Enhanced recovery programme (ERP) for patients undergoing bowel surgery Information for patients, relatives and carers
An enhanced recovery programme (ERP) has been established at Imperial College Healthcare NHS Trust for patients undergoing bowel surgery. The programme involves a coordinated team of doctors, nurses and other healthcare professionals to provide high quality care. Research has shown that it can reduce the risk of complications after surgery and help speed recovery. This leaflet aims to increase your understanding about the key aspects of the programme, and provides information about how you can play an active part in your recovery. If there is anything you are not sure about, please contact the colorectal nursing team on 020 3312 6560. Pre-admission assessment clinic Please note that if you do not attend this appointment, your operation may be cancelled and the date offered to another patient on the waiting list. You will have an appointment in the pre-admission assessment clinic one or two weeks before your admission date. This is to ensure that you are fit enough for surgery and anaesthetic. One of the ERP staff members will take your medical history and ask you about any medications you are currently taking. Please bring these medicines with you to this appointment. You may also have a routine chest X-ray, heart tracing (ECG) and blood tests. Other tests may also be arranged, such as special investigations of the heart or lungs, depending on your previous medical history. You will meet with one of the colorectal nurse specialists who will explain what is involved in the ERP and your planned surgery, and discuss your arrangements for going home. You will also have an opportunity to ask questions and talk about any concerns you may have about your operation or your stay in hospital. You may find it p2
useful to write these down and bring the list with you to your appointment. If you have been told you will or may need a stoma (a surgicallymade opening on your abdomen from your bowel), the stoma nurse will contact you before the operation to arrange an appointment to provide you with information, support and advice. We will also give you a supply of carbohydrate-rich drinks (pre-op drinks) to take home and give you details about when to take them. These drinks have been shown to reduce thirst and hunger, and to give an improved sense of wellbeing before and after surgery. Bowel preparation Depending on the type of surgery planned, you may need medicine to clear your bowel. We will either give it to you at the pre-admission assessment appointment to be taken the day before surgery, or we will give you an enema (an injection of fluid into your back passage to clear the lower end of your bowel) on the morning of your surgery. We will discuss this with you in detail at the appointment. If a bowel preparation is required The day before the operation, you may be asked to drink a laxative medicine to help clear your bowel. If you are taking laxative medicine you should not eat any solid food after breakfast until after your operation. The pharmacy will give you an information leaflet with your laxative to guide you about your diet. The bowel preparation will give you loose stools. It is important that you drink eight to ten glasses of clear fluids (drinks without milk) to replace the fluid you are loosing. This will stop you from getting dehydrated and feeling dizzy. However, if you feel very unwell after taking your bowel preparation, please contact the colorectal nursing p3
team for advice on 020 3312 6560 or go to your local accident and emergency (A&E) department. Eating and drinking before surgery If you are not having laxative medication, we will ask you not to eat anything for six hours before operation. You can drink water, black tea, black coffee or squash drinks up to four hours before your operation. No milk drinks are allowed. You will be provided with four cartons of carbohydrate-rich drinks (pre-op drinks). You will need to take two cartons of the pre-op drinks the evening before your operation and two cartons three hours before your operation. You must finish these drinks at least two hours before surgery. If you suffer from hiatus hernia or severe heart burn, you should not have anything to drink for three hours before operation. p4
On admission to hospital You will normally be admitted to hospital on the morning of your surgery. Please remember to bring any prescription medicines you are taking. The anaesthetist will come to see you on the morning of your operation to discuss your anaesthesia and pain control. Your doctor will confirm your consent for the operation and answer any last-minute queries you may have. We will then escort you to the operating theatre, where your details will be checked by the theatre staff. Prevention of blood clots To reduce the risk of blood clots forming after surgery, you will need to wear compression stockings during your hospital stay. You will also be given a blood-thinning injection every day after your operation until you go home. In most situations this medicine will be continued after you have been discharged from hospital. The nursing staff will discuss this with you. p5
After your operation You will be monitored in the recovery department located within the theatres area. When you are fully awake you will be escorted back to the ward. If you have had traditional open surgery, you will have one large cut (incision) that goes in a straight line from below the breast bone for a variable length down to the pelvis. If you have had keyhole (laparoscopic) surgery, you will have a number of smaller cuts on the abdominal wall. Small clips are usually used to seal the wound. They are removed ten to 14 days after the operation either in an outpatient clinic or by community nurses. Some patients may also have a wound in their bottom. Stitches or clips in this wound are usually removed about three weeks after the operation, either in the outpatient clinic or by community nurses. If you have a wound in your bottom, you will need to change position regularly to ensure you keep pressure off this wound. You may use a cushion when sitting down to ease pressure. p6
Pain control It is important that your pain is controlled so that you can walk about, breathe deeply, eat and drink, and sleep well. There are currently two main types of pain relief used immediately after surgery: Epidural, which provides a continuous supply of pain relieving medication through a tube in your back. It is inserted by the anaesthetist during your operation and can run up to three days after your operation. PCA (patient-controlled analgesia), which is a morphine infusion attached as a drip in your arm delivering a dose of pain relief every time you press the button. It has a security device that prevents patients from taking too much of the medication. The anaesthetist will discuss both methods with you in detail and advise you on the best option for you. The doctors may also prescribe other types of pain relieving medicines, which work in different ways. If required, you may have these regularly. Your doctor or ERP specialist nurse will discuss this with you. p7
Deep breathing exercises These are a very important part of your recovery and help to reduce the risk of chest infection. We will encourage you to sit up in bed and start breathing exercises on your return to the ward. Simply breathe in through your nose and out through your mouth slowly, then try to cough gently. Aim to do this sequence at least five times an hour. While in bed, it is important to do some leg exercises to help prevent blood clots from forming in your legs. You can do this by pointing your feet up and down, and then circling your ankles. Sitting out of bed and walking after your operation Six hours after surgery your physiotherapist or the nursing staff will help you sit out of bed for one hour, provided you are well enough. You should try to spend at least six hours out of bed each following day with some rest on the bed as needed. You will also be encouraged to walk up and down the corridor four to six times a day after surgery until you are discharged from hospital. Being out of bed in an upright position and walking regularly will: Help improve your breathing Reduce the risk of developing a chest infection or clots in your legs Help your bowel to start working sooner p8
Feeling sick Some patients may feel sick or be sick following surgery. This is usually caused by the anaesthetic agents or drugs we use, or due to slower than usual passage of food and liquid through the bowel. Some patients have found that chewing gum helps with that. Therefore, feel free to bring some chewing gum with you to hospital. You will be given medication during surgery to help reduce sickness but if you do feel sick afterwards, please tell us so that we can give you some medication to ease this. It is important to relieve sickness so that you feel better, which will enable you to eat and drink normally to aid your recovery. A tube may need to be inserted through your nose into your stomach to relieve any vomiting. Drinking and eating after your operation A drip will be put into a vein in your arm during the surgery to make sure that you get enough fluids after you wake up. It will be removed as soon as you are able to tolerate food and drink. You will be able to start to drink and have a light snack six hours after your operation. Your diet will consist of light meals and you should gradually increase your food portions as you feel comfortable. We will encourage you to have your meals in the dining room to make you feel more at home. We will also offer you some nourishing drinks to aid your recovery. p9
Passing urine and bowel movements We will put a catheter (hollow tube) into your bladder during surgery so that we can check that your kidneys are working well and producing urine. The tube will be removed after your operation when you are able to walk or when your condition permits. Bowel motions may take longer to go back to normal and may be irregular at first. This should settle and will depend on the type of bowel surgery you have had. The ERP specialist nurse will discuss it with you in detail. Washing and dressing You will have a wash on the first day and, provided you feel well enough, you can have a shower on the following days. We will also encourage you to wear your day clothes to feel positive about your recovery. Please do not hesitate to contact us if you have any questions or concerns between 09.00 and 17.00, Monday to Friday. Please phone the colorectal services administrator on one of the following numbers: 020 3312 6560 (St Mary s Hospital), or 020 3313 0860 (Charing Cross Hospital) Outside of these hours, please contact your GP or phone NHS Direct on 0845 46 47. For ward information or queries, please contact Charles Pannett ward manager or nurse in charge on 020 3312 6118. p10
How can I make a comment about my procedure or hospital stay? We aim to provide the best possible service and staff will be happy to answer any questions you may have. However, if your experience of our services does not meet your expectations and you would like to speak to someone other than staff caring for you, please contact the patient advice and liaison service (PALS) on 020 3313 3322 or 020 3313 0088 (Charing Cross and Hammersmith hospitals), or 020 3312 7777 (St Mary s Hospital). You can also email PALS at pals@imperial.nhs.uk. The PALS team are able to listen to your concerns, suggestions or queries and are often able to help sort out problems on behalf of patients. Alternatively, you may wish to express your concerns in writing to: The chief executive Imperial College Healthcare NHS Trust Trust Headquarters The Bays, South Wharf Road London W2 1NY p11
Colorectal surgery Published: September 2011 Review date: September 2014 Reference number: SCA/077/2011 Imperial College Healthcare NHS Trust p12