Impact of pharmacist involvement in enhanced recovery pathways in improving patient care in those undergoing lower gastrointestinal surgery

In a nutshell, the enhanced recovery (ER) programme is about improving patient outcomes and speeding up a patient's recovery after surgery. Since its introduction in the UK in 2002, ER pathways have been enrolled within multiple surgical subspecialties, with the primary aim being to reduce the length of inpatient stay whilst still providing a high quality package of care. One of the key stages of ER is optimising patients for surgery.

Fundamental to all aspects of ER is that patients are partners’ in their own care and are kept fully informed throughout their ‘surgical journey’. The benefits of such pathways are well recognised and fully supported by the ER partnership programme formed collaboratively between the Department of Health, NHS Improvement and the National Cancer Action Plan.

 The aim of this project is to demonstrate the impact pharmacist involvement can have on such pathways by implementing the NICE guidance on medicines optimisation [NG5] by:

• Ensuring patients are given the correct advice on medications to be stopped prior to surgery
• Through appropriate medicines reconciliation at the pre-admission stage, ensuring patients are provided with the correct peri-operative drug advice and do not miss doses of essential medication before and after surgery
• Through pharmacist review at pre-admission stage, identify patients that are suitable for medicine optimisation to ensure patients are in the best possible state for surgery
• Reduce post-operative complications by daily pharmacist review of patients on enhanced recovery pathways

The aims of this project are in line with the trust strategic aim and key priorities to deliver personalised and responsive care in partnership with patients.

Enhanced recovery (ER) pathways were first introduced within colorectal surgery at the Central Manchester University Hospitals NHS Trust in 2008. The pathway was until recently supported by a specialist dedicated ER nurse who led on the implementation of the protocols liaising with key stakeholders namely anaesthetists, surgeons and nursing leads.

Although the pathways heavily relied on medication related interventions both before and after surgery, for example, advising patients on medicines to start and stop before surgery, post-operative nausea and vomiting management and optimising analgesia control, there was no active or dedicated pharmacist involvement.

Current practice as it stands within the trust is that all elective patients attend a pre-admission clinic and are routinely seen by a member of the nursing staff. A full and detailed history is taken including any relevant past medical or surgical history, any medications the patient is taking and social history. Advice is given on which medications if any should be stopped prior to surgery, with nurses relying heavily on trust guidelines and protocols.

Patients are not reviewed by a pharmacist until the day of admission of surgery and by that time it is often too late to make any significant changes to peri-operative drug management or highlight any medicines optimisation issues. Furthermore, a pharmacist may not be able to see all patients on the morning of their planned surgery (see Figure 1 in supporting material).

Only colorectal patients were included in this study. Baseline data was collected on the service as it is currently delivered between 01/12/13 – 01/06/2014 and between 01/07/2015 - 01/09/2015. The baseline audit captured data on medicines reconciliation and the advice given to patients on medications if any that had to be stopped prior to surgery. All post-operative complications in the baseline group were also noted (see supporting material).

The implementation phase ran over two periods 1/8/14 – 1/12/14 and 1/6/15 – 1/2/16. In the Implementation phase, a pharmacist followed up patients in the pre-admission stage from the time they were listed for surgery. In the first instance, these patients were reviewed by a medicines management pharmacy technician and a drug history obtained. (Level 1 medicines reconciliation as per NICE guideline NG5).

These patients were then referred to a pharmacist who ascertained based on the patient’s ASA (American Society of Anaesthesiologists) grading, existing co-morbidities and drug history whether the patient needs to be contacted pre-operatively. A proforma with clearly pre-defined criteria was followed. For example a fit and healthy young patient with an ASA grade of 1 with no past medical history / not on any regular medication was not contacted.

In contrast, a patient with an ASA grade of 3 with a complex cardiac history will be followed up at this stage. Interventions at this stage included the pharmacist providing appropriate peri-operative advice to the patient over the telephone and ensuring this is followed up by a letter or email. The pharmacist would also use this opportunity to highlight any possible areas for medicines optimisation and discuss these with the relevant surgeon and anaesthetist.

Two weeks before surgery was due, these patients were contacted again via text message / telephone (service set up as part of this project) to ensure they stop their medication as intended.

The patient’s drug chart was also written up by a pharmacist prescriber prior to the patient’s admission to minimise harm to patients due to delayed and omitted doses of medicines which may occur due to inaccurate drug histories or patient’s medication not being prescribed. Post-operatively, patients were reviewed on a daily basis by a dedicated ER pharmacist with the aim of reducing post-operative complications. On discharge, medicines reconciliation was undertaken to ensure that all changes to medication are clearly documented for the patient and GP. Patients were fully engaged and involved in decisions regarding any medication changes in the intervention group (see Figure 2 in supporting material).

Some of the key challenges encountered during this project include:

1. Identifying patients in the pre admission stage once they were listed for surgery. This required engaging the admission coordinators and consultant secretaries who had their own workload to deal with
2. Due to lack of funding and trained staff, a medicines management technician was not always able to help with the medicines reconciliation in the pre-admission stage. This put extra workload and time pressure on the pharmacist
3. Engaging other key stakeholders within the trust to include the anaesthetists and the colorectal surgeons as the anaesthetists felt they were looking after the peri-operative drug issues and overlooked what a pharmacist could add to the team.

Demographic data were similar between both groups (See Table 1). Both quantitative and qualitative methods were used to analyse the data. Length of stay was analysed quantitatively using the Wilcoxon Signed Rank test for non-parametric data. Post-operative complications were analysed descriptively and qualitatively, these were assessed initially for themes and the following categories were chosen:

• Poor PONV management / incorrect / insufficient prophylaxis
• Post-operative ileus / obstruction
• Surgical site infections including wound site infections and those around the stoma (if applicable)
• Anastomotic leaks / abdominal collections / intra-abdominal abscess
• Poor post-operative pain management / extended opioid use / suboptimal dose / dose too high
• Sepsis (Urosepsis / HAP / sepsis of unknown origin)
• Cardiovascular issues (AF, poor BP control, omission of essential medication, heart failure (medications not optimised)
• Dehydration +/- Acute kidney injury, post-operative anaemia requiring blood transfusion
• High stoma output
• Pulmonary embolism
• Post-operative anaemia requiring blood transfusion
• Poor urea and electrolyte management (in particular Mg2+ and K).

Table 1: Demographic data

Once all the data was themed into the groups above, the two-tailed Chi squared test was used to statistically analyse the data. There was a significant reduction (p < 0.001) in the median length of stay between both groups (Baseline group – 10.5 days; Intervention group - 7.5 days).

The number of readmissions within a 30 day period was also very similar between both groups, with one patient in the baseline group being admitted five times mainly due to nausea / vomiting and high stoma output. The total number of complications was less in intervention group (Baseline group – 136; Intervention group - 75) as were the number of patients that had no complications (p > 0.05).

The main reduction in post-operative complications in the intervention group was improved post-operative nausea and vomiting management as well as improved post-operative pain control, the latter of which potentially reduced the incidence of bowel ileus in this cohort.

Better pharmacological management of high output stomas was seen in the intervention group and this potentially led to a reduction in the incidence of dehydration and concomitant AKI. There were also fewer cases of sepsis (see Figure 3 in supporting material). In the baseline group, there was no documentation of the peri-operative drug advice provided in the nurse led pre-admission clinic in nearly 70% of patients. Furthermore in the baseline cohort, 12% of patients could have benefited from medicines optimisation (see Table 2). 

Table 2. Peri-operative drug advice provided to patients

Key learning points can be summarised as follows:

• Setting up a new service / introducing new ways of working in a workplace is challenging, It is important to identify who the key stakeholders are and getting them on-board early on in the project
• Hold regular meetings to keep staff updated on the progress of the project
• In the current NHS financial climate, obtaining additional funding for new services is very difficult. It is important to be able to quantify the improvements that can be made in patient care with the new service
• Patient engagement was key in the success of this project as we involved patients in their care right from start of their surgical journey from the point they were listed for surgery.

Patients were kept informed of any changes to their medication and we employed shared decision making, involving patients in decisions on changed to their medication for example, post-operative pain management.

As a dedicated pharmacist followed a patient through their surgical journey, we felt we had formed a ‘relationship’ with the patient where they were viewed us as an ‘expert’ in their medication and were more likely to take our advice for example converting patient controlled analgesia to oral opioids, reducing doses of oral opioids, taking antiemetics for post-operative nausea and vomiting as a few examples.