Diary for Enhanced Recovery After Cardiac Surgery

What is ERAS At Blackpool Teaching Hospitals NHS Foundation Trust we aim to provide high standards of care based on current recommendations and protocols.

ERAS is part of this and ensures that all members of the hospital and primary care staff work together to ensure patients:

• are kept fully informed of what is happening at all times to enable you to make informed choices;

• are as healthy and fit as possible before receiving treatment;

• receive the best possible care during their operation;

• receive the best possible care whilst recovering;

• Play an active role in your own recovery.

You will follow an ERAS programme which will provide you with daily goals to strive to achieve. Please remember that these goals are set to be worked towards, but everyone is an individual and will achieve these goals at different times.

Please do not be disheartened if you do not always meet your goals each day. This programme has input from all members of the team that will treat you and includes:

• pre-admission screening and information;

• good pain relief;

• improved sickness plan;

• early walking after surgery;

• early removal of catheters; • less drips and drains;

• smaller wounds or keyhole surgery;

• early eating and drinking;

• reduced infection rates;

• shorter and more comfortable stay in hospital;

• you feeling involved in your care.

The booklet will give you some information about the programme and how you can play an active part in your recovery.

Moderate exercise before your operation will help strengthen your muscles and build up stamina which will benefit your recovery after surgery. This will allow you to mobilise earlier and reduce your risk of breathing problems such as chest infections which are common after major surgery.

Depending upon your general fitness levels and the effects of any treatments you have already undergone, you may have a reduced ability. Try going for a walk twice a day and increasing the distance over a period of time, to aid your personal fitness levels. Walking, cycling and climbing stairs are all good ways of improving your fitness.

You should choose an activity and an intensity that is appropriate for your current level of fitness. Ideally the exercise should raise your heart rate and make you feel breathless; however you should not be so breathless that you cannot hold a conversation. Please document on the next page the exercise that you do in the week prior to your surgery.

Our aim both before and after your admission is to reduce the risk of you developing any complications such as a chest infection. As well as your increased activity level prior to surgery we would also like you to complete regular deep breathing exercises both before and after your operation. These are very important to reduce the risk of complications, we will be encouraging you to carry them out as soon as you return from the operating theatre.

To help practice your deep breathing exercises we will give you an incentive spirometer device (this is often called a spiroball). You will be given this at either your thoracic school meeting, pre operative assessment or on the ward before surgery. Using this regularly before and after your surgery will aid your recovery post surgery.

If you are given an incentive spirometer before your admission it is important to bring it in with you when you come for surgery. As well as using this device we would like you to be aware of your oral hygiene as good oral hygiene reduces the risk of lung complications after major surgery and improves your overall general health.

Therefore brush your teeth for two minutes and use an antiseptic or chlorhexidine mouthwash twice a day. Please tick these off in the diary for the week leading up to your surgery

Eating Well

Good nutrition is always important but it becomes even more vital before and after surgery. After surgery you will have wounds that will heal better if you have been eating a healthy balanced diet before surgery. Try and eat your recommended 5 portions of fruit and vegetables in the days / weeks leading up to your admission, and include some sort of protein in your meals (meat, chicken, fish, eggs, pulses). Continue to eat and drink as normal the day before surgery. After surgery we will give you supplement drinks to boost your vitamins, mineral and protein intake. These are all essential elements needed for wound healing and your post operative recovery.

Preload Drink

At the pre-admission clinic you will be given a Pre-load drink that you should take before surgery. This drink provides you with extra carbohydrates that will help prepare your body for surgery. How and when you should take this drink will be explained to you at pre-admission. This drink is an important part of your pre-operative build up and it is essential that you take it as requested.

If you are a diabetic who takes insulin you will not be given the pre-load drink. It is important that you continue to eat and drink normally the day before surgery. Please have supper before 10pm and follow the instructions given to you at pre-admission clinic.

Smoking and Alcohol

If you smoke or drink please use this as an opportunity to stop or cut down as smoking increases your risk of developing complications. Cutting back or stopping completely will help speed up the healing process, your recovery and reduces the risk of complications, increasing your stay in hospital. For smoking cessation advice or drop in clinic times please call Stop Smoking Services on: Blackpool – 01253 951570 North Lancashire – 01524 845145 You must also limit the amount of alcohol you drink. Do not exceed national recommendations which are currently 14 units per week for both men and women. If you require support with reducing your alcohol consumption please contact your GP or ask the nurses to Contact the hospital Alcohol Liason Team (ALT) – 01253 953943.

Planning Your Discharge

We will talk to you about your discharge before you come into hospital. Most people want to leave hospital as soon as possible and in order to make your discharge a smooth process we start to plan for this before you are admitted. It is helpful for you to talk to your relatives, carers or friends about what help and support you will need following your discharge home.

If you live alone it is essential that you consider what help you may need when you go home. It is unlikely that you will be able to do many everyday jobs such as lift shopping bags, push hoovers or mop floors when you first go home. You may need a relative to stay with you for a short while after your operation, or carers to come in and help you.

Please tell us as early as possible if you have concerns about managing at home after your discharge from hospital. We can discuss support and the other options available to you and begin to organise your discharge. Your estimated length of stay will vary according to your pre-operative fitness. This will be discussed with you prior to your admission.

Wherever possible we aim to perform surgical techniques with smaller wounds or keyhole surgery and aim to remove tubes, drains and drips as soon as it is safe to do so. This helps reduce the risk of infection and helps you to mobilise more freely and easily.

Good effective pain control is an essential part of your recovery. If your pain is well controlled you will be able to breathe easily, walk about, eat, drink, sleep well and participate effectively in your Physiotherapy regime.

After your surgery you may be given a number of different pain relieving therapies but these will be discussed with you in detail before your surgery. It is essential that you let us know if your pain relief is not effective or starts to be less effective than it was.

Staff will encourage you to play an active role by regularly asking you to record your score for both pain and nausea (how sick you feel). Additional painkillers are available and the specialist pain team can see you if needed to help make you more comfortable.

Regular deep breathing exercises after your operation, carried out as soon as you return from the operating theatre, will reduce the risk of developing a chest infection. Performing leg and ankle movements every hour can reduce your chances of developing a blood clot (DVT). Early mobilisation, getting out of bed and walking around is a very important part of your recovery.

Following many operations you will get out of bed on the day of your operation and be encouraged to stay out of bed for at least two hours. You will be seen by a Physiotherapist the day after your operation. All patients, if clinically fit, will get out of bed the day after surgery and aim to be out of bed for at least eight hours. Short rests on the bed through out the day are allowed.

Early mobility will be encouraged by the staff and Physiotherapists and you will be encouraged to mobilise or walk around the ward aiming for 4-6 times a day starting on the day after your surgery

Most of our patients are encouraged to eat and drink normally and as soon as they want after their operation. The nutrition helps your body to recover more quickly. Sometimes surgery and medication can make you feel nauseated (sick), please let us know if you feel sick as we can give you medication to settle this feeling.

Staff will encourage you to play an active role by regularly asking you to record your score for nausea, in order for us to be able to treat your nausea with antisickness medication. When you are allowed to drink we want you to aim for 2 litres of oral fluid a day.

We will also supplement your diet with high protein and calorie drinks for a few days after surgery.

It is important you mobilise as much as possible. Before your ‘drips’ and ‘drains’ are removed you will be able to carry them around with you. Mobilisation is the key to your recovery. In order to mobilise you will need adequate pain relief, the doctors and nurses are keen to help you manage your pain.

On the booklet is a list of goals / targets you should be able to achieve prior to discharge, we acknowledge that every patient is an individual and everyone will achieve these goals at their own pace, so please document the post operative day on which the goal was achieved, for your own reference and to keep you motivated with the Enhanced Recovery Programme.

Prior to coming into hospital please have a look at the next section of your booklet. This is your ‘Daily Progress Record.’ Please familiarise yourself with this before your admission.

Please remember to bring your booklet with you on your admission day so you can complete your daily progress record.

Why we would like you to fill in a Daily Progress Record

We ask all our Enhanced Recovery patients to complete a patient diary. Using the diary will help you:

• achieve your goals and track your progress

• help you recover more quickly, with fewer complications

• help staff in helping you to recover

How to Use the Daily Progress Record

The diary covers all types of surgery and therefore covers 6 days. Once you are ready to go home there is no need to continue the diary. The nursing staff will explain the purpose of the diary to you but if you need further help with completing it please ask.

Please cross the box each time you do the task mentioned. For example, if you sat out in the chair twice. If you didn't, then put the reason why.

At the end of each day you are asked to mark on the line your overall pain score in the last 24 hours. The smiley face is no pain and the sad face is the worst pain.

Your Wound

It is not unusual for the wound to be uncomfortable for the first 2 weeks. Please let us or your GP know if your wound becomes progressively inflamed (very red), painful or swollen, or starts to discharge fluid or begins to open.

Blood Clots

Surgery increases the risk of blood clots, which is why it is important to maintain your mobility after surgery. You will need urgent medical attention if your calf becomes progressively painful or swollen or if you develop shortness of breath.

Sexual activity

Resume sexual intercourse once you feel confident to do so. If you remain relaxed and possibly adopt a more passive role, you may return more easily to your normal routine.

Bowels

Make sure you eat regularly and drink plenty of fluids. It is important to remain mobile. If you are loose or constipated for more than 4 days please contact us or your GP for advice.

Exercise

You should take regular gentle exercise several times a day. Gradually increase your exercise during the 4 weeks following your operation until you are back to your normal level of activity. Do not attempt to lift anything heavy for 6-8 weeks after surgery. Common sense will guide your exercise and rehabilitation.

Driving

There is no exact specified time or law that determines when it is safe to drive after surgery. Do not drive until you are confident you can drive safely and perform an emergency stop. This is usually at least 6 weeks after surgery. If you are still taking strong pain killers, which is unlikely, they will affect your ability to drive. It is recommended that you check with your car insurance company before you start driving again.

Follow-up

You will receive a follow-up appointment via the post. The date will depend on your surgeon and the type of surgery you have had. The ward staff and surgical team will be able to advise you when it is likely to happen.