CRITICAL CARE
Standardising fast-track surgical nursing care in Denmark Dorthe Hjort Jakobsen, Kirsten Rud, Henrik Kehlet and Ingrid Egerod
T
he demand for evidence-based health care is increasing, with a particular focus on quality improvement of surgical care. The perioperative period is fraught with challenges, including pre-existing comorbidities, stress-induced organ dysfunction, fluid imbalance, hypoxemia, postoperative pain, nausea, vomiting, ileus, immobilisation, malnutrition and fatigue, which all potentially contribute to prolonged hospital stay, extended convalescence and increased morbidity (Kehlet and Dahl, 2003; Kehlet and Wilmore, 2008). In the past decade, conventional surgical care has been modified to improve postoperative outcomes (Kehlet and Wilmore, 2008). The aim of this paper is to report on a national initiative in Denmark to improve the quality of surgical care by focusing on the provision of procedurespecific nursing care programmes.
Background
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Fast-track surgery is a term for comprehensive preoperative, intraoperative and postoperative care, integrating evidencebased, multimodal rehabilitation programmes aimed at optimising postoperative recovery, reducing morbidity, and improving convalescence (Kehlet, 2011a). The five key elements in fast-track surgical programmes are: preoperative counselling, surgical stress reduction, optimal dynamic pain relief, enforced mobilisation, and sufficient nutrition (Kehlet and Wilmore, 2008).The concept encompasses a state-of-theart approach to postoperative care, which includes reduction of tubes, drains and catheters, and recommendations for monitoring and rehabilitation (Kehlet and Wilmore, 2008; Kehlet, 2011a). A multidisciplinary approach is required, with collaboration of surgeons, anesthesiologists, nurses and physiotherapists. In addition, organisational changes are necessary to accommodate the many components in fast-track regimes. Fast-track programmes have shown enhanced recovery and reduced hospitalisation and morbidity in procedures such as elective open colorectal surgery (Varadhan et al, 2010; Kehlet, 2011a). A systematic review of conventional colon Dorthe Hjort Jakobsen is Clinical Head Nurse and Kirsten Rud is Head Nurse at the Unit of Perioperative Nursing, Rigshospitalet; Henrik Kehlet is Professor at the Section of Surgical Pathophysiology, Rigshospitalet; and Ingrid Egerod is Professor at the Trauma Centre, Rigshospitalet, Copenhagen, and the Faculty of Health and Medicine, University of Copenhagen, Denmark Accepted for publication: April 2014
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Abstract
Considerable variations in procedures, hospital stay and rates of recovery have been recorded within specific surgical procedures at Danish hospitals. The aim of this paper is to report on a national initiative in Denmark to improve the quality of surgical care by implementation of clinical guidelines based on the principles of fast-track surgery—i.e. patient information, surgical stress reduction, effective analgesia, early mobilisation and rapid return to normal eating. Fast-track surgery was introduced systematically in Denmark by the establishment of the Unit of Perioperative Nursing (UPN) in 2004. The unit was responsible for guideline construction and implementation using the ‘workshop practice method’: establishing a website, creating a knowledge centre, coordinating implementation agents, and arranging national workshops and conferences. The UPN has promoted implementation of fast-track regimes in all surgical departments in Denmark. We recommend the workshop-practice method for implementation of new procedures in other areas of patient care. Key words: Change management ■ Change agents ■ Clinical practice guidelines ■ Enhanced recovery ■ Fast-track surgery ■ Quality improvement ■ Standardisation surgery in 2006 reported a hospital stay of 8–12 days and a complication rate of 20–30% due to factors such as pain and paralytic ileus (Wind et al, 2006). Conventional versus fasttrack colorectal surgical programmes have shown a reduction of hospital stay from 8–12 days to about 3–5 days, limiting debilitating factors such as pain, paralytic ileus and other organ dysfunctions, while improving physical performance, pulmonary function and body composition, using the same discharge criteria as in conventional treatment (Kehlet and Wilmore, 2008; Varadhan et al, 2010). In addition, patients experience fewer complications and hospitals benefit from lower costs. Similar results have been found in fast-track courses of orthopaedic, gynaecological and urological surgery, with shorter convalescence, less fatigue and similar or better patient satisfaction compared with traditional care (Hjort Jakobsen et al, 2006; Zagar-Shoshtari et al, 2009). Fast-track programmes need to be supported by clinical-practice guidelines, which have been described as systematically developed statements aimed at assisting decision-making and providing criteria regarding diagnosis, management and treatment in specific areas of health care (Thomas et al, 1998; Thomas, 1999). Clinical-practice guidelines have become an integral part of contemporary patient care to ensure quality and safety. Guidelines have
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Context of fast-track implementation Multimodal fast-track surgical programmes were developed in Denmark, where health care is publicly financed through taxes. Most hospitals are public and the responsibility for running healthcare services is decentralised in regions and municipalities, but the state is in charge of legislation, supervision, general planning and economy (Ministry of Health and Prevention, 2008). There is a trend towards more specialised treatment by consolidating expertise at larger regional and university hospitals. Not all of Denmark’s 69 hospitals provide all types of treatment.
The Unit of Perioperative Nursing (UPN) Fast-track surgery was introduced systematically in Denmark by the establishment of the Unit of Perioperative Nursing (UPN) in 2004. The UPN was opened in Copenhagen and was run on a daily basis by two full-time employed nurses (UPN nurses) with clinical and managerial experience (first and second authors), supported by a senior physician and an academically prepared nurse (third and fourth authors). The steering committee consisted of these four individuals. The basic assumption was that implementation of new procedures would be better facilitated through a network of nurses than by requesting individual physicians to change their practice. The UPN was funded by the Danish Ministry of Health for an 8-year period, with the goal of promoting the principles of fast-track surgery for the most common short-term surgical procedures across the country. The UPN took on the following responsibilities: ■■ Establishment of a knowledge centre for fast-track programmes ■■ Establishment of a UPN website ■■ Leadership in networking among fast-track specialists across Denmark ■■ Arrangement of annual multidisciplinary fast-track conferences
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■■ Arrangement
of multidisciplinary workshops within each surgical sub-specialty ■■ Guideline construction, dissemination and implementation ■■ Identification and coordination of national implementation agents ■■ Publication of findings from fast-track research.
The workshop-practice method Quality improvement (QI) relies on the following steps: problem identification, establishment of baseline performance, selection of improvement strategies, monitoring of progress toward improvement goals, evaluation of unintended consequences of improvement strategies, and identification of effective and sustainable strategies (Partin et al, 2013). The UPN introduced the ‘workshop-practice method’ as an innovative process consistent with quality improvement for development of national multidisciplinary guidelines for fast-track surgical procedures. The two UPN nurses ran six workshops per year for 8 years (48 workshops in total) to produce 16 interdisciplinary clinical guidelines averaging three workshops per surgical procedure. During the first years, the four members of the steering committee were present at all workshops to develop and refine the workshop-practice method of implementation. Lunch and refreshments at workshops were paid for by the UPN grant, but the participants paid for their own transportation. The process consisted of the following steps for each selected surgical procedure: ■■ Review of relevant literature and initial guideline preparation by the two UPN nurses ■■ Workshops for clinicians from across the country, with surgeons, anaesthesiologists, nurses and physiotherapists from each hospital offering a particular procedure. Workshops included lectures, presentation of evidence and propositional guidelines, discussions and practice comparisons ■■ Guideline drafting by the two UPN nurses following each workshop ■■ Dissemination and email responses to first and second guideline drafts by workshop participants until consensus was reached ■■ Guideline finalisation and dissemination to website by UPN nurses ■■ Guideline update every 2–3 years by UPN nurses after additional workshops.
Clinical guidelines National guidelines including clinical pathways have been developed for 16 selected surgical procedures in 2004–2013. Each year a couple of new guidelines have been developed for fast-track surgical procedures including: aortic aneurysm, breast cancer surgery, colonic resection, hernia repair, hip fracture, hip replacement, hysterectomy, knee replacement, laparoscopic cholesystectomy, laparoscopic colonic resection, pulmonary resection, lumbar spondylolysis, ovarian cancer surgery, pancreatectomy, radical prostatectomy, and transtibial and trans-femoral amputations. All hospitals offering a particular procedure were invited to participate to promote a sense of national ownership. The total number of hospitals involved was 51.
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been shown to reduce inappropriate practice variations and promote evidence-based health care, as they translate research findings into practice, resulting in more structured and focused care (Grimshaw and Russell, 1993; Graham and Harrison, 2005; Hunter and Segrott, 2008). Implementation of procedure-specific clinical guidelines with the principles of fast-track surgery, including daily goals for nursing care and carefully delineated discharge criteria, have shown a reduction in complications and length of hospital stay (Basse et al, 2002; Kehlet and Wilmore, 2008). In the early 2000s, considerable variations in procedures, hospital stay and rates of recovery were recorded within specific surgical procedures at Danish hospitals (Møller et al, 2002; Jensen et al, 2007; Marx et al, 2007). Consequently, a need emerged for consensus on key elements of perioperative care to improve quality and standardise surgical care. After the basic elements of fast-track regimes were described within surgery and anesthesiology, the next step was implementation. In this article, we report on an initiative for improvement of nursing care within the paradigm of fasttrack surgical programmes at all surgical units in Denmark from 2004 to 2013.
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CRITICAL CARE Table 1. Nursing care pathway (pocket edition) for patients undergoing open elective colonic resection Preoperative care
Day of surgery
1–3 days postoperation
Discharge criteria
Information and dialogue Written hand-out Dialogue focus ■■ Patient involvement and individual preferences ■■ Reaction to cancer diagnosis ■■ Nurse-patient expectations ■■ History of pain, nausea and constipation ■■ Rationale for fast-track programme ■■ Specific goals for mobilisation, nutrition, pain management and discharge Pain relief ■■ Thoracic epidural analgesia for 2 days ■■ Paracetamol and NSAID/COX2inhibitors (after epidural removal at 2 days/48 hours) ■■ Information about VAS Nutrition ■■ Protein-enriched drinks as needed Mobilisation ■■ Plan for support according to the programme and the goals Elimination ■■ No bowel preparation, except for an enema the night before surgery
Premedication ■■ No routine sedative. Paracetamol (slow release) Pain relief ■■ Thoracic epidural analgesia for 2 days ■■ Paracetamol and NSAID/COX2inhibitors (after epidural removal) ■■ Pain assessed every 8 hours with VAS Nausea ■■ Ondansetrone 4 mg ■■ Nutrition ■■ Preop: NPO for 6 hours and no fluids for 2 hours ■■ Postop: 1 litre fluid PO, including two protein-enriched drinks, normal diet ■■ Stop IV fluid intake 4 hours postop, adjust fluid balance Mobilisation ■■ Out of bed ≥2 hours ■■ Anticoagulant therapy 4–12 hours postop Elimination ■■ Balance fluids ■■ No nasogastric tubes ■■ Weight
Information and dialogue ■■ Discharge planning with patient and family Pain relief ■■ Thoracic epidural analgesia for 2 days ■■ Remove epidural catheter in the morning ■■ Pain assessed every 8 hours with VAS Nausea ■■ Ondansetrone 4 mg Nutrition ■■ Normal diet ■■ 2 litres fluid PO, including four protein-enriched drinks Mobilisation ■■ Out of bed ≥8 hours ■■ Ambulate x 3 Elimination ■■ Remove urine catheter first day postop in the morning ■■ Balance fluids ■■ Record bowel function ■■ Weight
Discharge ■■ Third day postop if criteria are met Discharge criteria ■■ Patient feels confident about discharge ■■ Sufficient pain relief with oral analgesics ■■ Sufficient intake of food and fluids ■■ No wound problems ■■ Passing gas, normal bladder function ■■ Usual ADL level
VAS=visual analogue scale for pain assessment; PO=by mouth; NPO=nil by mouth; ADL=activities of daily living
Each of the 16 guidelines includes a condensed pocket edition (Table 1) and a number of individually referenced evidence-based nursing-specific sub-guidelines.As an example, the procedure-specific guideline for colonic surgery includes the following sub-guidelines: activity and convalescence; nutrition, post-operative nausea and vomiting (PONV), and fluid management; knowledge and development; pain and discomfort; elimination; breathing. The reason for dividing the main guideline into sub-guidelines was to create a format that included clinical pathways and clinical-practice guidelines. This enabled us to create consistent guidelines for a variety of different surgical procedures.
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Website An open Danish language website maintained by the two UPN nurses was developed as a tool for knowledge-sharing. The website provided all clinical guidelines, links to publications related to the UPN, announcement of workshops and conferences, and other instruments informing clinicians of fasttrack surgical programmes. Nurses from around the country have been able to contact the UPN for further assistance, and student nurses have also been engaged in the use of the website and consultations with the UPN nurses. The website has been the inspirational hub that has enabled clinicians to exchange ideas and share patient information, care plans, and so on.
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Agents and audits Studies have shown that despite the availability of clinical guidelines, it often takes years before they are integrated into practice (Kehlet et al, 2006; Maessen et al, 2007). The common saying is ‘17 years from bench to bedside’ (Morris et al, 2011). To speed up the process, experienced nurses were invited by the UPN to assist in the successful implementation of fast-track programmes across the country. The nurses were selected pragmatically on the basis of interest and familiarity with the concepts of fast-track surgery. Twenty-five nurses were chosen as ‘implementation agents’ at the major hospitals in Denmark, with responsibility to inform clinicians, implement guidelines and monitor guideline adherence locally. The agents were not funded by the project, which meant that each agent had to negotiate time for the project at their hospital. Twice a year, the UPN hosts 2-day seminars for implementation agents to sustain their momentum and improve their competencies. Topics have included introduction to quality programmes in the Danish healthcare system, training in public speaking and voice management, communication methods, and database construction.The implementation agents had a pivotal role as they have contributed to awareness-raising and dissemination of the fast-track concept at hospitals across the country. This part of the programme, including transportation, meals and
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8
Day Day Day Day
Hours out of bed after cystectomy
7
1 2 3 4
6 5 4 3 2 1 0
Hospital 1
Hospital 2
Hospital 3
Hospital 4
Hospital 5
Figure 1. Mean hours out of bed after elective cystectomy at five sites in Denmark on postoperative days 1 to 4
Quality-assessment and guideline impact Ongoing audits are necessary for improvement of surgical outcomes. It is essential that outcomes are documented and that feedback is provided to clinicians to demonstrate enhanced recovery, especially after implementation of a new clinical guideline. The UPN has conducted national procedure-specific audits every 2 years, providing an overview of implementation progress, and highlighting particular issues that need future focus in the ongoing quality-improvement process. Audits provide an excellent learning experience for clinicians and help sustain the drive to use and improve guidelines. National audit results have been presented at multidisciplinary workshops, where nationwide practice variations were identified and improvements made. The audits were done by UPN nurses and by implementation agents. To increase validity, some agents audited journals at each other’s units. The national audits included 20 patients from each hospital performing the procedure. In addition to audits, the UPN conducted focus groups with patients to identify problem areas during the shift from conventional to fast-track surgical regimes. A study of colonic surgery suggested that while some of the problem areas existed in both regimes, others were eliminated by factors such as avoidance of preoperative bowel preparation and increased focus on fluid management (Vilstrup et al, 2009). Focus-group participants were informed that participation was voluntary and consented verbally after being assured of anonymity and confidentiality.
Guideline improvements: mobilisation As an example, the UPN performed audits of postoperative mobilisation, which is a core responsibility of nursing. The audits showed up wide variations in post-surgical hours out of
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bed. Consequently, the guidelines for fast-track surgery were modified by the provision of detailed goals for postoperative mobilisation in a nursing guideline. This guideline did not require additional ethical approval as it was not regarded as a new intervention. Figure 1 shows variations in the mean hours out of bed after elective cystectomy on postoperative days 1 to 4 at the five sites in Denmark offering cystectomy.. According to the guideline for fast-track cystectomy, the mobilisation goal was 3 hours on first postoperative day (day 1), 6 hours on day 2, and 8 hours on day 3. None of the sites audited mobilised according to protocol, but the audit targeted the efforts and facilitated the process. Data were presented at national multidisciplinary workshops where variation and lack of adherence were discussed and clinicians inspired each other to find new ways to approach the problems.The variation might be explained by differences in pain management, mobilisation routines and postoperative information at each site (Burch, 2013). Figure 2 shows the variation of hours out of bed on the second postoperative day (day 2) at the six Danish hospitals offering elective fasttrack aortic aneurysm surgery. Only two sites met the goal of 6 hours out of bed on day 2.
Guideline improvements: fluid balance A national audit at all six departments in Denmark offering elective aortic aneurysm surgery showed weight gain of up to 10 kg in the immediate postoperative period in 2010. In response to this finding, we developed a specific sub-guideline for fluid therapy, after which the mean weight gain decreased from 5.5 kg to 4.2 kg in 2010 compared with 2012.The 2010 audit showed inadequate mobilisation, which was, in part, ascribed to pain. In response, we developed a sub-guideline on multimodal pain management (combining peripheral and centrally acting agents). Although the frequency of patients reporting pain on the first postoperative day only decreased from 38% to 36%, the mean hours out of bed on
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hotels, was funded by the grant and was considered a small payment for the services rendered.
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CRITICAL CARE
Guideline improvements: pain management A recent cystectomy audit including 20 patients at all five hospitals offering this procedure in Denmark showed that robot-assisted surgery is increasingly common. Our response to this was the development of a specific nursing guideline for pain management for patients undergoing robot-assisted cystectomy. As a result of this continuous improvement process, the length of stay has been reduced in all surgical areas in Denmark, while the quality of care has improved (Husted et al, 2012; Kehlet and Harling, 2012; Azawi et al, 2012).
Ethical considerations The establishment of the UPN and the development of clinical guidelines did not require separate ethical approval, because they were considered quality-improvement measures rather than research. The guidelines were evidence-based and used the results from research with ethical approval. Danish hospitals do not have internal review boards, but approval from regional ethics committees is required for biomedical and interventional research. Implementation of the programme at each site was the responsibility of the head physician.
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Discussion We set out to report on a national initiative in Denmark to improve the quality of surgical care by focusing on provision of procedure-specific nursing care programmes. Implementation of evidence into daily practice is always a challenge (Kehlet, 2011b). Despite increasing amounts of evidence to document the benefits of clinical guidelines based on the fast-track principles, national audits have shown slow change in surgical practice to adapt to evidence-based care. In a busy working day, it is impossible to keep abreast of all the latest evidence, and it does not make sense for each department to allocate time for this process. It is desirable, therefore, to centralise knowledge. Our main finding is that the establishment of the national UPN has been proven to accelerate implementation of fast-track regimes in all surgical departments in Denmark. Increased interdisciplinary collaboration and establishment of a national procedurespecific network has been the result of the workshop-practice method, which led to an alignment and an improvement in quality of the surgical care and treatment. When fast-track surgical regimes were first introduced, many nurses expressed scepticism because they feared premature hospital discharge (Norlyk and Harder, 2009). It is our experience that nurses who have an active role in guideline development gain a sense of ownership, which promotes a more positive attitude. It is clear that the perioperative outcomes improved, but ongoing quality assessment is essential (Kehlet, 2012). For safe and effective improvement of surgical care, it is important to respond to outcome findings. As the audit results show, there is room for improvement (Egerod et al, 2010) and when data are
British Journal of Nursing, 2014, Vol 23, No 9
8 Hours out of bed after aortic surgery
the second postoperative day increased from 2.4 to 4.8, and mean days in hospital decreased from 9.2 to 7.5. The audit also demonstrated an increase in frequency of patients eating a normal diet on the first postoperative day from 45% to 78% in 2010 compared with 2012.
Day 2
7 6 5 4 3 2 1 0
Hospital 1
Hospital 2
Hospital 3 Hospital 4
Hospital 5 Hospital 6
Figure 2. Hours out of bed on day 2 after elective aortic aneurysm surgery
presented to the clinicians, a plan is always made for further optimisation. Although we have reported on the success of a unit for nursing care, we stress that fast-track programmes require successful organisation of a multidisciplinary group (Kehlet and Wilmore, 2008). It is well established from organisation literature that an organisation must change as the tasks change, a factor that is often ignored (Hayes, 2010). Daily routines must be adapted to new knowledge regarding optimal mobilisation and best nurse–patient ratio according to shift and weekday. Guidelines and integrated pathways for care are essential for daily detailed goals for nursing care. A Danish study assessed hospital stay for hip and knee replacement surgery to identify important logistics and clinical areas for the duration of the hospital stay (Husted et al, 2006). The logistics set-up and the guidelines were examined in an attempt to identify potential improvements or barriers for quick rehabilitation and discharge. The conclusion was that departments with short hospital stay were characterised by both logistics (homogenous entities, regular staff, high continuity, using more time on and up-todate information including expectations of a short stay, functional discharge criteria) and clinical features (multimodal pain treatment, early mobilisation and discharge when criteria were met), facilitating quick rehabilitation and discharge. It takes about a year to implement a fast-track programme, but it takes an estimated 17 years to change routines and traditions permanently (Morris et al, 2011). It has been reported that adverse postoperative outcomes were significantly reduced with better adherence to the fasttrack programme (Burch, 2013). As a consequence, the multidisciplinary team involved must be well educated and, in addition, the nursing care plans and patient information need to be adjusted to the clinical guideline. To ensure implementation of the fast-track methodology we have to analyse barriers and facilitators.The effectiveness of strategies depends on the organisational context in which they are implemented (Hakkennes, 2008). The implementation of
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n Establishment
of a national Unit of Perioperative Nursing (UPN) has been proven to accelerate implementation of fast-track regimes in all surgical departments in Denmark
n Increased
interdisciplinary cooperation and establishment of a national procedure-specific network has been the result of the workshop-practice method
n Nurses
who have an active role in guideline development will encourage a sense of ownership of the guideline and a more positive attitude towards it
n Ongoing
quality monitoring is essential, but to secure improvement of surgical care, it is important to respond to outcome findings
a fast-track programme requires a dedicated and motivated team, and this team needs to be trained (Polle, 2007). At the onset, there were reservations about the fast-track concept from patients and from the nursing staff as they had to adjust to shorter nurse–patient contact. But over the years, these concerns have decreased as knowledge has increased about goals and results for fast-track surgery. The UPN has been a low-cost, high-impact solution to implementation of fast-track surgical regimes. Only two nurses were salaried, but the whole concept of short-term surgery in Denmark was changed. For future practice, we recommend the establishment of a national UPN that integrates information technology and communication among clinicians from different geographical and professional areas to pool their knowledge and share ideas to improve surgical-patient trajectories. Until recently, Danish nurses were unable to obtain academic qualifications. More attention should be paid to nurse specialisation and overall nurse structure in surgical departments, since the educational levels of nurses may have an important impact on postoperative morbidity and mortality (Aiken et al, 2003; Tourangeau et al, 2006).
Conclusions The innovative collaboration and method of guideline construction in fast-track surgery increases nurses’ knowledge and skills, and patients receive optimised treatment at all Danish hospitals alike. The UPN has been a low-cost programme with high impact on quality of surgical nursing care. BJN Conflict of interest: none Aiken LH, Clarke SP, Cheung RB (2003) Educational levels of hospital nurses and surgical patient mortality. JAMA 290(12): 1617–23 Azawi NH, Christensen T, Petri AL, Kehlet H (2012) Prolonged length of stay in Denmark after nephrectomy. Dan Med J 59(6): A4446 Basse L, Raskov HH, Hjort Jakobsen D et al (2002) Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition. Br J Surg 89(4): 446–53 Burch J (2013) Promoting enhanced recovery after colorectal surgery. Br J Nurs 22(5): 4–9 Egerod I, Rud K, Specht K et al(2010) Room for improvement in the treatment of hip fractures in Denmark. Dan Med Bull 57(12): A4199 Graham ID, Harrison MB (2005) EBN users’ guide. Evaluation and adaptation of clinical practice guidelines. Evid Based Nurs 8: 68–72 doi: 10.1136/ ebn.8.3.68. Grimshaw J, Russell I (1993) Effect of clinical guidelines on medical practice – a systematic review of rigorous evaluations. Lancet 342: 1317–22 Hakkennes S, Dodd K (2008) Guideline implementation in allied health
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KEY POINTS
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Standardising fast-track surgical nursing care in Denmark Dorthe Hjort Jakobsen, Kirsten Rud, Henrik Kehlet and Ingrid Egerod
T
he demand for evidence-based health care is increasing, with a particular focus on quality improvement of surgical care. The perioperative period is fraught with challenges, including pre-existing comorbidities, stress-induced organ dysfunction, fluid imbalance, hypoxemia, postoperative pain, nausea, vomiting, ileus, immobilisation, malnutrition and fatigue, which all potentially contribute to prolonged hospital stay, extended convalescence and increased morbidity (Kehlet and Dahl, 2003; Kehlet and Wilmore, 2008). In the past decade, conventional surgical care has been modified to improve postoperative outcomes (Kehlet and Wilmore, 2008). The aim of this paper is to report on a national initiative in Denmark to improve the quality of surgical care by focusing on the provision of procedurespecific nursing care programmes.
Background
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Fast-track surgery is a term for comprehensive preoperative, intraoperative and postoperative care, integrating evidencebased, multimodal rehabilitation programmes aimed at optimising postoperative recovery, reducing morbidity, and improving convalescence (Kehlet, 2011a). The five key elements in fast-track surgical programmes are: preoperative counselling, surgical stress reduction, optimal dynamic pain relief, enforced mobilisation, and sufficient nutrition (Kehlet and Wilmore, 2008).The concept encompasses a state-of-theart approach to postoperative care, which includes reduction of tubes, drains and catheters, and recommendations for monitoring and rehabilitation (Kehlet and Wilmore, 2008; Kehlet, 2011a). A multidisciplinary approach is required, with collaboration of surgeons, anesthesiologists, nurses and physiotherapists. In addition, organisational changes are necessary to accommodate the many components in fast-track regimes. Fast-track programmes have shown enhanced recovery and reduced hospitalisation and morbidity in procedures such as elective open colorectal surgery (Varadhan et al, 2010; Kehlet, 2011a). A systematic review of conventional colon Dorthe Hjort Jakobsen is Clinical Head Nurse and Kirsten Rud is Head Nurse at the Unit of Perioperative Nursing, Rigshospitalet; Henrik Kehlet is Professor at the Section of Surgical Pathophysiology, Rigshospitalet; and Ingrid Egerod is Professor at the Trauma Centre, Rigshospitalet, Copenhagen, and the Faculty of Health and Medicine, University of Copenhagen, Denmark Accepted for publication: April 2014
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Abstract
Considerable variations in procedures, hospital stay and rates of recovery have been recorded within specific surgical procedures at Danish hospitals. The aim of this paper is to report on a national initiative in Denmark to improve the quality of surgical care by implementation of clinical guidelines based on the principles of fast-track surgery—i.e. patient information, surgical stress reduction, effective analgesia, early mobilisation and rapid return to normal eating. Fast-track surgery was introduced systematically in Denmark by the establishment of the Unit of Perioperative Nursing (UPN) in 2004. The unit was responsible for guideline construction and implementation using the ‘workshop practice method’: establishing a website, creating a knowledge centre, coordinating implementation agents, and arranging national workshops and conferences. The UPN has promoted implementation of fast-track regimes in all surgical departments in Denmark. We recommend the workshop-practice method for implementation of new procedures in other areas of patient care. Key words: Change management ■ Change agents ■ Clinical practice guidelines ■ Enhanced recovery ■ Fast-track surgery ■ Quality improvement ■ Standardisation surgery in 2006 reported a hospital stay of 8–12 days and a complication rate of 20–30% due to factors such as pain and paralytic ileus (Wind et al, 2006). Conventional versus fasttrack colorectal surgical programmes have shown a reduction of hospital stay from 8–12 days to about 3–5 days, limiting debilitating factors such as pain, paralytic ileus and other organ dysfunctions, while improving physical performance, pulmonary function and body composition, using the same discharge criteria as in conventional treatment (Kehlet and Wilmore, 2008; Varadhan et al, 2010). In addition, patients experience fewer complications and hospitals benefit from lower costs. Similar results have been found in fast-track courses of orthopaedic, gynaecological and urological surgery, with shorter convalescence, less fatigue and similar or better patient satisfaction compared with traditional care (Hjort Jakobsen et al, 2006; Zagar-Shoshtari et al, 2009). Fast-track programmes need to be supported by clinical-practice guidelines, which have been described as systematically developed statements aimed at assisting decision-making and providing criteria regarding diagnosis, management and treatment in specific areas of health care (Thomas et al, 1998; Thomas, 1999). Clinical-practice guidelines have become an integral part of contemporary patient care to ensure quality and safety. Guidelines have
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Context of fast-track implementation Multimodal fast-track surgical programmes were developed in Denmark, where health care is publicly financed through taxes. Most hospitals are public and the responsibility for running healthcare services is decentralised in regions and municipalities, but the state is in charge of legislation, supervision, general planning and economy (Ministry of Health and Prevention, 2008). There is a trend towards more specialised treatment by consolidating expertise at larger regional and university hospitals. Not all of Denmark’s 69 hospitals provide all types of treatment.
The Unit of Perioperative Nursing (UPN) Fast-track surgery was introduced systematically in Denmark by the establishment of the Unit of Perioperative Nursing (UPN) in 2004. The UPN was opened in Copenhagen and was run on a daily basis by two full-time employed nurses (UPN nurses) with clinical and managerial experience (first and second authors), supported by a senior physician and an academically prepared nurse (third and fourth authors). The steering committee consisted of these four individuals. The basic assumption was that implementation of new procedures would be better facilitated through a network of nurses than by requesting individual physicians to change their practice. The UPN was funded by the Danish Ministry of Health for an 8-year period, with the goal of promoting the principles of fast-track surgery for the most common short-term surgical procedures across the country. The UPN took on the following responsibilities: ■■ Establishment of a knowledge centre for fast-track programmes ■■ Establishment of a UPN website ■■ Leadership in networking among fast-track specialists across Denmark ■■ Arrangement of annual multidisciplinary fast-track conferences
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■■ Arrangement
of multidisciplinary workshops within each surgical sub-specialty ■■ Guideline construction, dissemination and implementation ■■ Identification and coordination of national implementation agents ■■ Publication of findings from fast-track research.
The workshop-practice method Quality improvement (QI) relies on the following steps: problem identification, establishment of baseline performance, selection of improvement strategies, monitoring of progress toward improvement goals, evaluation of unintended consequences of improvement strategies, and identification of effective and sustainable strategies (Partin et al, 2013). The UPN introduced the ‘workshop-practice method’ as an innovative process consistent with quality improvement for development of national multidisciplinary guidelines for fast-track surgical procedures. The two UPN nurses ran six workshops per year for 8 years (48 workshops in total) to produce 16 interdisciplinary clinical guidelines averaging three workshops per surgical procedure. During the first years, the four members of the steering committee were present at all workshops to develop and refine the workshop-practice method of implementation. Lunch and refreshments at workshops were paid for by the UPN grant, but the participants paid for their own transportation. The process consisted of the following steps for each selected surgical procedure: ■■ Review of relevant literature and initial guideline preparation by the two UPN nurses ■■ Workshops for clinicians from across the country, with surgeons, anaesthesiologists, nurses and physiotherapists from each hospital offering a particular procedure. Workshops included lectures, presentation of evidence and propositional guidelines, discussions and practice comparisons ■■ Guideline drafting by the two UPN nurses following each workshop ■■ Dissemination and email responses to first and second guideline drafts by workshop participants until consensus was reached ■■ Guideline finalisation and dissemination to website by UPN nurses ■■ Guideline update every 2–3 years by UPN nurses after additional workshops.
Clinical guidelines National guidelines including clinical pathways have been developed for 16 selected surgical procedures in 2004–2013. Each year a couple of new guidelines have been developed for fast-track surgical procedures including: aortic aneurysm, breast cancer surgery, colonic resection, hernia repair, hip fracture, hip replacement, hysterectomy, knee replacement, laparoscopic cholesystectomy, laparoscopic colonic resection, pulmonary resection, lumbar spondylolysis, ovarian cancer surgery, pancreatectomy, radical prostatectomy, and transtibial and trans-femoral amputations. All hospitals offering a particular procedure were invited to participate to promote a sense of national ownership. The total number of hospitals involved was 51.
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been shown to reduce inappropriate practice variations and promote evidence-based health care, as they translate research findings into practice, resulting in more structured and focused care (Grimshaw and Russell, 1993; Graham and Harrison, 2005; Hunter and Segrott, 2008). Implementation of procedure-specific clinical guidelines with the principles of fast-track surgery, including daily goals for nursing care and carefully delineated discharge criteria, have shown a reduction in complications and length of hospital stay (Basse et al, 2002; Kehlet and Wilmore, 2008). In the early 2000s, considerable variations in procedures, hospital stay and rates of recovery were recorded within specific surgical procedures at Danish hospitals (Møller et al, 2002; Jensen et al, 2007; Marx et al, 2007). Consequently, a need emerged for consensus on key elements of perioperative care to improve quality and standardise surgical care. After the basic elements of fast-track regimes were described within surgery and anesthesiology, the next step was implementation. In this article, we report on an initiative for improvement of nursing care within the paradigm of fasttrack surgical programmes at all surgical units in Denmark from 2004 to 2013.
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CRITICAL CARE Table 1. Nursing care pathway (pocket edition) for patients undergoing open elective colonic resection Preoperative care
Day of surgery
1–3 days postoperation
Discharge criteria
Information and dialogue Written hand-out Dialogue focus ■■ Patient involvement and individual preferences ■■ Reaction to cancer diagnosis ■■ Nurse-patient expectations ■■ History of pain, nausea and constipation ■■ Rationale for fast-track programme ■■ Specific goals for mobilisation, nutrition, pain management and discharge Pain relief ■■ Thoracic epidural analgesia for 2 days ■■ Paracetamol and NSAID/COX2inhibitors (after epidural removal at 2 days/48 hours) ■■ Information about VAS Nutrition ■■ Protein-enriched drinks as needed Mobilisation ■■ Plan for support according to the programme and the goals Elimination ■■ No bowel preparation, except for an enema the night before surgery
Premedication ■■ No routine sedative. Paracetamol (slow release) Pain relief ■■ Thoracic epidural analgesia for 2 days ■■ Paracetamol and NSAID/COX2inhibitors (after epidural removal) ■■ Pain assessed every 8 hours with VAS Nausea ■■ Ondansetrone 4 mg ■■ Nutrition ■■ Preop: NPO for 6 hours and no fluids for 2 hours ■■ Postop: 1 litre fluid PO, including two protein-enriched drinks, normal diet ■■ Stop IV fluid intake 4 hours postop, adjust fluid balance Mobilisation ■■ Out of bed ≥2 hours ■■ Anticoagulant therapy 4–12 hours postop Elimination ■■ Balance fluids ■■ No nasogastric tubes ■■ Weight
Information and dialogue ■■ Discharge planning with patient and family Pain relief ■■ Thoracic epidural analgesia for 2 days ■■ Remove epidural catheter in the morning ■■ Pain assessed every 8 hours with VAS Nausea ■■ Ondansetrone 4 mg Nutrition ■■ Normal diet ■■ 2 litres fluid PO, including four protein-enriched drinks Mobilisation ■■ Out of bed ≥8 hours ■■ Ambulate x 3 Elimination ■■ Remove urine catheter first day postop in the morning ■■ Balance fluids ■■ Record bowel function ■■ Weight
Discharge ■■ Third day postop if criteria are met Discharge criteria ■■ Patient feels confident about discharge ■■ Sufficient pain relief with oral analgesics ■■ Sufficient intake of food and fluids ■■ No wound problems ■■ Passing gas, normal bladder function ■■ Usual ADL level
VAS=visual analogue scale for pain assessment; PO=by mouth; NPO=nil by mouth; ADL=activities of daily living
Each of the 16 guidelines includes a condensed pocket edition (Table 1) and a number of individually referenced evidence-based nursing-specific sub-guidelines.As an example, the procedure-specific guideline for colonic surgery includes the following sub-guidelines: activity and convalescence; nutrition, post-operative nausea and vomiting (PONV), and fluid management; knowledge and development; pain and discomfort; elimination; breathing. The reason for dividing the main guideline into sub-guidelines was to create a format that included clinical pathways and clinical-practice guidelines. This enabled us to create consistent guidelines for a variety of different surgical procedures.
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Website An open Danish language website maintained by the two UPN nurses was developed as a tool for knowledge-sharing. The website provided all clinical guidelines, links to publications related to the UPN, announcement of workshops and conferences, and other instruments informing clinicians of fasttrack surgical programmes. Nurses from around the country have been able to contact the UPN for further assistance, and student nurses have also been engaged in the use of the website and consultations with the UPN nurses. The website has been the inspirational hub that has enabled clinicians to exchange ideas and share patient information, care plans, and so on.
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Agents and audits Studies have shown that despite the availability of clinical guidelines, it often takes years before they are integrated into practice (Kehlet et al, 2006; Maessen et al, 2007). The common saying is ‘17 years from bench to bedside’ (Morris et al, 2011). To speed up the process, experienced nurses were invited by the UPN to assist in the successful implementation of fast-track programmes across the country. The nurses were selected pragmatically on the basis of interest and familiarity with the concepts of fast-track surgery. Twenty-five nurses were chosen as ‘implementation agents’ at the major hospitals in Denmark, with responsibility to inform clinicians, implement guidelines and monitor guideline adherence locally. The agents were not funded by the project, which meant that each agent had to negotiate time for the project at their hospital. Twice a year, the UPN hosts 2-day seminars for implementation agents to sustain their momentum and improve their competencies. Topics have included introduction to quality programmes in the Danish healthcare system, training in public speaking and voice management, communication methods, and database construction.The implementation agents had a pivotal role as they have contributed to awareness-raising and dissemination of the fast-track concept at hospitals across the country. This part of the programme, including transportation, meals and
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8
Day Day Day Day
Hours out of bed after cystectomy
7
1 2 3 4
6 5 4 3 2 1 0
Hospital 1
Hospital 2
Hospital 3
Hospital 4
Hospital 5
Figure 1. Mean hours out of bed after elective cystectomy at five sites in Denmark on postoperative days 1 to 4
Quality-assessment and guideline impact Ongoing audits are necessary for improvement of surgical outcomes. It is essential that outcomes are documented and that feedback is provided to clinicians to demonstrate enhanced recovery, especially after implementation of a new clinical guideline. The UPN has conducted national procedure-specific audits every 2 years, providing an overview of implementation progress, and highlighting particular issues that need future focus in the ongoing quality-improvement process. Audits provide an excellent learning experience for clinicians and help sustain the drive to use and improve guidelines. National audit results have been presented at multidisciplinary workshops, where nationwide practice variations were identified and improvements made. The audits were done by UPN nurses and by implementation agents. To increase validity, some agents audited journals at each other’s units. The national audits included 20 patients from each hospital performing the procedure. In addition to audits, the UPN conducted focus groups with patients to identify problem areas during the shift from conventional to fast-track surgical regimes. A study of colonic surgery suggested that while some of the problem areas existed in both regimes, others were eliminated by factors such as avoidance of preoperative bowel preparation and increased focus on fluid management (Vilstrup et al, 2009). Focus-group participants were informed that participation was voluntary and consented verbally after being assured of anonymity and confidentiality.
Guideline improvements: mobilisation As an example, the UPN performed audits of postoperative mobilisation, which is a core responsibility of nursing. The audits showed up wide variations in post-surgical hours out of
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bed. Consequently, the guidelines for fast-track surgery were modified by the provision of detailed goals for postoperative mobilisation in a nursing guideline. This guideline did not require additional ethical approval as it was not regarded as a new intervention. Figure 1 shows variations in the mean hours out of bed after elective cystectomy on postoperative days 1 to 4 at the five sites in Denmark offering cystectomy.. According to the guideline for fast-track cystectomy, the mobilisation goal was 3 hours on first postoperative day (day 1), 6 hours on day 2, and 8 hours on day 3. None of the sites audited mobilised according to protocol, but the audit targeted the efforts and facilitated the process. Data were presented at national multidisciplinary workshops where variation and lack of adherence were discussed and clinicians inspired each other to find new ways to approach the problems.The variation might be explained by differences in pain management, mobilisation routines and postoperative information at each site (Burch, 2013). Figure 2 shows the variation of hours out of bed on the second postoperative day (day 2) at the six Danish hospitals offering elective fasttrack aortic aneurysm surgery. Only two sites met the goal of 6 hours out of bed on day 2.
Guideline improvements: fluid balance A national audit at all six departments in Denmark offering elective aortic aneurysm surgery showed weight gain of up to 10 kg in the immediate postoperative period in 2010. In response to this finding, we developed a specific sub-guideline for fluid therapy, after which the mean weight gain decreased from 5.5 kg to 4.2 kg in 2010 compared with 2012.The 2010 audit showed inadequate mobilisation, which was, in part, ascribed to pain. In response, we developed a sub-guideline on multimodal pain management (combining peripheral and centrally acting agents). Although the frequency of patients reporting pain on the first postoperative day only decreased from 38% to 36%, the mean hours out of bed on
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hotels, was funded by the grant and was considered a small payment for the services rendered.
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CRITICAL CARE
Guideline improvements: pain management A recent cystectomy audit including 20 patients at all five hospitals offering this procedure in Denmark showed that robot-assisted surgery is increasingly common. Our response to this was the development of a specific nursing guideline for pain management for patients undergoing robot-assisted cystectomy. As a result of this continuous improvement process, the length of stay has been reduced in all surgical areas in Denmark, while the quality of care has improved (Husted et al, 2012; Kehlet and Harling, 2012; Azawi et al, 2012).
Ethical considerations The establishment of the UPN and the development of clinical guidelines did not require separate ethical approval, because they were considered quality-improvement measures rather than research. The guidelines were evidence-based and used the results from research with ethical approval. Danish hospitals do not have internal review boards, but approval from regional ethics committees is required for biomedical and interventional research. Implementation of the programme at each site was the responsibility of the head physician.
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Discussion We set out to report on a national initiative in Denmark to improve the quality of surgical care by focusing on provision of procedure-specific nursing care programmes. Implementation of evidence into daily practice is always a challenge (Kehlet, 2011b). Despite increasing amounts of evidence to document the benefits of clinical guidelines based on the fast-track principles, national audits have shown slow change in surgical practice to adapt to evidence-based care. In a busy working day, it is impossible to keep abreast of all the latest evidence, and it does not make sense for each department to allocate time for this process. It is desirable, therefore, to centralise knowledge. Our main finding is that the establishment of the national UPN has been proven to accelerate implementation of fast-track regimes in all surgical departments in Denmark. Increased interdisciplinary collaboration and establishment of a national procedurespecific network has been the result of the workshop-practice method, which led to an alignment and an improvement in quality of the surgical care and treatment. When fast-track surgical regimes were first introduced, many nurses expressed scepticism because they feared premature hospital discharge (Norlyk and Harder, 2009). It is our experience that nurses who have an active role in guideline development gain a sense of ownership, which promotes a more positive attitude. It is clear that the perioperative outcomes improved, but ongoing quality assessment is essential (Kehlet, 2012). For safe and effective improvement of surgical care, it is important to respond to outcome findings. As the audit results show, there is room for improvement (Egerod et al, 2010) and when data are
British Journal of Nursing, 2014, Vol 23, No 9
8 Hours out of bed after aortic surgery
the second postoperative day increased from 2.4 to 4.8, and mean days in hospital decreased from 9.2 to 7.5. The audit also demonstrated an increase in frequency of patients eating a normal diet on the first postoperative day from 45% to 78% in 2010 compared with 2012.
Day 2
7 6 5 4 3 2 1 0
Hospital 1
Hospital 2
Hospital 3 Hospital 4
Hospital 5 Hospital 6
Figure 2. Hours out of bed on day 2 after elective aortic aneurysm surgery
presented to the clinicians, a plan is always made for further optimisation. Although we have reported on the success of a unit for nursing care, we stress that fast-track programmes require successful organisation of a multidisciplinary group (Kehlet and Wilmore, 2008). It is well established from organisation literature that an organisation must change as the tasks change, a factor that is often ignored (Hayes, 2010). Daily routines must be adapted to new knowledge regarding optimal mobilisation and best nurse–patient ratio according to shift and weekday. Guidelines and integrated pathways for care are essential for daily detailed goals for nursing care. A Danish study assessed hospital stay for hip and knee replacement surgery to identify important logistics and clinical areas for the duration of the hospital stay (Husted et al, 2006). The logistics set-up and the guidelines were examined in an attempt to identify potential improvements or barriers for quick rehabilitation and discharge. The conclusion was that departments with short hospital stay were characterised by both logistics (homogenous entities, regular staff, high continuity, using more time on and up-todate information including expectations of a short stay, functional discharge criteria) and clinical features (multimodal pain treatment, early mobilisation and discharge when criteria were met), facilitating quick rehabilitation and discharge. It takes about a year to implement a fast-track programme, but it takes an estimated 17 years to change routines and traditions permanently (Morris et al, 2011). It has been reported that adverse postoperative outcomes were significantly reduced with better adherence to the fasttrack programme (Burch, 2013). As a consequence, the multidisciplinary team involved must be well educated and, in addition, the nursing care plans and patient information need to be adjusted to the clinical guideline. To ensure implementation of the fast-track methodology we have to analyse barriers and facilitators.The effectiveness of strategies depends on the organisational context in which they are implemented (Hakkennes, 2008). The implementation of
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n Establishment
of a national Unit of Perioperative Nursing (UPN) has been proven to accelerate implementation of fast-track regimes in all surgical departments in Denmark
n Increased
interdisciplinary cooperation and establishment of a national procedure-specific network has been the result of the workshop-practice method
n Nurses
who have an active role in guideline development will encourage a sense of ownership of the guideline and a more positive attitude towards it
n Ongoing
quality monitoring is essential, but to secure improvement of surgical care, it is important to respond to outcome findings
a fast-track programme requires a dedicated and motivated team, and this team needs to be trained (Polle, 2007). At the onset, there were reservations about the fast-track concept from patients and from the nursing staff as they had to adjust to shorter nurse–patient contact. But over the years, these concerns have decreased as knowledge has increased about goals and results for fast-track surgery. The UPN has been a low-cost, high-impact solution to implementation of fast-track surgical regimes. Only two nurses were salaried, but the whole concept of short-term surgery in Denmark was changed. For future practice, we recommend the establishment of a national UPN that integrates information technology and communication among clinicians from different geographical and professional areas to pool their knowledge and share ideas to improve surgical-patient trajectories. Until recently, Danish nurses were unable to obtain academic qualifications. More attention should be paid to nurse specialisation and overall nurse structure in surgical departments, since the educational levels of nurses may have an important impact on postoperative morbidity and mortality (Aiken et al, 2003; Tourangeau et al, 2006).
Conclusions The innovative collaboration and method of guideline construction in fast-track surgery increases nurses’ knowledge and skills, and patients receive optimised treatment at all Danish hospitals alike. The UPN has been a low-cost programme with high impact on quality of surgical nursing care. BJN Conflict of interest: none Aiken LH, Clarke SP, Cheung RB (2003) Educational levels of hospital nurses and surgical patient mortality. JAMA 290(12): 1617–23 Azawi NH, Christensen T, Petri AL, Kehlet H (2012) Prolonged length of stay in Denmark after nephrectomy. Dan Med J 59(6): A4446 Basse L, Raskov HH, Hjort Jakobsen D et al (2002) Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition. Br J Surg 89(4): 446–53 Burch J (2013) Promoting enhanced recovery after colorectal surgery. Br J Nurs 22(5): 4–9 Egerod I, Rud K, Specht K et al(2010) Room for improvement in the treatment of hip fractures in Denmark. Dan Med Bull 57(12): A4199 Graham ID, Harrison MB (2005) EBN users’ guide. Evaluation and adaptation of clinical practice guidelines. Evid Based Nurs 8: 68–72 doi: 10.1136/ ebn.8.3.68. Grimshaw J, Russell I (1993) Effect of clinical guidelines on medical practice – a systematic review of rigorous evaluations. Lancet 342: 1317–22 Hakkennes S, Dodd K (2008) Guideline implementation in allied health
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