The Gynaecological Oncology Group is the first gynaecological cancer unit in Australia to introduce a Fast Track Surgical (FTS) Program with Advanced Practice Nurse Supported Discharge (CNC Level 2).
What is a Fast track Surgery?
Fast track surgery combines various techniques used in the care of patients undergoing elective procedures. The methods include regional anesthesia, optimal pain control and aggressive postoperative rehabilitation including early oral nutrition and ambulation. The combination of these approaches reduces the stress response and organ dysfunction and therefore greatly shorten the time required for full recovery.
Preoperative education by our Clinical Nurse Consultant is an important step in the process. Such education has been shown to decrease the need for pain relief, can include instruction on relaxation, reduces anxiety and improves outcomes.
The program commences with preoperative counseling of the patient, optimizing medical care of those with diabetes, cardiovascular or other comorbidities. Patients are counseled by both admitting surgeon and nurse (in our case a dedicated Clinical Nurse Consultant or Nurse Practitioner). Issues discussed include the rationale and sequence of the program, informing the patient of their anticipated LOS and the criteria for discharge. Discharge planning is commenced including knowledge of support personel on discharge. That narcotic analgesia would be limited and adequate analgesia provided by a combination of intraoperative paracoxib sodium 40mg IV, Gabepentin 600mg PO and transverse abdominis plane (TAP) block with Naropin (Ropivicaine) 20ml of 1% solution containing 200mg, diluted to 40ml. Mechanical bowel preparations are not routine, fluid balance optimized to retain as close to normal intravascular volume and that unnecessary tissue trauma is avoided by good surgical technique. Strict attention to haemostasis is important and drains are avoided. Postoperatively meloxicam 15mg is prescribed for 3 days with regular paracetamol 1000mg every 6 hours. Oral liquids are allowed on the night of surgery and light diet on post op day 1 with rapid progression thereafter. Movicol one sachet in 125mL water, one to three times daily or Coloxyl with Senna one to two tabs at night is commenced routinely on post op day 1 and continued post discharge. All patients receive perioperative enoxaparin sodium 20-40mg SCI which is continued until discharge. Selected high risk patients are offered extended enoxaparin sodium prophylaxis. Intraoperatively mechanical sequential compression devices are employed and all patients have knee high TED stockings fitted and worn postoperatively for at least 1 month. In addition all patients receive intravenous ceftriaxone 1g prior to surgery unless allergic to penicillin or cephalosporins, in which case clindamycin (dose) is usually prescribed. Patients are mobilized on day 1 post surgery and catheters and IV fluids are removed on day 1 if the patient is haemodynamically stable. Patients are given an incentive spirometer or Triflow and encouraged to use the device 6 times per hour. Criteria for discharge include the patient adequately mobilizing without assistance, tolerating early oral feeding, managing their pain and discomfort with oral analgesia and having adequate home supervision. Post discharge patients receive a follow up phone call from our CNC day 2 post discharge and attend the Nurse Led Follow Up Clinic 1 week post discharge. They are reviewed by the Attending Medical Officer 2 weeks post discharge.
Overall and Sub-Set 5-Year Analysis of Laparotomies Managed by FTS 2008-2012
1. Carter J, Szabo R, Sim, W, Pather S, Dalrymple C, Philp S, Patel P, Nattress K, Cotterell S. Fast track surgery: a clinical Audit. Aust NZJ Obstet Gynecol 2010; 50:159-163
2. Carter J, Philp S, Arora V. Fast track gynaecologic surgery in the overweight and obese patient. Int J Clinical Med 2010;1(2):64-69
3. Carter J, Philp S. Assessing outcomes after fast track surgical management of corpus cancer. OJOG 2011;1:139-143.
4. Carter J, Philp S, Arora V. Early discharge after major gynaecological surgery: advantages of fast track surgery. OJOG 2011; 1:1-5..
5. Carter J, Philip S. Development and extended experience with a fast track surgery program in a gynaecological oncology service. Open Women’s Health Journal 2011;5:7-10.
6. Carter J. Fast track surgery in gynaecology and gynaecologic oncology: a review of a rolling clinical audit. ISRN Surgery 2012; 2012(7150):1-19
1. Carter J, Philp S, Arora V. Extended experience with an enhanced surgical recovery program. Poster Presentation. 13th Biennial Meeting of the International Gynecologic Cancer Society. Prague, Czech Republic, European Union. 23-26 October 2010
1. Carter J, Philp S, Arora V, Smirnova S, Patel P, Nattress K, Pather S, Dalrymple C, Cotterell S. Discharge on Postop Day 2 after Major Gynaecological Surgery. Is it Possible? Oral Presentation 25th Annual Scientific Meeting Australian Society of Gynaecological Oncologists. Bunker Bay Western Australia 23-28th March 2010
2. Carter J, Philp S. Am I doing what I think I am doing? A clinical audit assessing outcomes after fast track surgical management of corpus cancer. Australian Society of Gynaecologic Oncologists 26th Annual Scientific Meeting. Millbrook Queenstown New Zealand. 6th to 9th July 2011
3. Rao A, Pather S, Philp S, Carter J. A case controlled study comparing total laparoscopic hysterectomy and fast track open hysterectomy in a gynaecological oncology unit. Australian Society of Gynaecologic Oncologists 26th Annual Scientific Meeting. Millbrook Queenstown New Zealand. 6th to 9th July 2011
4. Carter J, Philp S. Program development and extended experience with a fast track surgery program. Australian Society of Gynaecologic Oncologists 26th Annual Scientific Meeting. Millbrook Queenstown New Zealand. 6th to 9th July 2011
5. Philp S, Carter J, Pather S, White K Fast track surgery and nurse-led follow up in gynaecological oncology: A new model of care, Oral Presentation, Cancer Nurse’s Society of Australia 14th Winter Congress, Sydney, Australia, July 2011
1. Professor Carter and Shannon Philp on behalf of the Group were finalists in the Premier’s Public Sector Innovation Awards in the category of Excellence in Delivery for their submission on Fast Track and Enhanced Recovery after Surgery for Gynaecological Cancer. 7th November 2011
2. Professor Carter, on behalf of the Sydney Gynaecological Oncology Group receives First Place Award in the Sydney Local Health District 2011 Quality Awards in the category “Improving access to timely quality healthcare: Fast track surgery: better outcomes for patients”. Presented by Chairman of SLHD Board Mr Ron Phillips, 6th December 2011
3. Professor Carter on behalf of the Sydney Gynaecological Oncology Group receives the “The Sydney Local Health District Board Award for Innovation in Healthcare in our Hospitals and Services”. Program of Fast Track and Enhanced Recovery after surgery for women with gynaecological cancer. Presented by Minister for Health and Medical Research, The Hon Jillian Skinner, 6th December 2011.