Kidney transplant patients from the North East and Cumbria are benefiting from much reduced length of stay following their surgery thanks to a new patient centred approach.
Enhanced recovery after surgery or ERAS is designed to help patients to recover more quickly from their operation and help them to play an active role in their own surgical pathway.
The multimodal approach relies on close patient and clinical staff engagement. It has been shown to not only reduce length of stay and risks of post-operative complications and side effects, but it also increased levels of patient satisfaction with staff reporting a noticeable increase in patient autonomy and engagement as they are directly involved in their care throughout their surgical journey.
For Newcastle’s kidney transplant team the results couldn’t be better and their hard work has seen them win not one but two awards.
Since the new initiative began in September 2021, more than 110 patients have followed the ERAS programme. Post operative stay in hospital has been slashed by 50% down to just 6 days, and there has been a similar reduction in the use of painkillers and a significant decrease in post-operative nausea and vomiting of around 39%.
Watch this video where members of Newcastle’s kidney transplant team explain how their award winning Enhanced Recovery after Surgery (ERAS) programme came about.
Introducing ERAS in transplantation
Lead nurse for enhanced recovery in transplantation Carrie Scuffell explains why and how they introduced the new approach at Newcastle’s Freeman Hospital:
“Our kidney transplant recipient patients were staying in hospital for an average of 12 days following their surgery compared to the national average of 8 days. As a recognised leader in transplantation we were keen to understand why and to reduce our post-operative length of stay in line with the national average. We also wanted to empower our patients and better prepare them for their transplant journey.”
ERAS is well established in many surgical specialties worldwide, but is a relatively new concept in transplantation. The kidney transplant team felt that the principles of this patient-centred approach could easily be adapted to suit the needs of kidney transplant recipients.
“We created a multi-disciplinary team comprised of transplant surgeons, doctors, anaesthetists and a nurse to develop a bespoke plan for our patients. To ensure the programme was truly patient centred, we would need to work with patients and we approached a local patient group, the Tyneside Kidney Patients Association. This would all require constant, closely managed oversight and coordination.”
Charitable funding
The team approached Kidney Care UK who generously funded over £100k to funds the roles of a specialist ERAS nurse and two physiotherapy assistants to oversee the creation of the programme from start to finish for a period of one year. Carrie took up the role of lead nurse and kick started the initiative.
“We began by gathering evidence of previous experience of ERAS in particular relating to kidney transplant, and also carried out an audit to help us identify areas contributing to prolonged stay in hospital,” explains Carrie.
“This was followed by a national survey involving all 23 UK transplant centres which has since been published nationally in the Annuals of the Royal College of Surgeons of England.
“As well as our working group we engaged as many colleagues involved in our kidney recipient transplant patients’ journey as possible which we felt was important to seek knowledge, ideas and feedback to help shape the future direction and encourage change in culture and practice.”
In May 2022 Newcastle Hospitals Charity agreed a grant of £107,019 to enable the team to build on the success of their Kidney Care UK-funded pilot.
The grant covers the 12-month salary costs of an ERAS Specialist Nurse in Renal Transplantation and an ERAS Physiotherapy Technical Instructor in Renal Transplantation.
Jon Goodwin, Head of Grant Programmes at NHC said: “Enhancing care for patients and supporting innovation across the Trust are two of our grant-making priorities, and we were delighted to support the team to develop their programme further and provide uninterrupted support to patients.”
Healthcare at its best with people at our heart
It soon became clear that regular communication with every member of the enhanced recovery group as well as the wider multi disciplinary team engendered a fully engaged, positive collaborative effort.
This led to the collective design and creation of staff education and documentation such as flow charts to help staff remember to check daily targets and monitor the patients’ progress through data collection and patient feedback.
Furthermore, to ensure the programme was truly patient centred, there was regular consultation with patient representatives from the local Tyneside Kidney Patients Association (TKPA). This gave invaluable insight from the patient perspective and guided the development of the patient journal which every kidney recipient now receives.
“The results so far have been very positive,” says Carrie, “and we have received great feedback from patients, staff and the wider transplant community.”
This is very much evident in testimonials from the patients themselves:
“The communication was great. I was self-medicating with supervision, they checked my medications, observations, and urine output. I felt like part of the team.”
“The ERAS process is by far the best advance in hospital care I have seen. It is patient focused, and as a patient, it gave me back some control over my mind and my body.”
Multi-professional approach
Aimen Amer is the lead renal transplant surgeon for the programme and member of the core ERAS team. A key focus of his role was to oversee the changes to surgical aspects of the programme such as during the operation with new techniques for pain control and fewer drain tubes, and earlier removal of lines and tubes in the days after the operation.
“It has been great to see everyone’s hard work come together to the benefit of our patients,” says Aimen. “The results so far have been very positive with patients recovering from their operation much more quickly and both staff and patients have given us very positive feedback.”
Frankie Dowen is a consultant nephrologist who was also a member of the core ERAS team. “My area of focus has been around the medical care and information for our patients having a kidney transplant. We have seen very promising results with lots of positive feedback from both colleagues and patients.”
Two physiotherapy technical instructors worked closely with Carrie and the team to deliver the mobility aspect of ERAS seven days a week.
Their input before and after the patient’s surgery so that they always understand what to expect, and what was expected of them from start to finish, empowered them, helping them to recover more quickly after their operation.
“Watching it all start with ideas and discussion and transform into a successful programme, with clear benefits to patients, has been an extremely rewarding process,” says Carrie. “I feel very privileged to have been part of it.”
Stages of ERAS
There are three main stages to Newcastle’s Kidney Transplant ERAS programme:
Stage 1 – Before surgery
The team help patients prepare for their transplant through regular communication, talking through the principles of enhanced recovery and what they can expect whilst in hospital.
They are also introduced to the patient journal which is designed to support patients during their hospital stay and provide daily information and targets to try to meet, with a section for them to record progress.
A digital version of the journal is under development in partnership with Patients Know Best (PKB) with the hope of adding valuable patient resources.
Stage 2 – just before the transplant and the immediate recovery period
A combination of elements of patient care around the time of the transplant operation is used to structure the recovery period.
This includes changes to pain relief and management of fluids, fewer tubes and lines where possible, and a personalised physiotherapy-led mobility programme.
Daily targets for both the patient and the transplant team provide a framework to help patients recover more quickly. Patients are encouraged to be involved in their recovery and use their journals to record their progress.
Stage 3 – discharge from hospital
Help patients go home sooner if they are ready with continued support at home.
The future of ERAS in transplantation
The outcome of the year long programme has demonstrably shown huge benefits and the initiative won an award from the Trust’s Clinical Audit and Guidelines Group, highlighting it as an excellent example of delivering Quality Improvement.
“I was delighted to receive The Q Factor award on behalf of the ERAS team”, says Carrie. “Then we won the Trust’s Celebrating Excellence Award for the Quality and Patient Safety category.
“It’s fantastic to see everyone’s hard work being recognised and appreciated. We hope that our programme will offer inspiration and ideas to others wanting to develop quality improvement projects, benefitting more patients in other departments in the future.”
Carrie adds: “We are now working on how to help patients to stay well or even improve their fitness while they are on the transplant waiting list, and we are also creating an electronic version of the journal. Patients will be able to access this by the app or website Patients Know Best, which will provide access to blood results and useful patient information.”
Following the success of the kidney recipient programme, the team is now developing an ERAS programme for liver transplant recipients.
Watch this space!
