety.108,130,160 Yet data that informs providers on the outcome of the changes is pivotal for sustainability but too often unavailable. In health care it is not uncommon to work with little data on the impact of practices and clinicians are often unaware of why their performance is superior or inferior.135 Auditing should be mandatory to determine clinical outcomes and to establish successful implementation of the care protocol.101 Data needs to be meaningful to the front-line care providers and should go beyond just LOS as a measure of success in achieving rapid surgical recovery.153 Example of How Data Could Be Displayed
An Outcome Record could be very advantageous to the reporting and displaying of data. The concept for such a tool would be to capture the pyramid of indicators that support rapid surgical recovery. These indicators could populate a Score Card or Report Card for the team to demonstrate the effectiveness and efficiencies achieved with this patient care methodology. Rapid surgical recovery is goal-directed and outcome-driven so this tool would address indicators such as the following: Major General Surgery (Colon Resection)
Cardiac Surgery
• Preop nutritional prep (Goal yes)
• Preop nutritional prep (Goal yes)
• Delirium (Goal no delirium)
• Normothermic on admission to CSICU (Goal
temperature > 36 degrees)
• eGFR > 60 (Goal > 60 for the administration of
• Delirium (Goal no delirium)
• NSAIDs last 24 hours (Goal regular doses x 7
• eGFR > 60 (Goal > 60 for the administration of
days if criteria met)
• O2 (Goal Room Air POD#2)
• NSAIDs last 24 hours (Goal regular doses x 7
days if criteria met)
• Full fluid diet (Goal by POD#0)
• O2 (Goal Room Air POD#2)
• Normal diet (Goal by POD#2)
• Normal diet (Goal by POD#1)
• Nausea (Goal no nausea)
• Nausea (Goal no nausea)
• Vomiting (Goal no vomiting)
• Vomiting (Goal no vomiting)
• Defecation (Goal POD#3)
• Defecation (Goal POD#3)
• Urinary catheter discontinued (Goal POD#2)
• Urinary catheter discontinued (Goal POD#2)
• Epidural discontinued (Goal by POD#2)
• Exercise Class (Goal start daily by POD#2)
• Walking independently in hallway (Goal by
• Climbed 1 flight stairs (Goal by POD#3)
• Patient discharged Goal Colon Resection
• Climbed 2 flights stairs (Goal by POD#4)
without ostomy Discharge POD#4 and Colon
• Patient discharged (Goal CABG POD#4; Valve
Resection with ostomy Discharge POD#6
Chapter 4 – Rapid Surgical Recovery: A Measurement Strategy This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption.
Annotated run chart, or annotated time series
• Data could be plotted on an annotated run chart or annotated series, which is a line graph showing results of improvement efforts plotted over time. • Changes are also noted on the chart at the time they occur as annotations, allowing the viewer to see the impact of the changes over time. • For example: A, B, C indicate when improvement efforts occurred. Percent of Eligible Patients Receiving ATC Non-opioids as
Background Ana lges ia
With such as a reporting system the inter-professional team would be able to view their progress and identify areas that need improvements. Chapter 4 – Rapid Surgical Recovery: A Measurement Strategy This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Example of a Pre- and Post-Implementation Data Collection Tool
For Major General Surgery (tool can be modified for other surgical procedures)
ID#: _ H# _ Age: _  Male  Female Surgeon Admission/Discharge Data
Admission date: D/M/Y _ OR date: D/M/Y _ Discharge date: D/M/Y _ Discharge disposition:  DWA  DAA  EXP  DWS  DTA  DTL  DTF  Unknown Preoperative Data
ASA classification:  1  2  3  4  5  E  Unknown As noted in the Medical History:  Diabetes  COPD  Peptic ulcer disease  Liver disease  Cardiac disease  Renal disease OR classification:  Elective  Emergent  Unknown Procedure:  R Hemicolectomy  L Hemicolectomy  Anterior Resection  Abdominoperineal Resection  Other _  Colostomy/ileostomy  Video-assisted Lab Values
Preop eGFR (Value closest to OR date) Postop eGFR (Lowest value after OR date up to POD#7) Pain Management (Data POD#0 to POD#7)
 Epidural: Date D/Ced D/M/Y _  PCA: Date started D/M/Y _ Date D/Ced D/M/Y _  IM injections  Suppositories  Meperidine  Tylenol® #3 or #2  Hydromorphone  Percocet  Oxycodone  Morphine  Ketorolac ATC Date started D/M/Y _ Date D/Ced D/M/Y _  Ketorolac PRN  Indomethacin ATC Date started D/M/Y _ Date D/Ced D/M/Y _  Indomethacin PRN  Acetaminophen ATC Date started D/M/Y _ Date D/Ced D/M/Y _  Acetaminophen PRN  Ibuprofen ATC Date started D/M/Y _ Date D/Ced D/M/Y _  Ibuprofen PRN  Other Chapter 4 – Rapid Surgical Recovery: A Measurement Strategy This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Opioid TOTAL Daily Doses GI Management (Data POD#0 to POD#7)
 NPO: Date D/M/Y _/Time: _  Preoperative bowel prep: Type  Clear fluids: Date started D/M/Y _  Full fluids: Date started D/M/Y _  Protein drink: Date started D/M/Y _  Regular diet: Date started D/M/Y _  NG: Date D/Ced D/M/Y _  Nausea: Date started D/M/Y _  Vomiting: Date started D/M/Y _  Bowel sounds: Date started D/M/Y _  Flatus: Date started D/M/Y _  Bowel Movement: Date started D/M/Y _ Mobility Management (Data POD#0 to POD#7)
 Urinary catheter: Date D/Ced D/M/Y _  Oxygen: Date D/Ced D/M/Y _  Heparin SC Date started D/M/Y _ Date D/Ced D/M/Y _  TEDS  SCD  Dangle: Date started D/M/Y _  Chair: Date started D/M/Y _  Walk assisted: Date started D/M/Y _  Walk unassisted: Date started D/M/Y _ Delirium Management (Data POD#0 to POD#7)
 Loxapine: Date started D/M/Y _  Psychiatry consult: Date seen D/M/Y _  Sitter: Date started D/M/Y _ Date D/Ced D/M/Y _ Incision Care (Data POD#0 to POD#7)
 Staples removed: Date removal ordered D/M/Y _ Postoperative Complications (Data POD#0 to POD#7)
 Return to OR  ICU admission  Delirium  GI Bleed  Ileus  DVT  PE  Wound infection  Atelectasis  Pneumonia  Other _ Post Discharge Data (Data within 30 days of surgery)
 Return to emergency Date D/M/Y _ Reason _  Re-admission to hospital Date D/M/Y _ Reason _ Chapter 4 – Rapid Surgical Recovery: A Measurement Strategy This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Rapid Surgical Recovery Results
For Cardiac Surgery – CABG and General Surgery – Colon Resection

Rapid surgical recovery pre- and post-implementation data was collected via retrospective chart reviews. Below
are some of the highlights when practice changed to align with rapid surgical recovery. See also
references74,99,105,122,126,127,137,141-157,200
Highlighted Results Fraser Health – Royal Columbian Hospital Colon Resection Surgery 3-day ↓ 1st meal (4 to < 1) 3 day ↓ 1st meal (4 to 1) 3-day ↓ 1st defecation (4.6 to 1.9) 1 day ↓ 1st defecation (3 to 2) 2½ day ↓ oxygen removal (4.7 to 2.2) 2 day ↓ oxygen removal (2 to 0 3-day ↓ 1st exercise class (5 to 2) 2 day ↓ walking unassisted (3 to 1) 33%  4 day discharge (1.6% to 35%) 4 day ↓ postoperative LOS (8 to 4) Chapter 4 – Rapid Surgical Recovery: A Measurement Strategy This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Rapid surgical recovery is often started as an initiative or project. Writing a project charter that formally authorizes and endorses the work is recommended. A Charter outlines the executive sponsor(s) as well as the goals, scope, and authority for a project. A Charter gives the project its clarity and structure and helps to guide the work of project/work teams. It is a tool to support ultimate success. Rapid Surgical Recovery: Literature Reviewed This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Example of a Rapid Surgical Recovery Project/Initiative Charter
(Charter can be modified by programs and centres as needed)
Goal Statement
 This initiative will use an inter-professional collaborative team approach in creating a rapid surgical recovery
(RSR) program by applying the Reimer-Kent Postoperative Wellness Model and the Kehlet Fast Track Surgery Principles for _ surgery patients at the Hospital and the team will work to optimize and enhance patient outcome by:  Working towards a major goal of achieving a stress and pain free operation through a well planned and coordinated multimodal approach to surgical care. • RSR brings care and treatment to patients directed at achieving this goal.  Working from the premise that patients will decondition and become dependent on care within the first three (3) days after surgery. • RSR strives to return patients to their functional baseline within this timeframe and to mitigate the stress response evoked by the surgical procedure on already impaired organs. • RSR debunks the myth that "patient is too young or to old &/or too sick" to receive preventive postoperative care as this approach to surgical care may be the most useful in exceeding high-risk patients.  Understanding that recent studies on surgical management have found many traditional methods wanting – unnecessary – harmful. • RSR is about bringing multimodal ‘best practices' based on available evidence that simplify care and treatment processes and when performed together have real potential to improve patient safety, access, and quality care. • RSR is supported as safe, along with a reduction in readmission rate, hospital stay, and postoperative complications.  Redesigning perioperative care so that patients regardless of age, comorbidities or procedure are rapidly returned to their functional baseline and receive care and treatment based on generalizable RSR concepts and principles that support a current world-wide movement to reform surgical care. RSR combines unimodal preventive-focused, best practices into a multimodal effort to optimize and enhance recovery. Ensuring patients receive these care and treatment strategies as the minimum standard for postoperative care will address the inseparable issues of patient safety, quality care, and access. • RSR concepts and principles address the following: Minimizing pain and suffering - A prerequisite for optimal surgical outcome and rapid return to
baseline or better function
. Achieved through providing optimal, dynamic, preventive pain relief
with multimodal/balanced non-opioid analgesia that is opioid-sparing and which is extended well
into the postoperative period (e.g., a minimum of the first week after surgery).
Normalizing gastrointestinal (GI) Function – by minimizing perioperative and postoperative
starvation; the interruption in chronic medication to treat pre-existing conditions; and preventing
nausea, vomiting, constipation and/or an ileus.
Minimizing inactivity – by mobilizing early and avoiding bedrest; preventing pressure ulcers
and hospital-associated falls; timely removal of attached lines, tubes and/or drains; preventing
catheter-associated urinary tract infection; preventing fatigue through balancing rest/sleep with
activity; and preventing deep vein thrombosis.
Promoting self-care – by supporting a Primary Health Care Model principle endorsed by the
Canadian Nurses Association of the healthcare provider working with rather than just merely
caring for the patient.
Preventing delirium – the Reimer-Kent Postoperative Wellness Model addresses many of the
factors that contribute to delirium (e.g., pain, malnutrition, dehydration, constipation, sleep
deprivation, immobility, deconditioning, etc.). The importance of recognizing and treating mild
delirium promptly to avert major delirium.
Rapid Surgical Recovery: Literature Reviewed This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Optimizing respiratory function – by minimizing periods of hypoxemia; eliminating the
requirement for lengthy periods of supplemental oxygen; and preventing pulmonary emboli.
Improving patient flow and access – by identifying postoperative complications early so that
organ dysfunction can be promptly treated before becoming organ failure; focusing attention on
finding out why a postoperative patient who initially was feeling well and making good progress
starts feeling unwell and begins to regress; ensuring timely, appropriate discharge once
discharge criteria have been met; avoiding lengthy hospitalization, especially from ineffective
pain management or gastro-intestinal dysfunction; and reducing the need for new
institutionalization and/or transfer to post-acute convalescent or rehabilitation services or care
facility.
 Establishing and using clinical practice support tools such as clinical pathway, pre-printed Doctor's Orders, and patient teaching material as these tools are vehicles that help to operationalize RSR and bring the concepts and principles directly to the patient through the inter-professional team. Change Drivers
 Need to address the waitlist and improve access to surgical care.
 RSR improves access to surgical care by creating an available hospital bed that has been vacated by a postoperative patient discharged in a timely and appropriate manner. It also mitigates the undue stress on patients and families, and the frustration for the health care team when surgery is cancelled or postponed because there is no bed or when the discharge is hastened to create a needed bed. • Postoperative length of stay tends to vary from site to site and physician to physician and seems to be associated with individual hospitals/practitioners and their practices rather than to the type of surgery performed. • Surgical outcome directly impacts patient flow, throughput and access, and access impacts wait  Need to ensure that patients receive safe, effective, and efficient surgical care.  RSR focuses on preventive rather than reactive care and is a unique way to cross the quality chasm and address the patient safety agenda. • One of the rules for creating a safer health care system outlined by the Institute of Medicine (2001) is to never react to anticipated patient needs. Reimer-Kent's Postoperative Wellness Model is a proactive and preventive based approach to dealing with anticipated postoperative issues, like pain, nausea, constipation, immobility, and respiratory compromise.  Need to spread a multimodal ‘best practice' approach in delivering routine postoperative care that has tangible benefits for both the patient and the health care system, yet remains under-valued, under-recognized, and under-utilized.  RSR is an innovative approach to care that differs from conventional surgical recovery and should not be confused as being the same as day surgery. As a matter-of-fact, day surgery patients would also benefit from receiving care and treatment based on RSR concepts and principles.  RSR is a form of patient specialization often challenged as easy and simple and just plain common- sense, yet it is not intuitive to busy uninformed practitioners and requires a shift in paradigms from illness-focused care to wellness-focused care.  RSR is counter-culture to current conventional or traditional postoperative care.  RSR focuses on the patient journey and as such requires system and process changes and may therefore be viewed as requiring too much effort, especially when seen as in addition to current practice instead being seen as a new minimum standard of care delivered to all surgical patients.  RSR, despite evidence to its effectiveness is still not taught in medical or nursing schools curriculums.  Need to support optimal clinical integration, by ensuring that all surgical patients are exposed to the model and principles that support RSR and that care is as seamless, effective, and as efficient as possible.  RSR is about empowering the inter-professional team and is an example of how to apply the World Health Organization's primary health care principles of access, health promotion, disease/illness prevention, appropriate technology, patient participation, and collaboration within an acute care surgical program. Rapid Surgical Recovery: Literature Reviewed This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Initiative Objectives
 To improve patient safety and quality care by using a bundle of multimodal strategies directed at optimizing
surgical outcome – specifically the prevention of postoperative pain, nausea, constipation, immobility and respiratory compromise so that:  100% of elective patients/families will be instructed on what is involved in RSR prior to admission.  100% of non-elective patients/families will be instructed on what is involved in RSR as soon as possible (e.g., < 12 hours) post-surgery.  100% of patients without documented liver dysfunction will receive around-the-clock (ATC) doses of acetaminophen for 7 days without interruption, regardless of any other pain management modality being utilized, as background analgesia for managing postoperative pain.  100% of patients without gastric ulcer history and without renal impairment will receive ATC doses of a NSAID for 7 days without interruption, regardless of any other pain management modality being utilized, as background analgesia for managing postoperative pain.  100% of patients will receive an appropriate opioid (e.g., morphine) to treat any and all pain rated at more than mild (e.g., less than 3 on a 0 to 10 verbal analogue scale).  100% of RSR units will limit the choices of opioids to ideally only 1 in order to encourage familiarity and avoid potential drug errors and mixing of opioids and doses.  0% of patients will receive the opioid meperidine due to its toxic metabolites and/or codeine due to its harsh side effect profile and metabolism issues (hyper and non-metabolizers) .  0% of patients will receive analgesics that combine the non-opioid with the opioid [e.g., acetaminophen with codeine (Tylenol #3), acetaminophen with oxycocone (Perocet)] in order to safely give non-opioids ATC.  0% of patients will thirst for more than 3 hours before surgery.  0% of patients will receive a diet of clear fluids.  100% of patients will start early feeding with normal food (i.e. GI Surgery full fluid diet POD#0 and regular diet by POD#2; non-GI surgery regular diet by POD# 1 or sooner).  100% of patients will have a first post-op defecation by POD#3.  100% of patients who were mobile before surgery will be able to mobilize unassisted by POD#2.  100% of patients who have effective pain relief with oral analgesics will have their epidural catheter removed by POD#2.  100% of patients will have their urinary catheter removed by POD#2.  100% of patients will receive venous thromboembolism (VTE) prophylaxis until discharge.  0% of patients eligible for pharmacological VTE prophylaxis will have mechanical prophylaxis.  100% of the entire care team (nurses, allied health care staff, surgeons, anesthetists, hospitalists/clinical associates, etc.) in all clinical areas (pre-admission clinic, OR, PACU, ward, home care) will receive education on RSR.
Initiative Outputs
 Improve surgical access.
 Make continued LOS improvements with a goal to establish an ALOS:ELOS ratio of 1 or less  Write practice support tools.  Create clinical pathway  Create pre-printed Doctor's orders  Create patient teaching material  Create staff education material  Redesign care and treatment processes so that they align with practice changes needed to support RSR.  Work within the organization's infrastructure for inter-professional team work (e.g. program teams, professional practice councils) to develop, implement and monitor progress and improvement.
Desired Outcomes
 Link to the FH Strategic Imperatives.
 Creating great workplaces and quality practice environments where people want to come and contribute. • Demonstrate how programs that adopt RSR can be centres of excellence in surgical care. Rapid Surgical Recovery: Literature Reviewed This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. • Improve staff recruitment and retention – evidence that new recruits have chosen to work in areas that have implemented RSR as well as current staff citing RSR as a reason to stay with a particular RSR program/unit because RSR embraces evidence-based ‘best practice' and enhances patient care and outcome. • Happy patients – Cardiac surgery patients comments about how remarkably well they felt, remarkable soon after their surgery were part of the reason Reimer-Kent's model is called the Postoperative Wellness Model. • Lessen the need for external consultants by using the RSR expertise that already exists within FH as internal consultants.  Ensuring quality care and patient safety – use evidence-based ‘best practice' to provide care that is centered on the patient. • RSR, amid the complex and competing demands within health care is an example of care that is highly patient-centered. • RSR aims to prevent postoperative morbidity and in and of itself creates a warning system for the early recognition of postoperative morbidity which in turn can lead to prompt treatment of organ dysfunction before the state of organ failure has been reached. • RSR focuses on preventing rather than merely reacting to anticipated postoperative issues (e.g., pain, nausea, constipation, immobility, and respiratory compromise), many of which are contributors to postoperative complications such as infection and delirium.  Working on a research and academic development agenda – increase the number of FH people leading/participating in research teams. • Conduct clinically relevant research on RSR outcomes by collecting pre- and post-implementation • Work to create a balanced score card that captures RSR indicators. • Contribute to the growing body of evidence/knowledge pertaining to RSR. • Contribute to the education of future nurses and physicians by designating and supporting RSR areas as clinical teaching unit where student in their practicum's will see how RSR concepts and principles are applied to patient care. • Support scholarly work and present an publish on RSR. originating within FH; attract graduate students interested in working on research pertaining to aspects of RSR.  Building capacity – implementing creative prevention initiatives – implement patient flow solutions. • Reduce overall cost of care and patient days by streamlining and standardizing care and treatment  Integrating – redesign the care delivery system and models to optimize clinical and operational performance, innovation and leading practice. • RSR is a critical component within a comprehensive framework for surgical optimization as preoperative efforts at surgical optimization will not be realized without ensuring that postoperative care is based on RSR concepts and principles. • RSR is a bundle of multimodal strategies that when performed together have real potential for improving patient safety, quality care and access. It has the potential to influence broader national initiatives such as Safer Healthcare Now. • The Reimer-Kent Postoperative Wellness Model is an innovative way in which to apply the primary health care principles of disease/illness prevention and health promotion, accessibility, collaboration, and appropriate technology directly to the care and treatment of patients in an acute care setting.  Creating progressive partnerships. • RSR is already spreading to other interested surgical programs within FH, and throughout Canada and has been cited on numerous documents as a best/leading practice such as: - The Canadian Nurses Association (CNA) (2012) National Expert Commission on the future of healthcare document "a Nursing Call to Action" The CNA (2009) document "Registered Nurses : On the Front Lines of Wait Times" Dr. Michael Rachlis' (2004) book " Prescription for Excellence: How Innovation is Saving Canada's Health Care System". • RSR is in keeping with a growing global movement to improve surgical care and is congruent with the aim of the NHS England to improve the quality of patient care through improving clinical Rapid Surgical Recovery: Literature Reviewed This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. outcomes and experience, and reducing the length stay by utilizing best practice principles of enhanced recovery models of care. In Scope
 Creating practice support tools (e.g., clinical pathway, pre-printed Doctor's orders and patient teaching
materials) to support the implementation of a RSR program.  Receiving the resources (equipment, technology and human resources) needed to implement a RSR  Defining boundaries so that the inter-professional team can remain focused on making RSR a reality and in holding the gains.
Out of Scope
 Working on other surgical initiatives being already addressed by other teams to avoid duplication and
redundancy (e.g., NSQIP, SSI, Optimization Clinics, etc).  RSR is an important component within a comprehensive framework for surgical optimization and links well with these initiatives; however RSR is not common practice and fills an important gap that currently exists within such a framework. Although RSR can inform as well as be informed by other initiatives it is a distinctly different initiative that needs to be supported to maintain focus and protected from competing priorities.  Being responsible and accountable over physician practice that misaligns with agreed to best practices.  Efforts need to be directed by the appropriate leaders at reducing variation in practitioner practice because non-standardized processes and highly individualized care paths are expensive and have the potential to interject doubt, confusion, and error within the inter-professional team charged with delivering this care.  Implementing non-physician authorized discharge when discharge criteria met.  RSR is about well-defined discharge criteria and the ability to identify which patients are ready for a timely and appropriate discharge, however, this may not correlate with actual discharge as it is up to the patient's physician to write the discharge order.
Interdependencies
 None known
Constraints
 Startup contingent on endorsement and support of senior leaders, surgical program champions and an inter-
professional team that is willing to engage in this collaborative work.  Resources: securing a RSR Coordinator role, data collector/analyst support, health records support, financial support for physician champions to attend meetings/presentations, support for staff to attend inter-professional team meetings. Principles
 Only one system, based on RSR concepts and principles, is acceptable as the standard of care for patients
recovering from surgery.
 Deviation from the outlined plan of care will be based on individual patient condition.

Critical Success Factors
 Creation of a system including processes, practice standards, and resources (equipment, technology and
human resources) that meet the practice needs of users and stakeholders and that is attainable and sustainable.  Resolution of identified problems related to implementing RSR before expanding to other areas. Rapid Surgical Recovery: Literature Reviewed This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption.  Production of clinical practice support tools (e.g., clinical pathway, pre-printed Doctor's orders, patient teaching material).  Implementation led by a RSR Coordinator whose role it will also be to evaluate the impact of the practice changes on patients; work with the inter-professional team to hold any gains; and identify process and systems issues and work to resolution in conjunction with the leads and sponsors.  Implementation after taking sufficient time to address resistance to change practice, and understanding current practice and how and why practices well change to avoid the potential for unsafe patient care during the change process. Assumptions
 Leadership from a Regional and Site level (Executive/senior leaders) who understand and support this
initiative including physicians and nurses.  This work is a dynamic process involving a myriad of changes. It is about building teams and consensus, collaborating, providing patient-centered care, avoiding premature discharge, and avoiding needless readmissions (especially from pain/GI upset). It will require that the leaders have a comfort level and clear understanding of what the aim of this work is so that they can allay the unease and fear this work may evoke.  An engaged and dynamic inter-professional team receptive to changing surgical practices and ready to implement multimodal RSR strategies for the selected patient population in a collaborative manner.  Adequate resources to support implementing, evaluating, and sustaining RSR. Rapid Surgical Recovery: Literature Reviewed This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Rapid Surgical Recovery: Literature Reviewed This blueprint is intended as a resource and reference document. FH and the author accept no responsibility for its use/interruption. Reference List
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(2001). Making health care safer, a critical analysis of patient safety practices. Chapter 52: Critical Pathways. Agency for Healthcare Research & Quality, http://www.ahrq.gov/clinic/ptsafety/chap52.htm. 184. Vermeulen, H., Storm-Versloot, M.N., Busch, O.R., & Ubbink, D.T. (2006). Nasogastric intubation after abdominal surgery: A meta-analysis of recent literature. Arch Surg. 141, 307-314. Available online at: http://archsurg.ama-assn.org/cgi/content/full/141/3/307. 185. Veterans Health Administration (VHA) National Pain Management Strategy (2000). Pain as the 5th vital sign: Take 5. Available online at: http://www.va.gov/PAINMANAGEMENT/docs/TOOLKIT.pdf. 186. Walker, H., Thorn, C., & Omundsen, M. (2006). Patients' understanding of pre-operative fasting. Anaesthesia and Intensive Care, 34 (3), 358-361. Abstract available online at: http://www.ncbi.nlm.nih.gov/pubmed/16802491. 187. Warner, M.A., Warner, M.E., & Weber, J.G. (1993). 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Recent advances: Management of patients in fast track surgery. British Medical Journal, 322, 473-476. Available online at: http://www.bmj.com/highwire/filestream/329170/field_highwire_article_pdf/0.pdf. 198. Wilson, T., Berwick, D.M., & Cleary, P.D. (2003). What do collaborative projects do? Experience from seven countries. Joint Commission Journal on Quality and Safety, 29 (2), 85-93. Available online at: http://www.chipolicy.org/pdf/5637.Joint%20Commission%20Journal%20Quality%20Safety%20What%20Do%20Collaboratives%20Do.pdf. 199. Wischmeyer, P. (2011). Nutritional pharmacology in surgery and critical care: ‘You must unlearn what you have learned'. Current Opinion in Anaesthesiology, 24 (4), 381-388. Abstract available online at: http://journals.lww.com/co-anesthesiology/Abstract/2011/08000/Nutritional_pharmacology_in_surgery_and_critical.5.aspx. 200. Wone, L., Merchant, R., & Reimer-Kent, J. (2008). Conventional wisdom's "NPO after midnight" can be detrimental. 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Wirtschaft   17 30. Januar 2014 Christof Becker: «Unsere Aufgabe ist es, die Nadel im Heuhaufen zu finden» Interview Christof Becker wechselt zur Wilhelm-Gruppe in Vaduz. Neben der Rekrutierung von Fach- und Führungspersonen wird er das Outplacement und den Aufbau einer neuen Dienstleistung im Gesundheitswesen betreuen. Gemeinsam mit Geschäftsführer Stefan Wilhelm gibt er Einblicke in den Arbeitsmarkt.

Doi:10.1016/s0300-483x(03)00339-

Toxicology 192 (2003) 249–261 Reducing acute poisoning in developing countries—options for restricting the availability of pesticides Flemming Konradsen , Wim van der Hoek , Donald C. Cole , Gerard Hutchinson , Hubert Daisley , Surjit Singh , Michael Eddleston a Department of International Health, Institute of Public Health, University of Copenhagen, Panum, Blegdamsvej 3,