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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Chapter 4 – Rapid Surgical Recovery: A Measurement Strategy
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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
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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
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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
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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
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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
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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
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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
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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
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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
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• 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
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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.
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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.
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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.
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,