Recovery Tool V2 43 Exeter

Results • All patients were successfully entered into the ERP. • As enhanced recovery principles became embedded in the unit, LOS reduced from a mean of 14 days over the initial year of the ERP to a mean of 9.2 days. • The complication rate was 6.6% for Clavien ≥3, and 43.5% for Clavien ≤2. The 30‐day mortality rate was 1.2%. • The 30‐day readmission rate was 13.9%.

Recovery Tool V2 43 Executive Summary. Administering Overpayment Recovery Audits in the State of Texas, Fiscal 2004 - 2008 Executive Summary Introduction and Procurement Summary The Comptroller of Public Accounts is required to contract with one or more consultants to perform overpayment recovery audits at state agencies and to summarize to the.

• In the most contemporary subset of 52 patients: the median time after ORC to sit out of bed, mobilise and open bowels was day 1, 2 and 6, respectively. Introduction Radical cystectomy (RC) continues to be associated with one of the highest overall morbidity rates and protracted lengths of in‐patient stay when compared with other major urological procedures. The national Health Episodes Statistics data (HES) in the UK has highlighted significant differences in both the length of stay (LOS) and readmission rates between individual surgical units for all major pelvic procedures and this variation is being addressed through a national Enhanced Recovery Partnership Programme (UK Department of Health).

Enhanced recovery programmes (ERPs) aim to deliver a coordinated, evidence‐based package of care designed to minimise the overall physiological impact of the surgical procedure, thereby facilitating an early return to mobility and an earlier discharge from hospital care. They focus not just on the procedure but also on the whole pathway from patient referral to subsequent discharge from hospital. The patient plays an active role in their own recovery. The reduction in LOS should not be seen as the primary goal but rather it is a useful surrogate marker for the effectiveness of improved planning and consistency in the delivery of care. ERPs were first popularised in colorectal surgery by Wilmore et al. In 2001 in Denmark and, consequently, much of the evidence‐base relates to the management of colorectal disease. The evidence for their use in RC is sparse by comparison, although the published series suggest that the benefits seen in colorectal surgery can be replicated in urological surgery,.

Intuitively this should be the case, given the comparability of the surgical procedures and corresponding patient pathways. The present study describes our experience with the implementation and refinement of an ERP for RC and urinary diversion, assessing the impact on LOS, complications and readmission rates. ERP Figure details the chronological process of the Exeter ERP, which encompasses all patients undergoing ORC and urinary diversion (ileal conduit or neobladder).

Further details of the inpatient aspect of the ERP are described in Table. The ERP addresses each step of the patient pathway and the philosophy is encompassed by the phrase in the patient information booklet as ‘helping patients get better sooner’. The aim is for each patient to be familiarised with the ERP before hospital admission with pre‐optimisation of any comorbidities. A ‘preparation‐for‐surgery’ visit takes place where, in addition to addressing comorbidities, social aspects of the patient discharge from hospital can be anticipated and planned for. Patient education runs simultaneously to this and is delivered by the wider multi‐disciplinary team including the surgeon, uro‐oncology nurse specialist and preparation‐for‐surgery practitioner. Operative Detail The exenterative component of the procedure is all performed extraperitoneally using a small infra‐umbilical incision.

The peritoneal cavity is then opened to perform the urinary diversion. Haemostasis is achieved using a haemostatic energy device (LigaSure TM, Coviden, Boulder, CO, USA). Bowel anastomosis is made using a continuous monofilament hand‐sutured single seromuscular layer technique with closure of the mesenteric defect. Bilateral single J stents are placed and brought out in the stoma or neobladder. Occasionally, an absorbable haemostatic agent (Surgicel Fibrillar, Ethicon, Somerville, NJ, USA) is used in the pelvis at the end of the procedure to control oozing from the dorsal venous complex.

Evolution of the ERP ERPs are built on the principle of continuous quality improvement and the on‐going incorporation of new evidence. Consequently, the programme is characterised by constant evolution as new techniques, technologies and clinical experience become incorporated.

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