Recovery Programme For Patients Undergoing An Anterior Resection

Recovery curriculum For Patients Undergoing An Anterior ResectionThe topic I consent chosen for my project is the deepen Recovery com prescribeer create ment whole toldy (ERP) for giganti fuckimouss infragoing elective colorectal mathematical consummation, and whether this aids with primeval discharge from hospital. I sh altogether converse handed-down pre and persuade private eye assessments onside the sensation wasting diseased for ERP. I entrust as puff up discuss each of the s take d bearteen modals used in spite of appearance ERP and how when it is used collaboratively back tooth aid with primaeval discharge. I pull up stakes in like manner discuss all complications that arise from ERP and traditional military operation and if in that location is either difference to the forbearing of. deep down the conclusion, I provide discuss the findings and either way of fetching additional noesis and skills.I will undertake a comprehensive search of literary special(a)vagantlytail its utilize the cinhal, pubmed data metrical units and reading literature that is functional indoors the university library. I will use quantitative research to analyse my data and incorporate this and either further learning into my conclusion.During the last four years of my training, I engender real a keen interest in colorectal mental process and this is roundthing I would like to expand on when I become a qualified moderate. I accept nourishd a lot of long-sufferings on the Enhanced Recovery Programme, notwithstanding I have never looked into this at both great length and I lossed to image if this had any(prenominal) benefit to the forbearing role or even whether it truly did mean early discharge from hospital.In the early part of the 1990s, surgery underwent a drastic commute it went from using long lasting anaesthetics to shorter betting acting ones. feature the smart anaesthetics and analgesic methods together with n ew running(a) techniques, a new surgical road was created and this square upms to have shortened the point private detective recuperation period. This mean that patients could be taken forbidden of main operating planetary houses as they didnt conductiness as overmuch convalescence time. Minor surgical cases were travel to smaller twenty-four hours diaphragm units (Apfelbaum 2002). The term for this new pathway was called spry enshrouding. Recovery times for patients on the fast cross political platform were advantageously shorter in comparison to those patients that were non. Arguments were bought up to justify the use of fast track surgery such as curve the throws take inload, abase hospital be and improve patient c ar by getting them back to their surgical turn back much(prenominal) quickly (Watkins 2001). The expansion of fast track meant that much than surgical procedures were being performed as day cases. The expansion of the fast track conc ept to colonic surgery was pioneered by Henrik Kehlet, a surgeon of the Hvidovre University hospital in Denmark. He stated that of 60 patients who underwent a colostomy on the fast track programme, 59 required a hospital stay of devil days.In 2001 Enhanced Recovery aft(prenominal)wards surgery (ERAS) group was formed, it was their business organization to look into the case mix, clinical counseling and clinical out comes of colorectal patients. What they embed was that in Denmark, the length of stay was take awayably shorter than Edinburgh, Sweden and Norway who were practicing tending that is to a greater extent traditional. The length of stay in spite of appearance Denmark was 2 days and the other(a) 4 had an average stay of amidst 7-9 days (Nygren 2005).With the experiences of Denmark in mind, ERAS group developed a new curtilage based concept that was holistic in its surface.There argon 17 key elements to the Enhanced Recovery Programme (ERP) (appendix1). The 17 e lements rout out be divided into 3 facets Preoperative, Intraoperative and Post operative. from each one one of these facets is evidence based and exclusively when they are used collaboratively in elective surgery do they produce a paradigm agitate on how we manage our patients. The concept of ERP is to append patient satisfaction and minify patient complications.A patient preparing for traditional exculpated catgut surgery used to be hustling in pre-operative assessment for a stay in hospital of roughly 14 days (Rickard et al 2004) Enhanced recovery patients are being prepared for a stay in hospital of 5 days (Elwood 2008).What ERAS did was to discover that at that place is a banquet between evidence and practice, one of the consistent findings in health benefit research was what should be through with(p) according to scientific evidence and dress hat clinical practice (Bodenheimer 1999). Improving the quality of bursting charge add-ons the amount of patients that ar e seen each year. This is be serve the right things are being done in a timely and organised fashion.PreoperativeThe effectiveness of the Enhanced Recovery Programme (ERP) depends on changing the patients outlook on their hospital stay. Encourage patients to cerebrate that a shorter stay in hospital is a viable option. surgical incision of Health (2009) states that the intensify recovery uses evidence based interventions both pre and brandmark operative.It is well established that stress levels rise when faced with the prospect of surgery but this concept has re cently been take exceptiond by Fearon K (2005a) in which he suggests that elements of the stress response target be reduced or even eliminated with the application of modern anaesthetic, analgesic and metabolic support. The ERP relies heavily on a multi professional approach involving all members equally.Tradition was that doctors gave the pre assessment training. But ascribable to time constraints on the consultants , this was often rushed receivable to the amount of other patients that conveyed to be seen and not all patients questions were answered. The introduction of nurse medical specialist pre assessment clinics upholded alleviate round of the pressure, and the atmosphere was more relaxed and the nurses arrest of the programme made it easier for patients to follow (Crenshaw, Winslow 2002).It is essential that all patients are well prepared for the operation, not just for a check on their physical condition but in like manner their psychological necessitate. Looking after the patients psychological enquires is an serious part of the enhanced recovery programme as it helps reduce the stress of surgery.Patients are counselled on the all-important(prenominal) parts of the enhanced recovery programme such as early militarisation and diet resumption. book binding for malnutrition will excessively take place at this appointment it should acknowledge cloging, height and the body m ass index should be calculated and any unintentional weight loss should be calculated use of the malnutrition oecumenic screening tool (MUST) should be used (appendix 2). It is in like manner reasonable to discuss discharge at this point. A patient being diagnosed with any distemper is hard enough to deal with but then to be told you need an operation.Obtaining consent is a vital component to the success of the programme. Gaining consent is more than signing a bit of paper (Department of health 2009). Consent must be apt(p) freely and without coercion. All the facts must be disposed over close the treatment and any trys should be discussed.The core ethical regulation according to royal col pine of nursing (2004) is respect for the individuals rights. Gaining consent is a ratified requirement.As a nurse the NMC (2008) states that, we are accoun evade for our own actions so we must ensure consent is obtained to begin with any procedure is carried out. round patients may not wish to know all the facts if this is the case the consultant in charge of the patients care should document this in the patients medical records, and all healthcare professionals should adhere to this. Patients are encouraged to bring in their own clothes so they are not sitting around in bed all day. Patients with disabilities or who may require more help are also identified at this visit.It is explained in the pre assessment what is evaluate of the patient after surgery. Clarke (2005) suggest that only forty twain per cent of day surgery patients in the UK are currently offered a pre-assessment visit, within my own personal experience a pre assessment appointment is well advised, as this gives the patient time to ask any questions and alleviate any last minute fears. This part of the ERP has not changed from the preoperative counselling for traditional surgery. The preoperative assessment is a critical component of ERP as it gives patients familiarity over their own care. One of the main principles of the enhanced recovery care is that intestine preparation is avoided as this mickle ground dehydration and electrolyte derangement particularly in the older patient (Burch, J.2009) a point that is also increase by Holte (2004a) he also goes on to state that bowel prep passel also be very stressful. The trust that I am placed only one of the consultants uses bowel preparation chemical formulaly in the form of an enema as these help prevent invest operative constipation and contamination of the surgical area by faeces and is only ever used if a stoma formation is not required. Bowel preparation is still used for traditional surgery with viva sodium phosphate being the most convenient method. However denotes were raised that by not giving bowel preparation this could cause problems invest operatively, but these fears have not surfaced (Holte et al 2004b). A young cogitation by Guenaga (2005) suggested that giving viva bowel preparation mint c ause anastomotic leaks, and may cause suffer contagious diseases and possibly death.Nil by mouth after midnight originated in 1946 when reports suggested that a higher risk of pulmonic aspiration existed among patients that had general anaesthesia that had not fasted. Reassessment of this tradition began in the 1980s where numerous studies failed to demonstrate that fasting ensured that the stomach would be exculpate (Crenshaw, Winslow 2002). Also noted was patients that had prolonged fasting would complain of headaches, dehydration, hypovalemia and hypoglycaemia. As a result, in 1999 Ameri laughingstock Society of Anaesthesiology developed guidelines that support a more liberal preoperative fasting protocol.The original belief of null by mouth (NBM) from midnight before surgery is still widely adopted for some surgical procedures and is still applied to some elective cases (Maltby 2006).Consumption of oral smooths up to 2 seconds prior to surgery is known to reduce brand op erative vomiting without any adverse effects, contrasting with patients that are starved normally prior to surgery (Khoyratty, Bhavik, Ravichandran 2010).There are several elements of the programme that are important, one element is the careful use of legatos, traditional surgery uses too much (Burch 2009). It is documented that hyperglycaemia increases diabetic complications, in a study by Nygren et al (1999) also put up that patients that werent Diabetic had the same amount of glucose within their blood work as patients with type2 diabetes.Patients on the enhanced recovery programme are inclined two clear lucre soak ups to take 800mls is taken the night before surgery, 400mls is to take with breakfast (Grover 2010) this reduces the preoperative thirst and hurt but it also reduces post operative insulin resistance, therefore patients are in a better anabolic state to benefit from post operative nutrition, The Carbohydrate drink consists of 12.6g of complex carbohydrate in the form of Maltodextrin Nygren et-al (2006). Having these carbohydrate drinks is the equivalent of having 2 roast dinners. A patient on a morning list must not eat after midnight but can have clear fluids until 3am. In contrast, consumption of an appropriate pastiche composed of water supply, minerals and carbohydrates offers some protection against surgical trauma in harm of metabolic status, cardiac function and psychosomatic status. Oral intake shortly before surgery does not increase gastric residual great deal and was not associated with any risk of aspiration.For normally nourished patients restoration of gastro intestinal (GI) function is one of the primary goals of post operative care. A recent study by Khoyratty, Bhavik, Ravichandran (2010) make up that many another(prenominal) of their patients voluntarily fasted longer than was given in the written instructions this is not advisable as this can cause post operative complications and can counteract the healing proce ss. This was also noted by others (Baril Portman 2007). Food and drink is a basic need and is needed to sustain life and aid with the healing process.A patient will routinely have a catheter inserted on the operating table and close monitor of Urine output is vital, minimum output per hour is usually 35mls if it reduces then the team should be called because understanding fluid management is vital for the ERP to work. Intravenous fluid will have been prescribed avoiding normal saline and ideally stopping after 24hours (Billyard et al 2007).Fluid eternal sleep charts are vital as 60% of a males body weight and 55% of a females body weight is made up of water and electrolytes one third of this fluid is extracellular (ECF) and two thirds intracellular (ICF). A reduction of 5% in total will result in thirst and consequently considered to be mild dehydration (Welch 2010). Inadequate fluid intake or fluid loss can also cause dehydration. Patients who have had major abdominal surgery w ill have some fluid loss. With reference to preoperative and post operative patients Intravenous fluid on traditional surgical patients were given 3.5 to 5l of intravenous fluid on the day of surgery (Tambyraja et al 2004) however recent studies have represent that providing no more fluid than is necessary to maintain fluid eternal rest (for example a patients body weight), as this reduces post operative complications and then reducing a patients stay in hospital (Brandstrup et al 2006).For more traditional surgery the patient would normally be on restricted oral intake but this is not the case with ERP so monitoring intake is vitally important.Poor urine production can get going to renal failure and electrolyte im proportionateness. Monitoring fluid balance is important because as nurses we need to care encompassing monitor a patients input and output, as measly monitoring can lead to poor outcomes.The hourly catheter bag is changed to a leg bag on day 1 after the operation t o make it easier for the patient to ring but strict fluid balance must be maintained (Burch J 2009). This should include stoma output if a patient has had a stoma. The catheter is usually removed on day 2 post operatively as long as there are no post operative complications and strict out put is still monitored. While fluid balance charts are a advanced and useful tool for monitoring fluid balance they are only as clear as the data recorded on them, other comfortably way of monitoring fluid loss or gain is to weigh a patient, as 1000mls is equivalent of 1kg any rapid weight gain can be directly related to a change in fluid status.The detrimental effects of fluid imbalance can be life threatening, therefore the importance of strict monitoring and accurate recording can not be stressed enough. Nursing module of all levels should strive to complete fluid balance charts as fully and as accurately as possible.Traditional surgery required starvation a patient the day before surgery . When a patient returned from theatre they were not allowed to eat until the Surgeon could hear normal bowel sounds and sometimes this may not happen for 4-5 days post operatively. So a patient could be starved of anything to eat and drink for as long as a week. A patient undergoing colorectal surgery may already be malnourished and the complications following surgery are greatly increased. Malnutrition can affect any tissue, muscle and organ within our bodies it can also have an affect on our psycho-social welfare (Todorovik 2003). National instal for Clinical Excellence (2006) state in their nutritional support in adults that malnutrition is usually caused by physical factors. A recent study into nil by mouth versus early feeding found that of 837 patients that met with inclusion criteria found that early feeding reduced the risk of any type of infection although the risk of vomiting was increased (Lewis, et al 2001).Patients on the programme are encouraged to drink and eat str aightaway if they feel like it. ordinarily sips of water are offered and if tolerated they are offered nutritional supplements to drink, usually one about an hour after surgery, if this is tolerated then another will be given and left for the patient to drink at leisure (Fearon 2005b), Billyard (2007) contradicts this and states the patient should drink at least 2L including three nutrition drinks on returning to the ward. formerly a patient can tolerate fluids without vomiting or olfactory sensation nauseous, they can progress on to solid foods usually something light.A concern for surgeons was post operative ileus (POI). POI is a well recognised result of any abdominal surgery and is frequently experienced by patients, Leir (2007) states that it is not a life threatening complication but is a expensive post operative complication. POI is defined as a transient impairment of intestinal relocation after abdominal surgery (Han-Geurtz et al, 2007).There are many factors that hav e shown to increase its progression such asLocal intestinal inflammationAnaesthetic AgentsOver hydrationPost operative analgesia(opiates)Reduced mobility.POI along with nausea and vomiting are the most common complication.POI can be minimised with the use of epidurals. Scoop et al (2006) stated that mid- pectoral epidural is considered the pinnacle of the enhanced recovery programme. Although it is possible to use Patient Controlled Analgesia (PCA), Morphine can increase the risk of vomiting it can also cause the bowels normal peristaltic endeavour to temporarily paralyse.Recent research in to POI and the different approaches to treatment found by giving a patient grate as a form of Sham feeding ( fashioning the body think it was eating) helped with gut motility. Schuster et al (2006) found that gum was an inexpensive and of some benefit after colostomy formation. quintuplet randomised trials of chewing gum to restore the natural gut motility found that patients who were chewing g um passed flatus 24% earlier and had bowel movement 33% earlier, which shows a significant and positive conclusion of early discharge which on average 17.6% earlier than those that did not have the chewing gum (Chan and Law 2007). POI is usually diagnosed with symptoms of nausea and vomiting along with abdominal distension, annoyance and the failure to pass flatus or faeces. Parnaby et al (2009) found although flatus and faeces were passed earlier in patients who chewed gum it did not have any bearing on early discharge or post operative complications. If tachycardia is present then other causes should be excluded. The treatment for POI is inserting a nasogastric tube (NG) although one is inserted during the intubation process during surgery it is removed as soon as the surgeon has finished operating because there is good evidence to suggest that leaving a NGT in place can cause pneumonia (Cheatham et al 1995).Once a diagnosis of POI has been made, all oral intake should discontinu e, and the patient should be removed from the programme and the traditional approach should commence. Patients are encouraged to take regular anti emetics to aid the patient with early return of oral intake the trust that I work cyclizine is the anti emetic of choice.Post operative suffer is always a concern this is why Professor Kehlet designed the ERP because he believed every patient deserved to have a aggravator free recovery. For patients to understand pain nurses need to be able to educate the patient. Biggs (2009) states that slight than 1% of university education is spent on pain and the effects of pain. It is vital that nurses have an understanding of pain physiology in order to educate our patients and in turn increase patients knowledge and reduce anxiety, increasing patient satisfaction.Regular pain assessments should be maintained at rest and on movement by a competent nurse (DH2009). It is stated by Vickers et al (2009) that pain should be classed as the Fifth Vita l sign. In postoperative patients on ERP, it is vital that nurses monitor pain because pain can reduce a patients need for all the other parts of ERP.Concerns have arisen about the use of thoracic epidurals as the analgesia of choice due to immobility and urinary retention, but if inserted high enough in a thoracic position it is possible to mobilise safely and with fewer side effects such as constipation, this means that opiates which have an adverse effect on the bowel can be avoided and again this can help oneself to an earlier discharge. 1 gram of paracetamol is given 4 times a day and is given in mating with PCA or epidural, this is also part of multimodal approach. Also, the afferent nerves are bar resulting in less stress response less gut palsy and a decreased risk of pulmonary complications (Jorgenson et al 2000).The epidural dot is reduced 48 hours after surgery, and once epidural is running at 2mls per hour then a trial without epidural should commence and pain reass essed after 1 hour if minimal or no pain then commence co codomol 30/500 every 6 hours and oral Non Steroidal Anti Inflammatory Drug (NSAID) diclofenac 50mg every 8 hours (British National Formulary, 2009) with this in mind the consultant can prescribe a mild laxative for patents as this will avoid constipation although this is not the case where stoma formation occurs. Alternatively, at the anaesthetists request oral paracetamol 1g 6 hourly may be given also diclofenac 50mgs 8 hourly and 10-20 mgs of Oxynorm every 2-4 hourly. As a nurse I am cognizant of the importance of pain management within the ERP because psychologically a patient in pain will not feel like eating, or mobilising so keeping on top of pain by using trust pain charts and ensuring that pain relief is delivered on time helps reduce anxiety. In theory, there is nothing stopping nurses from giving paracetamol or co-codamol every 4 hours during the day as making the patient comfortable will aid sleep meaning that para cetamol or co-codamol will not be needed between midnight and six in the morning, it also means that extra pain relief may not be needed thus reducing post operative complications. On saying all of this post operative pain is believed to be at its worst directly after surgery and the intensity is expected to diminish over time (Buyukilmaz et-al 2010), the humankind Health Organisation analgesic ladder (2007) is used in turnround for surgical patients. on return from surgery patients, initial observations should be taken by the trained nurse so she has a baseline to work with. All further observations should be meticulously maintained as per any hospital policy.The use of Bair huggers during surgery has reduced the incidence if hypothermia during the operation it is important to maintain a constant core temperature as it was found that all of the anaesthetics used during operations caused hypothermia also there are several non pharmacological reasons that warrant the use of Bair hu ggers for example shaving the surgical come in (Sessler and Akca 2002). transgress infection is a serious and costly complication. During colorectal surgery, the incidence of wound infections increases to 10%. Ikeda et al state that all incidences of wound infections occur during the first off two hours of any surgical procedure. The primary connection between hypothermia and surgical site infection (SSI) is vasoconstriction because of a decrease in tissue oxygenation and if a patient is immunosuppressed which most colorectal patients are this can also cause SSI. Blood loss during surgery can increase the risk of SSI due to blood transfusions during surgery. On return to the ward from recovery the nurse in charge of the patient must ensure that the wound site is checked for bleeding and check the dressing for any sign of hydrant through the nurse would expect to see some excess on the dressing but it should be regularly monitored so any problems can be found early. Port sites wh ere a patient has had laparoscopic surgery should be checked. When a stoma has been formed, the nurse should look at the site making sure it is pink/red in colour and it is warm and there is no excessive bleeding. Wound infections can delay discharge so any problems should be found early reported to the patients team and the correct antibiotics can be prescribed early and may only delay discharge by 2-3 days.Anti thrombotic prophylaxis is a must within colorectal surgery treatment is usually commenced the evening following surgery and move on a small maintenance dose of 40mg of enoxaprim (Dylan 2010) until the patient has regained full mobility. There are no further advantages in general surgery for extended use of enoxaprim but there are advantages for patients undergoing orthopaedic surgery. Associated use of low dose heparin and continuous use of epidural analgesia is open for discussion as there have been reported cases mainly in the United States of epidural haematomas (Tryba 1998). A patient undergoing stoma formation under ERP pathway can have their discharge delayed due to teaching, on how to care for the stoma. Although pre-operative teaching does occur, the reality often does not sink in until after the operation. The stoma nurse specialist will see the patient on the day after the operation. The patient returns with a clear see through bag so nursing staff can see when the stoma becomes active. Teaching begins at the bedside where the patient may only want to observe the proceedings, but all of the time the stoma nurse actively encourages the patient to take note of the proceedings. Psychologically the patient may need lots of reassurance as to them this is not natural (Rust 2007). A patient with a stoma should plan for a stay in hospital between 5 -10 days and it usually takes this long for a patient to be able to manage their stoma. To become self caring with a stoma is the patients biggest psychological battle (Bekkers et-al1996). So on my under standing of the research available stoma formation does infact delay discharge by four days depending on the patient and his/her ability to manage.Patients are not always proactive recipients of care (Ellwood 2008). Early Mobilisation is important to reduce complications such as chest infections. Chest infection rates have dropped from 4% to less than 2% this is because patients are not laying in bed for days. grapple rest not only increases insulin resistance it also decreases muscle timberland and in addition, there is an increased risk of thromboembolism. On the ward, the physiotherapist has a book which nurses can refer patients and patients should be seen on day 1 following surgery.Patients are encouraged to sit in the chair for two hours on the day of surgery to encourage deep breathing (Francis 2008). A care plan should be formulated with a specific mobilisation plan incorporated. It is essential that a patient should be nursed in an environment that encourages early mobilis ation.Anti embolic stockings are also prescribed. The stockings facilitate venous return from the lower extremities. They also provide venous thrombosis. As nurses, we should make sure the patient is lying down as this allows the veins to relax. The stockings should be removed at least once a shift, so that the nurse can inspect the patients legs and feet for any signs of redness as the skin around the heel can break down very quickly. Encourage leg exercises every hour during the day. Muscle contractions compress the veins, preventing a clot. Contractions also foster arterial blood flow.The introduction of the enhanced recovery nurse has been invaluable not only for the patients but also for staff. The role of the ERP nurse (ERPN) is thoroughgoing to the programme as she/he co-ordinates patient care from the beginning. The ERPN works freely within the colorectal team seeing patients in clinics. He/She helps the patient through their hospital admission reinforcing the goals and l iaising with hospital ward staff. ERPN works most within the surgical team, colorectal cancer team and stoma nurses.The biggest challenge for the ERPN was changing the practice of nursing staff on the wards repeated teaching sessions with all new nurses and doctors with regular feedback and all new updates to the programme (Elwood 2008). Unfortunately, within the trust I am placed the already busy colorectal cancer team initiate all of the teaching, ERP has become a with child(p) part of the daily schedule within the trust that a need for an ERP nurse is deemed necessary and funding for the post has become available.Although regular care pathways and protocols are in place, an integrated care pathway was drafted but due to increased pressure from our consultants the document was abandoned, and deemed unworkable but after reviewing the evidence it seems to be used within most other trusts that incorporate the ERP as part of their surgical planning.Nursing interventions within the E RP can influence the out come so it is important that the nurse looking after the patient has the most up to date knowledge and skills and able to detect when a patients condition deteriorates.Another useful tool is a patient journal so that the patient can keep a record of when they got up so the patient is aware of when they can get back into bed. On the first day of surgery, the Patient should aim for 2 hours and then 6 hours until discharge (Fearon et al 2005). Patients are encouraged to walk 60 meters from day one post operatively.To enable continuity of care nurses need to consider the clients needs for assistance within the family unit.Discharge planning begins even before the patient comes into hospital the process is usually started at pre admission clinic. The nurse will take a full social history this is obtained so nursing staff on the ward are aware of any social problems.Fearon et al (2005c) stated that patients are fit for discharge after the following criteria has b een metHave good pain control with oral analgesia atomic number 18 eating solid food and no Intravenous FluidsAre commutative with all ADLsAnd willing to go homeAll patients should be discharge with an information leaflet including a telephone number of the ward in case they have any problems. In some of the trusts, an enhanced recovery nurse specialist post has been created and on discharge, the ERPN will telephone the patients on the programme at home to allay any fears and to check that there are no post operative complications. a telephone helpline has been target up at one London hospital so that patients can have direct contact with someone during out of hours and they are hoping that this will reduce the amount of AE admissions. The ward I worked on would refer all patients on the ERP to the district nurse with first visit being on the day of discharge, making sure that the referral form states that the patient is currently on ERP. Patients can telephone the ward if proble ms occur within the first 24 hours. Because patients on ERP are discharged earlier, this means that potentially serious complications can occur at home for example anastomotic leaks (King et al 2006). Therefore, it is important that patients have a port of call once they are home and within the community setting. The need for support at discharge is also unlikely, compared to a patient who has traditional open surgeryReadmission rates for patients on ERP shows that from 1998-2008 334 patients of which 99 (30%) were on ERP and 235 were not (Larsson et-al 2010). The 99 on ERP tolerated soft diet approximately 2.5 days earlier than those not on ERP and were discharged at least 2 days earlier from hospital.Recent research done by 2 Doctors searching the colorectal cancer data base for the trust found ERP has reduced the length of stay by 3 to 5 with no change in mortality or readmission, the beat results came from a gynaecology ward where the nursing staff followed the ERP care pathway in its entirety.ConclusionTraditional Perioperative procedures and prac