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"There’s a real team spirit and a feeling that we are doing things quite well."

Cheryl Messer

There are two major areas where we have a role to play.  The first of those is in delivering the objectives of the programme and the other is in communication.  To go into those in more depth: Delivering the objectives of the programme would be greater patient and carer involvement, a better patient experience, and better team-working and job satisfaction, and of course an earlier discharge from hospital.  And then as far as communication is concerned, important for me to communicate with my anaesthetic colleagues and also to communicate their views back to the Rapid Recovery team and to work with all the disciplines within the Rapid Recovery team. 

Before I was involved with the Rapid Recovery Programme, most of my anaesthetics would have been under general anaesthetic, but since the inception of the programme the vast majority are done under regional technique.

Regional technique would be either a spinal anaesthetic or a combined spinal with epidural, but with the patient sedated, having a nice infusion of Propofol, so that they don’t hear any of the surgery going on because most of my patients do not want to hear the surgery going on.

Previously it was quite difficult to make regional technique attractive to a patient, they’d much prefer not to know anything about the surgery so with the Propofol infusion they don’t need to be aware of any of the surgical procedure.

As part of the Rapid Recovery Programme, having the Joint Replacement School has been the time when I can explain to them in more detail.  Myself or one of my anaesthetic colleagues gives a ten minute talk to them about the different techniques of anaesthesia and that’s the time when we’ve got a chance to explain to them that a regional technique is possible, in fact probably very good for them, and that they can be asleep even though they’re having a regional technique.

The final say would normally be with the patient, there may be times when a general anaesthetic would be a high risk to them for various reasons, and in that case, from a clinical perspective it would be better to do a regional technique, but in the end the patient will have the say as to what happens to them - obviously we’re not going to force anybody to have a regional technique that shouldn’t.

There are many benefits, both clinically, such as probably there is a reduction in the incidence of blood clots occurring, DVTs and pulmonary embolism, there’s suggested that there is less bleeding during the operation, the patient themselves would hopefully feel less dizzy or less sick after the operation, after the anaesthetic, and they usually are very awake at the end and wanting their first cup of tea, and I think if we want to get them up and mobilised, getting them eating and drinking as soon as possible is important.

For the patients I do think that because they know exactly what to expect when they come into hospital that they are much more calm and confident as they come in on the day of surgery they are less anxious they are ready to comply with the various things that they have to do for their time in hospital. So I would say that much better patient experience and from my point of view more satisfied patients mean that I have much more job satisfaction and I enjoy the team working across the disciplines that we work with in rapid recovery.  There’s a real team spirit and a feeling that we are doing things quite well. we’ve still got a lot to develop but we have seen an improvement in the patient experience and also that patients getting out of hospital quicker so we’re really seeing positive results

The major benefit that Rapid Recovery brings, or that they should be aiming for, is better communication across the disciplines, and I think that’s where you can really make progress if you try, and that’s the starting point for making any change because change is difficult to bring about.

Before the Rapid Recovery Programme started, about seventy percent of anaesthetics were under general anaesthetic, now we have only about thirty percent are done under general anaesthetic, so many more are done under regional technique.  That’s been the main change in anaesthesia.

In terms of pain management we’ve seen the setting up of a standardised pain protocol for post-operative pain management, so that’s been quite a step forward, trying to get a standardised regime for all the patients.

The Rapid Recovery Programme is trying to get people mobilised as soon as possible after surgery, obviously if they’re groggy from a general anaesthetic they can’t mobilise, but also if they’re in a lot of pain they can’t mobilise, and so it is absolutely essential that we get good pain relief in order that they can get out of bed and get moving as soon as possible.

I think that’s a great benefit of the Joint Replacement School in that the patients get to hear that actually this isn’t a pain free procedure, they are having a major joint replaced, it is going to be a little bit painful at least.  But we do reassure them, our pain nurse specialist reassures them that we will aim to keep there pain below a score of 4 on a scale of 0- 10, or that would be mild to moderate pain, but we definitely don’t tell them that there’s no pain. So I think that’s been important to let our patients have the expectation that this pain is normal to some extent, but it’s manageable pain, and it’s not pain that’s going to stop them mobilising.

They’re really important to the programme because we do work with a lot of the disciplines, we liaise with the acute pain team, we work with the surgeons in theatre, we meet the physios and OTs on the ward, so I think we’ve got an important role in communication among the team, and obviously if we want to evolve anaesthesia and pain management then its all about discussing these things with colleagues, and that’s the way to move forward.  You can’t do anything on your own as an island, you’ve got to go out there and communicate. 

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