Implementing oesphageal Doppler in Enhanced Recovery

Oesophageal Doppler:

Enhancing Recovery from

Major Surgery

Daniel Conway

Consultant Anaesthetist

Manchester Royal Infirmary

Oesophageal Doppler.

A Great British Invention

Conflict of Interest: Dr Conway &

NTAC have not received funding

or financial interests in Deltex

Medical

Oesophageal Doppler Monitoring

a. Reduces Complications and Length of

Stay for major surgery

b. Should be available in all hospitals

that perform major surgery

c. Technology Adoption is achievable

and cost-effective

Implementation Failure?

• Anaesthetists, Surgeons and the

evidence-base all support its use

• Implementation across NW region is

haphazard at best

• We now have an opportunity to

implement as part of enhanced

recovery with SHA support

Optimisation with ODM

200ml 200ml

stroke volume

filling

Optimisation Studies

Conway, Mayall, Latif, Gilligan, Tackaberry Anaesthesia 2002

Optimisation Studies Noblett, Snowden Br J Surg 2006

• 108 colorectal

surgical patients

• Fluid Challenge SV

optimisation

• Hospital LOS 7 v 9

days p<0.005

• Diet 2 v 4 days

• ↓ Crit Care Admits

Implementation Failure? Why

Scepticism: RCT

vs the real world

Changing practice

1. Needs training

2. Implies current

care may be

sub-optimal

Fail at the first ,

second etc hurdle

Alternate

Hypotheses eg

fluid restriction

Who pays – who

benefits?

Competing priorities

for resources

Leadership Failure

Capital and

Consumable Costs

Can anaesthetists

alter surgeons

outcomes !!!!

Implementation Project

To successfully introduce oesophageal

Doppler guided fluid Rx for major

surgical patients in 3 NHS Hospitals

Derby, Whittington & MRI

Oct 2008- Oct 2009

Successful Adoption

• Engage Management

• Engage Clinicians

• Control Initial Roll-out

• Demonstrate Effective Implementation

• Develop of an adoption plan to share

across the NHS

– How to Why To Guide

Project Team at MRI

• 12 Anaesthetic Champions

• Surgeons

• Audit Facilitator

• Project Manager at NTAC

Support of Middle Management

Support from MD and Chair of Trust

The Challenge

Silo Budgeting

Engaging Management:

The Business Case

• Overcoming Divisional silos to recognise benefit for the organisation

• Address Fears

– What if ODM sits on shelf

– What if we use loads of probes

• Controlled Implementation

• Costs and benefits balance

• Get a manager to co-author document

Engaging Clinicians

• How will it improve patient care ?

– Critically appraise studies

– PROMs in the real world

• Limited Implementation

– Champion approach?

– Stick with narrow evidence base

• Survey Training Needs

Evidence & Guidelines

Centre for Evidence Based

Procurement (PASA)

in patients undergoing high risk surgery

use of ODM guided fluid administration

(sic) is likely to result in fewer deaths,

complications and a shorter LOS

costs seem likely to be compensated for

by reductions in LOS

Progress since 2008

Progress Nov 09

• 4 monitors purchased Oct 08

• 32 probes per month

• Staff training completed

• 200 Doppler patients and 200 pre-

implementation controls

– Length of Stay

– Complications

Before and After

Similar Patients

36

37

34

36

32

33

34

35

36

37

38

Intervention Control

Mean POSSUM score

Median POSSUM score

4 Day ↓ Post-op LOS

15

24

11

15

0

5

10

15

20

25

30

Intervention Control

Mean LOS

Median LOS

20% ↓ in CVC insertion rates

58%

72%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Intervention Control

25% ↓ in re-admission rate

12%

16%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Intervention Control

43% ↓ in Re-operation Rate

8%

14%

0%

2%

4%

6%

8%

10%

12%

14%

16%

Intervention Control

↓Critical Care Use

17%

25%

42%

53%

0%

10%

20%

30%

40%

50%

60%

Intervention Control

ITU

HDU

• Support Implementation ODM in 10 NW

Trusts 2009-2010

• Demonstrate LOS reductions

• Develop core metrics for major surgery

• Springboard for establishing ERS

– Colorectal --- Upper GI

– Orthopaedic --- Urology

– Vascular --- Gynaecology

Enhancing Peri-Operative

Pathways

• Evidence Base is starting point

• Need to Create Culture of Innovation

–Clinicians work with management

–New technology and working practice

– Improvements for patients are

demonstrated

–Experiences shared

Any Questions?

Step Change

We Can

Believe In