Get well sooner: enhanced recovery

Patsy Westcott / 01 May 2016

A medical revolution is helping patients to bounce back from surgery faster.



If you’re booked in for a major operation sometime soon and expecting months of tough recovery afterwards, you could be in for a big surprise.

Innovative methods are transforming the way health professionals approach surgery and aftercare, so that a lot of the old stress, pain and drawn-out healing times are becoming a thing of the past.

How to prepare for surgery

Enhanced recovery techniques

Enhanced-recovery techniques, as they are known, were developed in Denmark for people having bowel surgery. But they’re now used in some 85% – and growing – of UK hospitals, for anything from hernia repair to urological procedures, and even cancer and heart operations.

‘Five years ago it was the norm for hip-replacement patients, for instance, to spend seven or eight days in hospital,’ says consultant orthopaedic surgeon Mr William Bartlett of the Whittington Hospital in North London. ‘Now it’s an average of three nights, and some people even go home the next day.’

8 tips to help you recover from surgery faster

Questioning traditional methods

Enhanced recovery (ER) has emerged largely because doctors have questioned long-held surgical methods – and found them wanting.

New techniques that reduce an operation’s impact on a patient’s body, such as keyhole surgery and drugs to reduce blood loss, are crucial parts of the programmes. Using shorter-acting but effective anaesthetics is also important.

This reduces the often consequent nausea and gut slowing of post-op patients. Feeding by tube post-op used to be routine but is now also avoided as it can leave patients vulnerable to infection and other problems. It’s thought to be better to get back to eating normally as soon as possible.

Get back on your feet faster

But, surprisingly, ER also limits the use of that mainstay of post-operative care, total bed rest. The latest research shows that, in many cases, it’s important for patients to get moving as soon as possible.

Prolonged immobility increases the risk of blood clots, reduces lung function and raises the risk of pneumonia, as well as leading to muscle wasting in a surprisingly short time, especially among older people.

Starving patients before surgery is another established technique that ER rejects. It was done to reduce the risk of aspiration – breathing partially digested food into the lungs. But, says Dr Chris Snowden, consultant anaesthetist at Newcastle’s Freeman Hospital, ‘The risk of aspiration is less than previously thought and we now know that hunger and dehydration [caused by fasting] can be very detrimental to healing, especially in older patients, who are susceptible to falls and to loss of muscle.’

Instead, hospitals are increasingly encouraging you to keep your strength up by eating up to six hours prior to surgery and drinking a carbohydrate- plus-electrolyte drink, similar to still Lucozade, a couple of hours beforehand.

Read Helen Pierce's diary of a hip replacement - from the hospital bed to getting back in the driving seat

Fine-tuning post-operative painkillers

Doctors are also fine-tuning the use of powerful post-operative painkillers, such as morphine, to avoid nausea, drowsiness and other counter-productive side effects such as constipation.

‘In the past, someone who’d just had a knee operation would be sent to a higher-dependency ward overnight, attached to a morphine pump, dosed up with anti-sickness drugs, and kept on a light diet or fluids,’ says Mr Amir Qureshi, who is a consultant orthopaedic and trauma surgeon at Southampton University Hospital. ‘By contrast, today they are sitting up comfortably in a normal ward, and walking that evening.’

Changing patients’ attitudes

But fast-track recovery isn’t just concerned with better treatments and practices – it’s also about improving patients’ mindsets.

‘We have moved a long way from people being passive recipients of care,’ says surgeon Mr Bartlett. Not knowing what will happen to you during an operation, and why, can cause anxiety that is a big barrier to recovery. ‘We aim to educate patients so they are empowered and their active involvement will help.’

‘There should be no surprises,’ says Mr Qureshi. ‘In my practice anyone having a hip or knee replacement attends “joint school”, where they can watch videos and read patient diaries to ensure they know exactly what to expect.’

Both his and Mr Bartlett’s ER programmes give patients timetables of what level of recovery they should expect – such as being able to walk with a frame – and when. ‘This gives them milestones [to aim for] and reassures them that things are going to plan,’ says Mr Qureshi.

Continuing your recovery at home

Your recovery from surgery doesn’t stop when you leave hospital, of course, and ER programmes aim to have a positive impact here, too. You’ll find out, for instance, what sort of facilities or room layout you might need when you get home, or what kind of help you might want from family and friends.

If an older, frailer patient has a social-care package in place – such as someone to help with their cleaning or shopping – hospitals such as Torbay, in Devon, ensure that the local authority is ready to restart them as soon as a person goes home. The Whittington, meanwhile, has a 24-hour phone line for patients to access an ER nurse, who also calls them after discharge to check their progress.

The latest thinking on ER

A whole new discipline, perioperative medicine (POM), is building on ER to focus more on a patient’s long-term health.

‘POM is about the pathway from the moment you first visit the GP to three, six, nine months after surgery,’ says Dr Chris Snowden. ‘ER can’t be considered successful if people are still struggling to do their shopping and other activities of daily life.’

One programme, being tested at Freeman Hospital, addresses lifestyle factors, such as quitting smoking, moderating alcohol consumption (alcohol can increase the risk of infection and falls post-surgery) and eating a nutritious diet. It also identifies and treats any pre-existing conditions such as diabetes, heart problems or urine infections, to optimise recovery.

Freeman researchers have been using an intensive, hospital-based activity programme for older, unfit patients in order to get them in better shape before their operation.

‘You can improve cardiovascular function by 20% in just six weeks, and patients are highly motivated at this time,’ explains Dr Snowden. The researchers are now looking at setting up a similar community-based programme.

The future for Enhanced Recovery programmes

If anything is holding ER back, it’s a lack of specific healthcare professionals to champion the programmes.

One in five NHS trusts don’t have an ER leader and only three in ten have a dedicated nurse. But the Royal College of Anaesthetists is developing a countrywide network of perioperative specialists and a programme of training. And at a recent King’s Fund think-tank conference, health professionals from a range of backgrounds shared good practice and discussed how to roll it out to more hospitals nationwide. So if you don’t have an ER programme near you, it might not be too far away.

Cynics might argue the new initiatives are simply about a cash-strapped NHS saving money. Putting a patient on an ER programme can be much cheaper than keeping them on a ward for weeks at £200 to £300 a day. But, says Dr Snowden, it’s about far more than economics. ‘Patients don’t like being in hospital and this is about enabling them to get home and back to normal as soon as possible.’

And that’s surely something we all want for ourselves and our loved ones.

Enhanced Recovery programme case study: Jim Tanner

When keen golfer Jim Tanner learned last year that he needed a knee replacement, the prospect was depressing.

‘As an engineer, I spent my working life crawling round engines so I wasn’t surprised when I developed joint problems,’ says the 67-year-old former merchant seaman. ‘But I’d recently had spinal surgery and wasn’t looking forward to another operation.’

Thanks to an enhanced-recovery programme at Southampton University Hospital, however, the process was much easier. He attended the hospital’s ‘joint school’, which prepared him for surgery by telling him what to expect and what he could do to help his recovery.

Meanwhile, his surgeon, Mr Amir Qureshi, explained that, in a departure from usual procedure, he wouldn’t be using a tourniquet to reduce bleeding but would employ anti blood-loss drugs instead, to try to avoid post-operative pain and swelling. A long-acting regional nerve block to numb pain would also be used to encourage faster recovery and reduce side effects.

‘On the day of surgery I went into hospital in the morning, was operated on in the afternoon, and was home the next day. I was amazed by how quickly I was up and about. I had cartilage removed from my knee in my twenties and remember lying in bed for 12 days.’

Three months later, Jim was almost back to normal. ‘I’ve just been out shopping and I’m going driving on the range,’ he says. ‘I can’t wait to get my clubs out.’

This article was first published in the May 2016 issue of Saga Magazine. For great articles like this, subscribe to the print edition or download the digital edition today.

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