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Enhanced Recovery after Surgery (ERAS): An Orthopaedic Perspective

Article  in  Journal of perioperative practice · October 2013

DOI: 10.1177/175045891302301004 · Source: PubMed

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Journal of
Perioperative
Practice

In this issue
Podiatry: an illustration of surgery provided by allied health professionals

Glucose-insulin infusion maintains perioperative glycaemic control

October 2013
Enhanced recovery after surgery (ERAS): an orthopaedic perspective Volume 23
Issue 10
The issues surrounding social network sites and healthcare professionals ISSN 1750-4589

October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589
Comment
210 FROM THE PRESIDENT
How does the Keogh report impact on
perioperative care? Marval highlights the key evidence
222 CLINICAL FEATURE
Sue Lord
211 GUEST EDITORIAL
Vive le (evidence-based practice)
revolution
Jed Duff
Regulars
212 OPEN FORUM
Readers’ letters and book reviews
214 VIEWPOINT
Why are perioperative practitioners
reluctant to publish?
215 NEWS
Recent nationwide developments
on the health scene and forthcoming
events
Features
228 CLINICAL FEATURE
218 CLINICAL FEATURE
Podiatry: an illustration of surgery
provided by allied health professionals
As with the prescribing of medicines,
the provision of surgery continues
to evolve and this is particularly
true in the delivery of foot surgery
which, until the 1960s, in the United
Kingdom was practiced exclusively
by medically qualified surgeons. Over
the last 40 years however podiatric
surgery performed by podiatrists
The Journal of Perioperative Practice
Managing Editor Christine Wiles
Email: chris.wiles@afpp.org.uk
Tel: 01423 882950 Fax: 01423 880997
JPP Advertising Open Box Publishing
Email: francesmurphy60@yahoo.com
Tel: 0121 353 1469
October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589
Contents
has become established as a viable,
safe and cost effective alternative to
gained considerable popularity in
orthopaedics recently, however their
traditional models of service provision widespread adoption remains to be
as described by Anthony Maher seen. This article by Jonathan White,
Robert Houghton-Clemmey and Paul
concerning ERAS in orthopaedic
A novel glucose-insulin infusion
maintains perioperative glycaemic surgery
control through multiple transitions
233 CLINICAL FEATURE
of care
The issues surrounding social network
To measure the efficacy of the
sites and healthcare professionals
Glucose-Insulin Infusion-Parkland
This article by Taraneh Azizi discusses
Protocol (GIPPr) compared to issues surrounding online social
subcutaneous (SC) insulin, blood
glucose readings were reviewed in
networking, and the implications of
the use of these sites by healthcare
diabetic adults admitted for surgical professionals. The article provides
intervention of a soft tissue or guidance to healthcare professionals,
bone infection in Dallas, Texas by as the increased use of sites like
Nora Renthal, Erin Roe, Beverley Facebook and Twitter have the
Adams-Huet, and Philip Raskin. potential to bring risks to healthcare.
Hypoglycaemia occurred in 0.69% Use of these websites can be a very
of readings in GIPPr-treated patients grey area, and boundaries need to
compared to 4.52% in SC-treated be clearly set to ensure protection of
service users and healthcare
patients. The GIPPr maintained a
staff alike
higher proportion of blood glucose
readings between 3.89-10mmol/L
compared to SC insulin (85.40%
versus 50.68%)
Enhanced recovery after surgery
(ERAS): an orthopaedic perspective
Enhanced recovery after surgery is
a programme that aims to improve
the care of elective surgical patients.
Accelerated care pathways are
delivered using a multidisciplinary
approach, leading to reduced
lengths of hospital stay, improved
quality of treatment, and better
outcomes. These programmes have
The Association for Perioperative Practice Views expressed are those of the writers and do not
Daisy Ayris House necessarily reflect the policy, opinions or beliefs of
42 Freemans Way AfPP.
Harrogate
HG3 1DH Manuscripts submitted for consideration by the Editor
must be the original work of the author and not under
General: 01423 881300 consideration by any other publication.
Membership: 01423 882944 Advertisements or other inserted material are
Events: 01423 882948 accepted subject to current terms and conditions.
Website: www.afpp.org.uk Acceptance of an advertisement does not signify
endorsement of the products or services by AfPP.
Email: hq@afpp.org.uk
JPP is published 10 times per year.
© AfPP 2013, all rights reserved.
209
FROM THE PRESIDENT
How does the Keogh
report impact on
perioperative care?
“Of the 14 trusts investigated by Sir Bruce Keogh’s team, all but Colchester, Dudley and
Blackpool are now under special measures. However, the report outlined specific failings at all
14 trusts.”
The remaining 11 trusts include:
• Basildon and Thurrock University in addressing and rectifying these failings.
Hospitals NHS Foundation Trust
• Buckinghamshire Healthcare
NHS Trust
• Burton Hospitals NHS
Foundation Trust
• East Lancashire Hospitals NHS Trust
• George Eliot Hospital NHS Trust
• Medway NHS Foundation Trust
• North Cumbria University Hospitals improved patient care. It is also important
NHS Trust
• Northern Lincolnshire and Goole poor or dangerous practice. We all know
Hospitals NHS Foundation Trust
• Sherwood Forest Hospitals NHS and confidence to speak out but we must
Foundation Trust
• Tameside Hospital NHS
Foundation Trust
• United Lincolnshire Hospitals
NHS Trust
Some of the key specific failings covered
areas such as ‘never events’, infection
control, staffing levels, treatment of
dementia/mental health patients, staff
AfPP board of TRUSTEEs
President
Sue Lord, Head of Department, Allied
Health and Medicine, Faculty of Health
& Social Care, Anglia Ruskin University
(Trustee)
VICE President
Mona Guckian Fisher, Specialist
Healthcare Consultant and Cardiac
Theatre Sister, Queen Elizabeth University
Hospital Birmingham (Trustee)
210
Charlie Cooper 16th July 2013
working long stretches without days
off, inconsistent safety checks and
maintenance of equipment, lack of
compassion, lack of patient dignity and
long waiting times for patients.
I am sure like me many of you live and
possibly work near or for one of the trusts
named above and feel mortified at the
findings from the report and wish to help
This cannot be done alone, but through
working together as a team you can make
significant changes to patient care. As
discussed by some of our speakers at
the recent summer residential weekend
(Jules Wyman, Tracy Coates and Angela
Cobbold) good leadership and teamwork
is key in ensuring patient safety and
to challenge and speak out when we see
how hard it can be to find the strength
always keep the patient at the center of
our focus.
There is constantly a challenge for us all
to economize and save money here and
there but sometimes these savings can
cost us more in the long run when there
is a never event or an infection at the end
of it. This can cost the trust thousands
of pounds in compensation and longer
ELECTED TRUSTEEs Tracey Williams, Senior Lecturer in
Ruth Collins, Staff Nurse, Hillsborough Operating Department Practice and
Private Clinic (Trustee) Nursing Studies, University of Central
Lancashire (Trustee)
Ann Conquest, Recovery Sister, Bedford
Hospital (Trustee) CHIEF EXECUTIVE
Dawn L Stott
Adrian Jones, Orthopaedic Surgical Care
Practitioner, Trauma & Orthopaedic
Department, Norfolk & Norwich University
NHS Trust (Trustee)
October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589
lengths of hospital stay as well as the
reputational cost, which many of the
above trusts are now suffering from. But
more important is the cost to the patient
and their relatives in the physical and
emotional trauma they have to go through.
So are you going to work together as a
team to make a difference or give up
without a fight because it seems like too
much hard work? Think to yourself “how
would I feel if that was me at the receiving
end of that neglect?”
Sue Lord
President AfPP
president@afpp.org.uk
Find AfPP on Facebook
www.facebook.com/safersurgeryuk
Reference
Cooper C 2013 Sir Bruce Keogh’s report: The 14
NHS trusts and their failings The Independent
Online 16 July Available from: www.independent.
co.uk/life-style/health-and-families/health-news/
sir-bruce-keoghs-report-the-14-nhs-trusts-and-their-
failings-8711708.html [Accessed 12 September 2012]
Professional Advisory Service
For members of AfPP needing advice on
professional and clinical issues:
Email: advice@afpp.org.uk
Telephone: 01423 881300
If you are not a member please contact
our membership helpline on
01423 882944

Vive le (evidence-based
practice) revolution
On a daily basis, perioperative practitioners are faced with questions regarding their practice,
such as; ‘is the care I’m providing effective?’ or ‘what is the best intervention for this patient?’
For the past 20 years the Cochrane Collaboration has helped us answer these questions. As a
member of the Cochrane Nursing Care Field I’ve been asked to write this editorial to celebrate
this significant milestone.
I’m sure there is no one reading this
article who is unfamiliar with the name,
Cochrane, but you may be surprised to
learn that behind the brand is an
international network of more than
31,000 dedicated volunteers from over
100 countries all working together to
prepare, update, and promote Cochrane
systematic reviews. There are now over
5,000 Cochrane systematic reviews and
they have become the first line of call for
healthcare practitioners, policy-makers,
and patients seeking rigorous information
to make well-informed healthcare
decisions.
For healthcare practitioners, like me, who
trained in more recent times, it’s
important to remember that healthcare
has undergone enormous changes in the
past 20 years. Clearly one of the most
significant changes has been the
evidence-based practice revolution. The
term evidence-based practice may only
have been coined in the early 1990s but
by the time I commenced my nursing
studies in 1995 it was already the
prevailing discourse. In fact, as a student,
I remembered finding it difficult to imagine
a time before evidence-based practice, in
the same way as I found it difficult to
imagine a time when patients could
smoke in bed. This all pervasive cultural
change certainly was revolutionary and the
Cochrane Collaboration was at its
vanguard.
Today, thanks to the work of groups like
Cochrane, evidence-based practice is
recognised by healthcare professionals,
regulatory agencies, and the wider
community as the gold standard for the
provision of safe and effective care.
Unfortunately, however, this widespread
acceptance hasn’t necessarily resulted in
uniformed improvements in practice.
There remain numerous examples of
significant gaps between research
evidence and clinical practice in many
fields. A classic example from our own
field, and one that has frequently been
October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589
guest editorial
discussed in this journal, is preoperative to make the most of this valuable
fasting practices (Bothamley & Mardell resource to improve practice and continue
2005, Khoyratty & Modi et al 2010, the revolution.
Roberts 2012). As you well know, for many
years there has been strong evidence Dr Jed Duff RN PhD
against the need for extended Clinical Research Fellow, St Vincent’s
preoperative fasting (Brady Marian & Kinn Private Hospital Sydney
et al 2010), yet despite this, we still see Chair, Australian College of Operating Room
patients routinely fasted from midnight, or Nurses (ACORN) Standards Committee
even earlier.
Phone: 61 2 8382 7449
Email: jduff@stvincents.com.au
Of course, anyone who has attempted to
improve practice knows it’s not an easy Jed is a member of the Cochrane Nursing
task. Closing the evidence-practice gap Care Field
involves the identification of rigorous
research findings and then the translation References
of these findings into routine care. The Bothamley J, & Mardell A 2005 Preoperative fasting
Cochrane Collaboration has been revisited British Journal of Perioperative Nursing
instrumental in providing us with high- 15 (9) 370
quality, timely reviews of the research
Brady Marian C, Kinn S, Stuart P, & Ness V 2010
evidence; our challenge, and where we
Preoperative fasting for adults to prevent
have been lacking to date, is the adoption perioperative complications Cochrane Database of
of this evidence into our routine practice. Systematic Reviews
What we appear to be missing is the
crucial step between knowledge Khoyratty S, Modi, B, & Ravichandran D 2010
Preoperative starvation in elective general surgery
generation and knowledge application.
Journal of Perioperative Practice 20 (3) 100
Thankfully, Cochrane provides assistance Mahar P, Wasiak J, Batty L, Fowler S, Cleland H, &
to meet this challenge, too. One of my Gruen R L 2011 Interventions for reducing wrong‐
most frequently visited Cochrane groups is site surgery Cochrane Database of Systematic
Reviews
the Effective Practice and Organisation of
Care (EPOC) Group. EPOC produce reviews Roberts S 2012 Preoperative fasting: a clinical audit
on strategies to improve healthcare Journal of Perioperative Practice 23 (1) 11-16
delivery and the healthcare system. The
reviews evaluate the effectiveness of
various change strategies (audit and
feedback, reminders, didactic education
etc.) on different types of practices. A
relevant example for perioperative
practitioners is their review ‘interventions
for reducing wrong‐site surgery’ (Mahar &
Wasiak et al., 2011). This is a small but
growing collection of reviews but given our
increasing need to better understand how
to translate evidence into practice, one
that I imagine will continue to expand.
For the last 20 years the Cochrane
Collaboration has done an outstanding job
at providing us with evidence on what to
change and how to change it. It is our duty
211
OPEN FORUM
Book Review
Continuing Professional
Development in Health
and Social Care: Strategies
for Lifelong Learning
2nd Edition
At a glance
Content .....................
Ease of use ................
Value for money........
• Auldeen Alsop
Wiley Blackwell Chichester UK 2013
IBN: 978-1-4443-3790-7
Paperback, 176 pages, £29.99
Also available as an e-book
212
A
book about continuing professional Chapters one and two attract no criticism
development (CPD)…should come from me per se in that they are factually
with a strap line reading ‘this book accurate and current except I am tempted
may contribute to your regulatory body to ask who they are actually written for? If
requirements’. this book is to be useful to practitioners in
This is the second edition of Auldeen
the field I suspect it needs a makeover to
an easier read. Chapter three is worth the
Alsop’s Continuing Professional
wait however and both ODPs and theatre
Development in Health and Social Care and
claims to be extensively updated. Indeed
nurses will find both this chapter and
chapter seven [Learning in the workplace]
the first edition was released in 2000 and
very useful in prepping a portfolio and
preceded HPC registration of (amongst
profile for HCPC or NMC purposes
others) Operating Department Practitioners
respectively. Chapters three, seven and
and it’s change to Health and Care
nine will be the most useful to perioperative
Professions Council (HCPC) subsequent
practitioners. Chapter nine deals with
to the inclusion of social workers to that
writing skills and this is essential reading to
register.
any practitioner thinking of applying for an
academic module or programme (preferably
As you may have noted already there
before you apply).
has been no mention of the Nursing &
Midwifery Council (NMC) and yes, there is
So, I have already stated that their book
little reference to nursing per se within the
would be of some use to perioperative
text of this book. This is hardly surprising
practitioners but is it worth £29.99?
given that Ms. Alsop is an Occupational
(£21.00 if you possess a Kindle).
Therapist and so the contents of this book
reflect the HCPC standards. This is not to
I think this is one to access via your post-
say that this publication does not apply to
graduate or university library unless you are
nursing however. The basic principles and
either an academic or a practice educator
tents underpinning CPD are all here, are
with specific responsibility for CPD. Though
current (to a degree) and are as relevant to
un-complicated in the main, this book is
nursing as they are to ODPs and the other
not an easy read and if I was to purchase a
allied professions. CPD is…CPD at the end
book on the basis of three strong chapters I
of the day.
would expect it to be more user-friendly.
The claim to be extensively updated can Bernard V. Pennington
be upheld and the reader may note that Senior Lecturer, Edge Hill University, Manchester
many of the references appear dated. I
say appear because for example, when
considering reflection; the references used
do (in my opinion) stand the test of time.
In addition the inclusion of new chapters
addressing the CPD needs of support If you would like to comment on
workers and students does give credence any issues concerning
to this claim. perioperative practitioners,
So who would want to purchase this book? email: editor@afpp.org.uk
Well, the author claims that this book
focuses on CPD in the widest possible or write to:
context. This is useful, particularly in the
current environment of austerity within The Editor
healthcare. Training and education are The Journal of Perioperative Practice
always the first things to go - right? Daisy Ayris House
However, you do have to get as far as 42 Freemans Way
chapter three [the professional portfolio] Harrogate
before you overcome the academic HG3 1DH
wordiness of chapters one and two.
October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589
VIEWPOINT
Thoughts and reflections on issues of interest to perioperative practitioners

KEYWORDS Knowledge / Dissemination / Perioperative care

Provenance and Peer review: Invited contribution; Not peer reviewed; Accepted for publication April 2013.

Why are perioperative

practitioners reluctant to publish?
As perioperative practitioners, the
professional obligation to continually
update our knowledge so the care we
provide is safe and effective is ever
present. Advancing technology, over-
stretched resources and an ever changing
perioperative environment challenge our
understanding of the perioperative setting
on a daily basis. Never has the need for
educated and informed perioperative
practitioners been required more than
now in order to help make the decisions
we need to address these challenges.
Most of you will have undertaken some
form of professional study to enhance
your knowledge, or even undertaken a
piece of research that helped obtain
new knowledge on a topic related to
perioperative care. Some of you will be
involved in work-based learning by carrying
out clinical audit to help shape the service
you provide. Alternatively, you may be
unaware of the knowledge you acquire as
you take time to reflect upon an episode
of patient care. Sharing this newfound
information not only helps inform both
practice and policy in the modern
perioperative setting, but is also an
integral part of our professional obligation
to disseminate any new knowledge that
relates to perioperative care. In order to
do this we need to make the evidence
accessible to others.
There are a number of ways this can
be achieved, including presenting at
regional and national meetings or
through the publication of a manuscript
in a healthcare journal. Oerman & Hay
(2010), however, suggest that healthcare
professionals are reluctant to publish
their work. Lack of time, fear of rejection
and the unwillingness of the perioperative
practitioner to assume the unfamiliar
role of author are common reasons for
the failure of practitioners to turn the
knowledge and evidence they acquire into
a publishable document. Uncertainty over
the submission process can also deter
would-be authors. The following steps may
help you get your own work published.
Before you start, know your target
audience. Take for example this journal,
the Journal of Perioperative Practice.
Its aim is to promote safe and effective
standards of perioperative care and it is
read by practitioners who work in varying
fields of perioperative practice. Hence
manuscripts that relate to practice in the
operating theatre, recovery, anaesthetics
and surgical wards within any specialty will
be welcomed for submission along with
those covering aspects of pre-admission,
discharge, endoscopy and support
services including decontamination.
Issues surrounding perioperative
education, management, leadership and
innovation are also encouraged. In fact,
manuscripts are welcomed on any aspect
of perioperative care written in the style of
a case study, literature review, reflective
piece, research paper or audit.
Alternatively, perhaps you have an original
viewpoint on a particular issue? Choosing
a topical subject or an issue that has
had little exposure is more likely to be
published so read through back copies of
the journal; has your topic been explored
before? Do your findings bring something
new to the perioperative arena?
Before submission, structure your
manuscript by using headings and sub-
headings such as introduction, main
themes and, if applicable, your findings.
Don’t forget to include a succinct
conclusion that summarises your work.
Take time to read through the text – it
must have correct grammar usage if it
is to be reliable and noteworthy. Ask a
trusted colleague to read through it too.
Have you covered pertinent and up-to-
date issues that relate to your topic? Are
references recent or of historical value?
To ensure that your work is written in the
correct format for submission, follow the
editorial guidelines printed at the end of
this journal - this will ultimately save you
time in preparing your manuscript.
After submission, prepare for additional
work. Each manuscript is reviewed by
the editor and, if suitable, is double-blind
peer-reviewed by members of the review
panel who are experts in their own field
of perioperative practice. Your manuscript
may require a few additional changes
or necessitate a rewrite. Either way,
reviewers will offer constructive advice on
how this can be achieved.
Rejection is often disappointing and
can deter authors from resubmitting but
even successful authors have had work
rejected at some point in their career. So
don’t let this discourage you. Turning an
academic essay or the evidence obtained
from clinical work into a manuscript that
is suitable for submission has a learning
curve all of its own but it is extremely
satisfying when you see your article in
print. More importantly the information you
have may help fill a gap in knowledge and
influence the future of perioperative care.
Whatever your role, as a perioperative
practitioner you have a professional
duty to pass on your knowledge to other
perioperative practitioners. Publishing an
article based on the evidence you have
acquired is the gold standard by which
this can be achieved.
n Julie Quick
MSc, NMP, SCP, RGN
Surgical Care Practitioner, Theatres,
Manor Hospital, Walsall
Reference
Oerman MH, Hay JC 2010 Writing for Publication
in Nursing 2nd Edition New York: Springer Publishing
Company

214 October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589

 NEWS

News Update
WHO Patient Safety Programme (EPC) with contractual saving guarantees
written into a 10-year agreement with
A new WHO publication, ‘Ethical Issues in Patient Safety energy services company British Gas.
Research’, recently published, reflects on the specific ethical Under this partnership arrangement, the
questions that can arise in the conduct of patient safety Health Board will work closely with British
research and improvement activities, and aims to provide clear Gas but will have the contractual assurance
guidance on how to interpret internationally accepted ethical of a guaranteed saving in the event of
principles in such contexts. The publication also includes under-performance.
patient safety and quality improvement activities, not always
considered research, but which sometimes contain some NMC appoints Council
ethical risks to patients or providers.
www.who.int/patientsafety/research/ethical_issues/en member from Northern
Ireland
NHS England welcomes NHS England is currently evaluating the first
The Privy Council has confirmed the
additional £250 million to stage of the ‘Safer Hospitals, Safer Wards’
appointment of a new Council member
Fund and expects to announce how the
the Safer Hospitals, Safer initial funding has been awarded at the end from Northern Ireland to the Nursing and
Wards Technology Fund of October 2013. Midwifery Council (NMC), in addition to
the existing Chair and 10 other members
NHS England has welcomed the £250m appointed earlier in the year.
extension to the ‘Safer Hospital, Safer Hospital green scheme first
Wards’ Technology Fund, increasing its of its kind in Welsh NHS Registered nurse and health visitor, Maura
value to over £500m to help patients get Hywel Dda Health Board is making huge Devlin, will take up her position at the NMC
better and safer care. strides in ensuring its hospitals are energy from 1 October 2013 and will complete the
efficient, thanks to capital funding of nearly NMC’s new Council. The Council consists
The fund is available to NHS Trusts to £9.3m from the Welsh Government of six lay members, including Chair Mark
support the widespread adoption of Addison, and six registrant members, and
modern, safe electronic record-keeping, The health board has been successful includes representatives from each of the
replacing outdated paper based systems in four linked business cases under the four countries of the UK.
for patient notes and prescriptions with Guaranteed Energy Savings Initiative – the
integrated digital care records (IDCRs). first of its kind in the Welsh NHS.
The ‘Safer Hospitals, Safer Wards’ Fund
The funding will pay for:
Raising concerns
will also help to deliver NHS England’s
• a new biomass boiler at Published by the Nursing and Midwifery
commitment to allow everyone to book
Glangwili Hospital Council (September 2013), Raising
GP appointments and order repeat
• energy efficient lighting upgrades concerns: Guidance for nurses and
prescriptions online by March 2015. The
across its hospital sites, including midwives provides guidance for nurses
money will be spent on digital systems that
Bronglais, Withybush, Prince Philip, and midwives on raising concerns,
connect across different health and care
Glangwili, Amman Valley, Llandovery setting out broad
organisations, meaning:
and Bryntirion principles that
• doctors, nurses and social care
• combined heat and power plant will help them
professionals in accident and
replacements at Withybush and think through
emergency can access patients’
Prince Philip Hospitals the issues and
complete medical details, giving
• building energy management take appropriate
patients personal and effective
systems across its hospital sites, action in the
treatment with full knowledge of their
including Bronglais, Withybush, public interest.
medical and care history;
Prince Philip, Glangwili, Amman This new
• more effective discharge from
Valley, Bryntirion, Hafan Derwen, edition includes
hospitals into the community as
health and care professionals have Bro Cerwyn, South Pembrokeshire information on
access to information on the individual and Tenby. recent
needs of patients; legislation that
• health and care professionals will have The projects will not only help the
offers protection
this information at their fingertips so Health Board to significantly reduce its
to whistleblowers
can spend more time seeing patients consumption of energy and carbon, but will
as well as updated information on
and less time filling in paperwork; also be more cost efficient, ensuring the
organisations nurses and
• errors will be reduced, as it will stop best spend of NHS money.
midwives can go to for confidential
drugs being prescribed incorrectly support and advice.
because patients’ paper notes have The business cases were submitted in the
www.nmc-uk.org/Publications/Guidance
been lost. context of an Energy Performance Contract

October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589 215

NEWS

News Update
Continued

NMC Council agrees a
model of revalidation for
nurses and midwives
The NMC (Nursing and Midwifery Council)
has committed to introduce a proportionate
and effective model of revalidation by
the end of 2015 which enhances public
protection.
Council agreed that revalidation will
require a third party (such as an employer
or manager) to confirm that the nurse or
midwife who is revalidating is complying
with the revised Code. This confirmation will
take account of feedback from patients,
service users, carers and colleagues.
Revalidation will take place at the point of
renewal. The Code and standards will be
reviewed and revised to ensure they are
compatible with revalidation. Guidance for
revalidation will also be developed.
As required by current legislation, nurses
and midwives will continue to renew their
registration every three years and will
declare that they have practised for 450
hours during those three years. The amount
of continuing professional development
(CPD) required will be reviewed, and the
definition of a suitable CPD activity will be
clarified.
The NMC will regularly monitor revalidation
submissions made by nurses and midwives.
This monitoring will be both random and
risk-based and will be informed by other
regulators and from the NMC’s own fitness
to practise processes
The model of revalidation which was
approved by Council has been developed
with substantial input from a range of
stakeholders and requires no changes to
NMC legislation. However, after the model
has been introduced and evaluated, the
NMC may request changes to its legislation
if there is sufficient evidence that this would
further increase public protection.
Jackie Smith, NMC Chief Executive and
Registrar said: “This model of revalidation
will increase the public’s assurance that the
nurses and midwives on our register are
capable of safe and effective practice.
“It will provide a means of checking that
those nurses and midwives continue to
meet our standards in terms of conduct and
competence, and that they have continued
to keep their skills and knowledge up to
date.
“We hope to see nurses and midwives take
ownership of this process. It will promote
their professionalism and will encourage
them to reflect on the standard of care they
provide to patients and clients throughout
their careers.
“We appreciate the work that our
stakeholders have put in so far to help
develop this model and we look forward
to hearing from a range of people in the
consultation that follows to ensure that
revalidation is as robust as possible.”
Health Minister Dr Dan Poulter said:
“Nurses and midwives have some of the
most important jobs in the NHS caring for
patients every day. Making sure they are
up to speed with the latest treatments and
practices will help them maintain the high
standards they and patients expect.
“That is why I support the NMC in its drive
to introduce revalidation – it will improve
safety and quality of care and reassure
patients that nurses remain fit to carry
out their important work. I look forward to
seeing the consultation and pilots.”
A consultation will follow. Early
implementers will revalidate by the end of
2015.

AfPP Forthcoming Events

AfPP forthcoming events 2013
Date Location Topic

17 October Bradford Royal Infirmary AfPP Patient Safety Roadshow

17 October Cedar Court Hotel, Harrogate Theatre Access Course

30 November Heart Hospital, London Safety Matters! Lessons Learned from

Perioperative ‘Never Events’

19 December Harrogate Theatre Access Course

For online registration and further details: www.afpp.org/events

Keep a look out for details about our 50th Anniversary Celebrations in 2014

216 October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589

CLINICAL FEATURE
KEYWORDS Podiatry / Foot surgery / Day surgery / Allied health professionals

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication November 2012.

Podiatry: an illustration of
surgery provided by allied
health professionals
by Anthony Maher
Correspondence address: Department of Podiatric Surgery, Nottinghamshire Healthcare NHS Trust, Park House Health and Social Care Centre, 61 Burton Road, Carlton, Nottingham,
NG4 3DQ. Email: anthony.maher@nottshc.nhs.uk

As with the prescribing of medicines, the provision of surgery continues to evolve and this is
particularly true in the delivery of foot surgery which, until the 1960s, in the United Kingdom was
practiced exclusively by medically qualified surgeons. Over the last 40 years however podiatric
surgery performed by podiatrists has become established as a viable, safe and cost effective
alternative to traditional models of service provision.

Introduction
The provision of healthcare in the UK
continues to evolve and, increasingly, nurses
and allied health professionals (AHPs) are
now responsible for delivering patient care
and treatment which was once considered
the sole preserve of the medical profession.
The shift in the delivery of care was
accelerated with the publication of the NHS
Plan (DH 2000). The plan has since been
superseded, but the changes it introduced
to the NHS can be evidenced in part by
the development of many new roles such
as: advanced care practitioners, surgical
care practitioners, nurse consultants,
extended scope physiotherapists, and AHP
consultants.
The prescribing of medicines provides
another clear example of the changing
delivery of healthcare. Although doctors
remain responsible for the majority of
prescriptions, the role of AHP supplementary
prescribing in primary care and specialist
clinics is developing (Stuart et al 2010).
Independent prescribing, introduced for
nurses in 2006 and soon to be introduced
for physiotherapists and podiatrists, met
with initial concern from some quarters of
the medical community but has since proved
a success with more than 48,000 nurse
prescribers registered with the NMC in 2009
(Lomas 2009).
As with the prescribing of medicines, the
provision of surgery continues to evolve
and this is particularly true in the delivery of
foot surgery which, until the 1960s, in the
United Kingdom was practiced exclusively
by medically qualified surgeons. Over the
last 40 years however podiatric surgery
performed by podiatrists has become
established as a viable, safe and cost
effective alternative to traditional models of
delivering foot surgery (Borthwick & Dowd
2004). Podiatrists have pioneered the
development of day case foot surgery under
local anaesthesia within the NHS (Maher
& Metcalfe 2009). As early as 1994 the
value of podiatric surgery was recognised in
a joint report by the Department of Health
and the NHS Chiropody Task Force. ‘Feet
First’ heavily endorsed podiatric surgery
and commended it to all purchasers of
healthcare services (DH 1994).
What exactly is podiatry?
Podiatry is the allied health profession
responsible for the assessment, diagnosis
and treatment of the foot and lower limb.
The professional titles are legally protected
and regulated by the Health and Care
Professions Council (HCPC). Pre-registration
training comprises a three or four year
BSc degree, usually with many shared
modules across other health professions
programmes. Once qualified, podiatrists
are able to offer a range of treatments
including the management of skin and nail
disorders, management of lower limb soft
tissue disorders, gait analysis, manufacture
and prescription of orthotic shoe inserts,
and the management of complex wounds.
Podiatrists have an important role within
multidisciplinary healthcare teams and work
closely with nurses and doctors, particularly
in the fields of tissue viability, diabetes
and rheumatology (NICE 2004, Williams &
Bowden 2004).
Perhaps a lesser known fact is that
podiatrists also graduate with the ability to
undertake minor surgical procedures (to
address skin and nail lesions) and are also
trained to administer local anaesthetics.
As early as the 1960s, chiropodists in
the UK, spurred on by the achievement
of their podiatry colleagues in America,
recognised a need for the safe provision of
high quality elective foot surgery (Borthwick
2005). Access to local anaesthetics was
first granted in 1968 through an exemption
to the Medicines Act which subsequently
allowed for a significant expansion of scope
of practice.
Training programs were rapidly developed
with both American podiatrists and British
doctors offering support in the early days
and, by the 1980s, podiatric surgery
had established itself in the NHS. Today
there are more than 40 units providing
treatment across England (Borthwick
2005, SCP 2012). Scotland is also
planning to introduce podiatric surgery
and collaborative work is ongoing with the
Society of Chiropodists and Podiatrists
(SCP), the Royal College of Surgeons
Edinburgh and the Royal college of

218 October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589


In its first four years the department assessed over 5,000 patients and
performed 2,335 surgical procedures
Physicians and Surgeons Glasgow (Tagoe
2008).
The path to a career in
podiatric surgery: extension
of scope of practice
Post graduate training in podiatric surgery
has been offered to podiatrists since the
early 1970s and has continued to evolve
as educational demands have changed.
Initially, post graduate examination was
offered exclusively by the professional
bodies and early training followed a
pupilage system. Over the last 20 years,
the emphasis has moved from training
provided by professional bodies towards
the universities and NHS. Today podiatrists,
who have completed an undergraduate
degree and at least two years post graduate
experience, must next study an MSc in the
theory of podiatric surgery. These degrees
are offered at a number of universities in
England and Scotland and are typically
studied part time whilst the podiatrist
also gains further clinical experience. All
candidates then undergo a formal objective
assessment of their skills, knowledge and
understanding before applying for a training
post.
Initial surgical training is delivered over
a minimum two year period, though
more typically training posts are offered
on three year contracts, all of which are
advertised through the NHS Jobs website.
During training candidates are continually
assessed and keep a reflective log of all
clinical, CPD and surgical activity; two
formal examinations must also be passed
within a maximum of three attempts. The
first examination is class room based and
incorporates written theory questions
and a clinical scenario focused viva voce.
The second examination requires the
candidate to complete a number of surgical
procedures with two examiners observing,
followed by a further viva voce. Successful
completion leads to the award of Fellowship
of the College of Podiatry.
Having gained a fellowship in podiatric
surgery, candidates are required to
complete an additional certificate of
completion of specialist podiatric training
(CCSPT). This is achieved through a three
year post as a podiatric registrar. On
October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589
completion of the MSc studies, fellowship
examinations and surgery training to CCSPT,
the candidate may apply for consultant
grade posts in the NHS.
Regulation and registration
Podiatrists who have completed surgical
training are directly regulated by the Health
and Care Professions Council. Invasive
bone and joint surgery represents a
significant extension in scope of practice
and so, to improve clarity and reduce public
confusion, the HCPC has recently agreed to
annotate the register in order to highlight
those podiatrists who are appropriately
qualified to provide foot surgery (HCPC
2012). Registration with the HCPC must be
renewed every two years and is dependent
on practice in accordance with the council’s
standards of conduct and on maintaining
an appropriate and relevant portfolio of
continuous professional development
(CPD). All NHS podiatrists are additionally
governed by local clinical and corporate
governance frameworks. NHS employers
require an annual appraisal, while the SCP
requires those practicing surgery to undergo
a 360 degree appraisal every three years
(SCP 2012).
Working environments
Podiatric surgery has its NHS roots in
primary care because most surgical units
were developed through an expansion
of existing community podiatry services.
This means that novel ways of working
were sought, including the development of
purpose built day surgery units, often in a
community setting. Today many community
trusts still provide podiatric surgery
while others, through the Transforming
Community Services agenda (DH 2009),
are now provided by the acute sector. At the
time of writing, over 150 podiatrists have
completed surgical training in England,
though not all practice surgery.
Quality assurance
Historically in the UK it has been
acknowledged that foot surgery was
associated with poor outcomes and high
rates of litigation (Thomas 1991). Two
editorials on the subject, separated by 11
years, also suggest that there was little
emphasis on specific training or specialism
CLINICAL FEATURE
in foot surgery (The Foot editorial 1991,
Foot and Ankle editorial 2002). Podiatrists,
having expanded their scope of practice
into a potentially problematic field, were
therefore keen to evaluate outcomes, and
in doing so have developed a system for
audit and quality assurance (Tollafield &
Parmer 1994).
As a result of development work by David
Tollafield, the SCP is now able to offer
all members access to an online audit
and evaluation tool known as ‘PASCOM’
or Podiatric Audit of Surgery and Clinical
Outcomes (Rudge & Tollafield 2003).
This system allows podiatrists to monitor
treatment outcomes with respect to patient
satisfaction, quality of life, complications
and adverse incidents. The current online
system which was launched in May 2010
has registered more than 25,000 patients.
An example podiatric
surgery unit in a
community setting
The Department of Podiatric Surgery
in Carlton, Nottingham was set up by a
community healthcare trust in the 1997,
with the purpose of providing foot surgery
in a community setting, and was staffed
exclusively by podiatrists and podiatric
surgeons. In its first four years the
department assessed over 5,000 patients
and performed 2,335 surgical procedures
(Kilmartin 2002). Podiatric surgery rapidly
became a popular choice with patients
and their GPs. The team initially struggled
to meet demand, with waiting times for
surgery (referral to treatment) peaking at 25
months in 2001. However with continued
investment in staff and facilities, the wait
is now comfortably maintained within the
18 week target for referral to treatment.
The department continues to operate on
between 500 and 700 patients a year
under local anaesthesia, accounting for
more than 70% of NHS elective day case
foot surgery in Nottingham.
The department now sits within a purpose
built health centre, opened in 2006,
with twin dedicated lamina flow theatres
designed and equipped specifically for
podiatric surgery. The department has
increased its skill mix and employs a
multidisciplinary team including podiatrists,
219
CLINICAL FEATURE
Podiatry: an illustration of surgery provided by allied health
professionals
Continued
operating department practitioners, nurses,
health care assistants, two consultant
podiatrists and a team of dedicated
administrators. The department also has its
own outpatient facility where up to 5,000
new patient assessments, preoperative
reviews, dressings and non-surgical
treatments are completed every year.
Phlebotomy and pharmacy services are also
available. The only essential services not
available on site are diagnostic imaging,
pathology, sterile services, and laundry
which are provided at the local acute
facility.
All new patients requiring foot surgery
undergo a thorough health assessment
incorporating a standard medical, family
and drug history. Those patients deemed
not to be suitable for day care surgery, such
as those requiring perioperative medical
management, are referred to a secondary
care centre for further assessment and
treatment.
Foot surgery at Carton is almost invariably
elective in nature and there is therefore
an emphasis on collaboration and patient
participation in the decision making
process. When consenting patients for
surgery, a minimum two step procedure is
followed and is supported by a thorough
discussion of the treatment options
(conservative and surgical), the likely
benefits of surgery (or of doing nothing), and
the potential risks and complications. This
information is reinforced with printed advice
sheets which confirm the diagnosis and
treatment options. As a minimum, patients
will attend a new patient assessment, x-ray
review (if indicated), telephone follow up
consultation (if indicated) and preoperative
assessment. All patients are tested for
MRSA and risk assessed for venous
thromboembolism (VTE).
Patients are typically given a three to four
hour time slot for their operation and so
they arrive at various times throughout the
day, as opposed to block booking which
can see patients remaining on the ward for
the majority of the day. The unit has the
capacity to admit a maximum of only three
patients at any one time, and so accurate
timing is critical to the smooth running of
the day.
220
Podiatry
Formerly known as chiropody, the profession changed its name in the 1990s falling in
line with other English speaking countries. The terms ‘podiatry’ and ‘chiropody’ are both
protected by the Health Professions Order 2001. Entry into podiatry and registration
with the HCPC is now only possible with a BSc (Hons) degree in podiatry.
Podiatric surgery
Podiatric surgery is the branch of podiatry responsible for surgical repair of the foot and
its associated structures. Podiatrists wishing to practice surgery undertake a minimum
additional seven years post graduate academic and professional training. Almost all
podiatric surgery is provided on a day care basis and the vast majority is performed
under local anaesthesia.
FCPodS
Fellowship of the College of Podiatry in Surgery, abbreviated to FCPodS, is the only
qualification in podiatric surgery that is recognised by the HCPC, NHS employers and
major insurance companies.
Scope of practice
The current scope of practice in podiatric surgery is quite simply – the foot and its
associated structures. In practice, the most common conditions treated by podiatric
surgery are hallux valgus (bunions), hammer toes, hallux rigidus, nerve entrapments,
soft tissue lumps and bumps and tendon disorders.
Society of Chiropodists and Podiatrists
The society is the largest of the podiatry professional bodies, with approximately
10,000 members. In addition to trade union functions the society encompasses The
College of Podiatry which is the educational body responsible for the training, appraisal
and examination of surgical trainees and fellows. The college is an independent body
which has an arm’s length relationship with its parent organisation.
Table 1 Key facts
Surgery is performed under local In theatre, patients are cared for by a
anaesthesia (LA), and so extremely anxious healthcare assistant throughout the
patients are referred to secondary care procedure. Music is available and the foot
for treatment under intravenous sedation is screened; there is a conscious attempt
or general anaesthesia. For patients with to create a relaxed and comfortable
only mild anxiety, oral sedation is arranged, atmosphere. Almost all procedures are
allowing treatment to proceed under LA. performed with a pneumatic tourniquet
Anaesthesia is administered by a registered typically placed proximal to the malleoli.
podiatrist and a variety of blocks are used, Patient monitoring, theatre preparation
depending on the scenario. These range and instrumentation are much as would
from the relatively simple digital blocks be found in a typical hospital theatre
or local infiltration through to the more setting. Particular attention is paid to sterile
advanced ankle and popliteal nerve blocks. fields, hand washing and skin preparation,
The popliteal block has been found to resulting in an audited postoperative
be an excellent solution for both surgical infection rate of below 1%.
anaesthesia and postoperative analgesia
following foot surgery, as it can offer up To assist a smooth discharge, the patient’s
to 36 hours pain relief. Currently, 17% of relatives are usually contacted towards the
our patients have a popliteal nerve block end of the operation to ensure that they
and 72% have an ankle block. Pain relief is are ready and waiting for the journey home
supplemented with analgesics and NSAIDs as soon as the patient is fit for discharge.
as necessary, most typically ibuprofen All patients are transferred from theatre
and co-dydramol. Eighty eight percent of straight to what would traditionally be
patients report satisfactory or excellent pain considered second stage recovery. If an
control immediately following surgery. admission for medical care was required,
October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589
 CLINICAL FEATURE

the patient would be admitted in References Stuart L, Fox M, Borthwick A et al 2010

partnership with the local emergency
medical service. All patients receive a
thorough verbal and written discharge
from a qualified member of staff (usually
a podiatrist or ODP involved with the
procedure) and are provided with the
number for the emergency out of hours
service. The following day, patients are
contacted for a telephone review and are
then seen in clinic at between 7 and 14
days post operation. For most procedures,
no more than a single dressing appointment
is required and the patients are then
reviewed again, prior to discharge from the
service at six months post operation.
The department is a contributor to the
PASCOM project mentioned above. All
consenting patients are audited throughout
their care pathway with respect to health
related quality of life, satisfaction, and
complications. Ninety four percent of
patients feel that their aims have been
either partly or wholly met following surgery.
In addition, we consider the success or
failure of treatment from the clinician’s
perspective. Other in house audits focus
on quarterly-assessed record keeping, and
infection control.
Conclusion
About podiatric surgeons Available from:
www.feetforlife.org/foot-health/foot-surgery/
about-podiatric-surgeons/ [Accessed January 2013]
Borthwick A, Dowd O 2004 Medical dominance or
collaborative partnership? Orthopaedic views on
podiatric surgery British Journal of Podiatry 7
(2) 36-41
Borthwick A 2005 ‘In the beginning’: Local
anaesthesia and the Croydon postgraduate group
British Journal of Podiatry 8 (3) 87-94
Department of Health 1994 Report of the joint
Department of Health and NHS Chiropody Task
Force – Feet First: Department of Health
Department of Health 2000 The NHS Plan: a plan
for investment, a plan for reform
Available from: www.dh.gov.uk/en/
Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_4002960
[Accessed January 2013]
Department of Health 2009 Transforming
community services: enabling new patterns
of provision Available from: www.dh.gov.uk/
en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_093197
[Accessed January 2013]
Editorial 1991 The Foot 1 (1) 1-2
Editorial 2002 Chiropody, podiatry and orthopaedics
2002 Foot and Ankle Surgery 8 (2) 83
Health and Care Professions Council 2012
Supplementary prescribing: patient, podiatrist and
professor perspectives The Diabetic Foot Journal
13 (3) 110-14
Tagoe M 2008 Leading the way Surgeons News
Available from: http://archive2.surgeonsnews.info/
content/content.aspx?ID=433 [Accessed January
2013]
Thomas T 1991 Medical litigation and the foot The
Foot 1 (1) 3-5
Tollafield D, Parmer D 1994 Setting standards for
day care foot surgery a quinquennial review Part 1
British Journal of Podiatric Medicine and Surgery
6 (1) 7-20
Wiliams A, Bowden A 2004 Meeting the challenge for
foot health in rheumatic diseases
The Foot 14(3) 154-8
Further reading
A list of articles reporting the outcomes of
podiatric surgery can be accessed at:
www.feetforlife.org/foot-health/foot-surgery/
about-podiatric-surgeons/
Further Information
The Health and Care Professions Council
www.hpc-uk.org
Society of Chiropodists and Podiatrists
www.scpod.org
About the author
Anthony Maher
BSc (Hons), FCPodS

Annotation of the register – qualifications in

The provision of healthcare in the UK
continues to evolve and, increasingly,
nurses and AHPs are developing new roles
and taking on new responsibilities for
delivering patient care and treatment. Over
the last 40 years podiatrists have pioneered
the development of day case foot surgery
under local anaesthesia within the NHS.
Podiatric surgery performed by podiatrists
has become established as a viable, safe
and cost effective alternative to traditional
models of service provision, and is popular
with both patients and commissioners alike.
Consultant Podiatric Surgeon, Nottingham
podiatric surgery Available from: www.hpc-uk.org/
assets/documents/10003A3Eenc06-annotationofregi
sterpodiatricsurgery.pdf [Accessed January 2013] No competing interests declared
Kilmartin T 2002 Podiatric surgery in a community
trust: a review of activity, surgical outcomes,
complications and patient satisfaction over a 4 year Members can search all issues of the BJPN/JPP
period The Foot 11 (3) 218-27 published since 1998 and download articles free of
charge at www.afpp.org.uk.
Lomas C 2009 Nurse prescribing: the next Access is also available to non-members who pay a
steps Available from: www.nursingtimes.net/ small fee for each article download.
nursing-practice/clinical-specialisms/prescribing/
nurse-prescribing-the-next-steps/5003904.article
[Accessed January 2013]
Maher A, Metcalfe S 2009 A report of UK experience
in 917 cases of day care foot surgery using a
validated outcome tool The Foot 19 (2) 101-6

National Institute for Health and Care Excellence

2004 Type 2 diabetes: prevention and
management of foot problems Available from:
http://guidance.nice.org.uk/CG10/Guidance/pdf/
English [Accessed January 2013]

Rudge G, Tollafield D 2003 A critical assessment of

a new evaluation tool for podiatric surgical outcome
analysis British Journal of Podiatry 6 (4) 109-19
Society of Chiropodists and Podiatrists 2012

October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589 221

CLINICAL FEATURE
KEYWORDS Insulin / Infusion / Protocol / Inpatient / Perioperative

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication January 2013.

A novel glucose-insulin
infusion maintains
perioperative glycaemic
control through multiple
transitions of care
by Nora Renthal, Erin D Roe, Beverley Adams-Huet, and Philip Raskin
Correspondence address: Philip Raskin, MD, Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Blvd., G5.238, Dallas, TX 75390-8858, USA.
Email: philip.raskin@utsouthwestern.edu

To measure the efficacy of the Glucose-Insulin Infusion--Parkland Protocol (GIPPr) compared to

subcutaneous (SC) insulin, blood glucose readings were reviewed in diabetic adults admitted for
surgical intervention of a soft tissue or bone infection in Dallas, Texas. Hypoglycaemia occurred
in 0.69% of readings in GIPPr-treated patients compared to 4.52% in SC-treated patients. The
GIPPr maintained a higher proportion of blood glucose readings between 3.89-10mmol/L
compared to SC insulin (85.40% versus 50.68%).

Introduction
Perioperative glycaemic control represents
a unique challenge in patients both with
established diabetes and those with newly-
discovered hyperglycaemia. Acute infection
and stress-related insulin resistance may
contribute to higher rates of hyper- and
hypoglycaemia. Furthermore, patients
awaiting surgery are usually held without
oral nutrition (made ‘nil by mouth’, (NBM))
and may transfer between multiple medical
and surgical services perioperatively. With
the result that each transition may further
disrupt efforts to control glucose variability.
While glycaemic variability affects medical
and surgical patients hospitalised with
both critical and non-critical illness, the
perioperative ‘window’, defined as the
12-24 hours before, during and immediately
following a surgical procedure, is marked by
additional risk which may translate to added
complications. Uncontrolled hyperglycaemia
fuels infection, slows wound healing,
delays recovery, and increases end-organ
dysfunction (Akhtar et al 2010). Meanwhile,
the propensity toward treatment-induced
hypoglycaemia may be increased in
patients unable to take oral nutrition and
the physical symptoms of hypoglycaemia
may be obscured by anaesthesia during
the perioperative period (Raju et al 2009).
Increased intra-hospital transitions-of-care
(i.e. ‘hand-offs’) among medical, surgical
and anaesthesia services, especially if left
unstructured, can increase communication
errors (Sullivan 2007) between providers
and expose patients to glucose extremes
and related bad outcomes.
Intravenous insulin therapy is considered
the standard of care for managing inpatient
hyperglycaemia (Moghissi et al 2009)
particularly during periods of critical illness.
However, in the US no single insulin infusion
protocol has been adopted as a national
standard (Wilson et al 2007). Reductions
in morbidity and mortality among patients
with acute myocardial infarction (Malmberg
1997, Malmberg et al 2005), recent
coronary artery bypass grafting (Furnary et
al 2003), critically-ill surgical patients (Van
den Berghe et al 2001, Van den Berghe
et al 2006), and patients undergoing non-
cardiac, non-vascular surgery (Noordzij
et al 2007) have generated interest in
algorithm-driven insulin infusions. Current
inpatient glycaemic management strategies
focus on the delineation between critical
and non-critical illness, and increasing
individualisation of glycaemic targets
based on the severity of underlying illness.
Less evidence, either in the form of well-
constructed trials or consensus guidelines,
exists for inpatient glucose management
in the perioperative setting (Inzucchi &
Rosenstock 2005).
A recent review of different intravenous
(IV) insulin protocols by Wilson et al
(2007) showed that the quantity of insulin
delivered and the complexity of instruction
varied widely. Several institution-specific,
paper-based, and computer-driven
algorithms have emerged for perioperative
management (Malmberg et al 1995, Van
den Berghe et al 2001, Markovitz et al
2002, Trence et al 2003, Furnary et al
2004, Goldberg et al 2004, Davidson et al
2005, Osburne et al 2006, Juneja et

222 October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589


The Glucose-Insulin Infusion-Parkland Protocol (GIPPr) is a nurse-
implemented protocol which was first used in 1989
al 2007). Reasons for the lack of the
widespread adoption of these could include
the inability to compare protocols head-
to-head in hospital settings matched for
patient acuity and nursing staff familiarity.
Furthermore, the reliance on complicated
nomograms for insulin titration may lead
some infusion protocols to be overlooked
in favour of locally developed, institution-
specific protocols.
The Glucose-Insulin Infusion-Parkland
Protocol (GIPPr) is a nurse-implemented
protocol which was first used in 1989 in
the University Diabetes Treatment Center
at Parkland Memorial Hospital in Dallas,
Texas. The GIPPr targets a glycaemic
range of 3.89-10mmol/L by utilizing IV
insulin (Units-100 regular insulin, 1ml/
hr) to a maximum dose of 10units/hour
with adjustment based on peripheral
capillary blood glucose (CBG) readings up
to 16.7mmol/L. Insulin and dextrose IV
Figure 1 Schematic of the Glucose-Insulin Infusion—Parkland Protocol (GIPPr)
October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589
solutions are hung ‘piggy-back’ fashion and
the dextrose is activated at CBG values less
than 11.1mmol/L as a ‘backstop’ to protect
against hypoglycaemia. The insulin and
dextrose infusion rates are titrated by whole
or half number units based on hourly CBG
readings. The algorithm is shown in
Figure 1. Additionally, the protocol can be
modified with higher insulin infusion rates
(up to 20 units/hour) to accommodate
blood glucose levels over 16.7mmol/L and
enhanced insulin resistance fuelled by
‘glucotoxicity’. Increasing the concentration
of the dextrose solution (from 5% to 10%
or even 50% for patients with central IV
access monitored in the intensive care unit)
is necessary in patients at risk for volume
overload. This protocol has been used in
many clinical conditions over the years and
has been shown to be safe, effective and
very ‘nurse-friendly’.
CLINICAL FEATURE
The Society of Thoracic Surgeons advocates
the use of IV insulin for maintenance
of intraoperative blood glucose levels
to a target range of 3.89-10mmol/L in
established diabetic patients (Lazar et
al 2009). Separate glucose and insulin
infusions may provide better control and are
more acceptable to nursing staff (Simmons
et al 1994, Robertshaw et al 2004).
Therefore, we performed an observational
study to assess the effectiveness of the
GIPPr in patients who are most vulnerable
to glucose extremes due to underlying
infection, their NBM status, and the multiple
intra-hospital hands-off necessary to
facilitate surgical intervention.
Methods
Study design
We performed a retrospective chart
review (January 2009 to June 2012) of
125 patients, selected at random, with
uncontrolled hyperglycaemia, admitted
to Parkland Memorial Hospital which is a
county-sponsored, teaching hospital based
in Dallas, Texas. The study was approved
by the University of Texas Southwestern
Medical Center Institutional Review Board
and Parkland Hospital Clinic Research
Department. Informed consent was waived
because personal health information was
not collected, and it was not logistically
feasible to collect for this retrospective
quality improvement project.
Inclusion criteria were patients with a
diagnosis of Type 2 diabetes mellitus with
a severe soft tissue and/or bone infection,
requiring either irrigation and debridement
(I&D) (n=59) or amputation (n=66).
Determination of the surgical procedure was
made through review of operative notes.
Exclusion criteria were pregnancy, diabetic
ketoacidosis, hyperosmolar nonketotic
syndrome, acute coronary syndrome, and
acute cerebrovascular accident. Patient
demographics are shown in Table 1.
Patients meeting the aforementioned
criteria were then grouped based on
whether they were treated perioperatively
with the GIPPr (n=93) or subcutaneous
insulin (SC) (n=32) for glucose
management. Blood glucose values were
sorted into three categories: hypoglycaemia
(<3.89mmol/L), euglycaemia
(3.89-10mmol/L), and hyperglycaemia
223
CLINICAL FEATURE

A novel glucose-insulin infusion maintains perioperative

glycaemic control through multiple transitions of care
Continued

patient resumed oral food intake (two to

Factor Data three hours).
Total PGII SQ p value*
Outcomes
Total number of patients 125 93 32 -- The primary outcome of the current study
Age (in years) 50.2 ±10.2 49.6±10.3 52.0±9.8 0.27 was capillary blood glucose measurements,
Sex which were grouped according to:
Male (n) 80 60 20 0.83 hypoglycaemia (<3.89mmol/L),
euglycaemia (3.89-10mmol/L), and
Female (n) 45 33 12 hyperglycaemia (>10mmol/L) as defined
Race by the American Association of Clinical
% Hispanic 48.8% 47.3% 53.1% 0.68 Endocrinology and American Diabetes
% Caucasian 13.6% 14.0% 12.5% 1.00 Association (Moghissi et al 2009). Blood
glucose measurements were plotted
% African-American 36.0% 36.6% 34.4% 1.00 throughout the preoperative, intraoperative,
Procedure Type and two postoperative time points
Irrigation & Debridement (n) 59 41 18 0.31 (post-anasthesia care unit [PACU] and
Amputation (n) 66 51 14 0.31 postoperative floor). Secondary outcomes
included differences in glycaemic control
Metabolic Profile# based on transfers of care and differences
HbA1c (%) 10.5 ± 2.3 10.7 ± 2.4 10.1 ± 2.2 0.20 in glycaemic control based on surgical type.
Total Cholesterol (mg/dL) 144 ± 52 140.4 ± 49 156 ± 61 0.18
Statistical analysis
Triglycaerides (mg/dL)
Statistical analyses were carried out on
Median [25th - 75th percentile] 133 [93-183] 136 [91-173] 128 [93-225] 0.46 the data to confirm that the two treatment
LDL (mg/dL) 81 ± 36 79.9 ± 34 88.9 ± 43 0.21 groups did not vary significantly. Statistical
HDL (mg/dL) 31 ± 13 31.2 ± 13 31.8 ± 13 0.82 significance was designated at two-sided
p<0.05 and analysis was performed with
SAS version 9.2 (SAS Institute, Cary, NC).
*p-values were calculated using two-tailed Student’s t-tests for continuous variables and
Fisher’s Exact test for categorical variables. #Data represent mean ± standard deviation Results
unless otherwise indicated.
We conducted a retrospective chart review
of a total of 125 patients (Table 1). Ninety-
Table 1 Participant characteristics during hospitalisation three patients were treated with GIPPr,
from whom 1,367 perioperative CBGs were
(>10mmol/L). Additionally, blood glucose Parkland Glucose Insulin Infusion collected (hourly measurements according
values were evaluated to determine if Protocol to the infusion protocol). Thirty-two patients
glycaemic fluctuations occurred during or The GIPPr is displayed in Figure 1. As were treated with subcutaneous (SC)
immediately following transfers-of-care. discussed previously, hourly capillary blood insulin, from whom 221 perioperative
To achieve this, blood glucose values glucose measurements were obtained using CBGs were collected (as needed based on
were analysed based on the location of point-of-care glucose meters. last insulin injection, patient symptoms
the patient in the perioperative process, or provider discretion). There was no
grouped into: preoperative, intraoperative, Definition of time periods difference between the patients treated
post-anesthesia care unit (PACU), or The preoperative period was defined as the with the GIPPr or SC insulin with regard to
postoperative hospital floor. time point at which the patient was made age, sex, surgical procedure type, or basic
NBM; this usually fell between midnight and metabolic characteristics (Table 1).
Preoperative care 05:00 for morning procedures, or 12 hours
Following admission, all patients underwent prior to the scheduled operating theatre Our primary outcome measure was to
preoperative surgical assessment and were time for afternoon and evening procedures. determine the percentage of euglycaemic
kept NBM prior to surgery. Glucose control The intraoperative period was defined as (3.89-10mmol/L) blood glucose readings
was maintained with GIPPr (n=93) or SC the time of transfer into the operating room perioperatively, and, secondarily, to
insulin injections (n=32) while patients until the time of transfer to the PACU. The investigate the rate of hypoglycaemic events
were NBM. Due to variability in the timing PACU period was defined as time of transfer (<3.89mmol/L), as hypoglycaemia poses
of GIPPr initiation and uncertainty regarding to PACU until time of transfer to the hospital the greatest risk to the patient. The rate
the patients’ oral intake in the emergency floor. The postoperative-floor period was of hypoglycaemia in the GIPPr group was
department, these blood glucose values defined as two hours following return to the found to be 0.69% (Figure 2A), whereas the
were omitted from analysis. hospital inpatient medicine unit, before the rate of hypoglycaemia in the SC group

224 October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589

 CLINICAL FEATURE

The type of surgery did not associate with a higher

frequency of hyper or hypoglycaemia

in the minutes immediately following

transfers to the next level of care. The
percentage of euglycaemia differed by a
A. B. standard deviation of only 3.3% between
locations: 85.6% of CBGs were euglycaemic
pre-operatively, compared with 82.1% intra-
operatively, 82.1% during the PACU period,
14% 45% and 88.9% post-operatively (Figure 2C).
1% 5% Analysis of the SC group demonstrated a
5.3% standard deviation in the percentage
of euglycaemic blood glucose readings
between locations: 50.9% of CBGs were
85% 51% euglycaemic pre-operatively, compared with
57.7% intra-operatively, 57.7% during the
PACU period, and 47.1% post-operatively
(Figure 2C).
C.
100%

90%
Lastly, subgroup analysis was conducted
on patients treated with the GIPPr. The
80% type of surgery did not associate with a
70% higher frequency of hyper or hypoglycaemia.
Additionally, the mean CBG values did not
60%
vary within these subgroups according to
50% location and time in the perioperative period
(Figure 3), location p=0.14, subgroup by
40%
location interaction, p=0.49. However, the
30% I&D subgroup had consistently higher CBG
20% values (inter-group difference 1.0 mmol/L,
95% CI [0.2-1.81mmol/L]) compared
10%
to the amputation subgroup over time,
0% p=0.01 from repeated measures analysis
INFUSION SQ INFUSION SQ INFUSION SQ INFUSION SQ
(least squares means (95%CI) were 8.7
PRE-OPERATIVE INTRA-OPERATIVE PACU FLOOR-POST mmol/L (8.1-9.3mmol/L) and 7.7mmol/L
(7.2-8.2mmol/L) for I&D and amputation
hypoglycemia euglycemia hyperglycemia subgroups, respectively).
(<3.89 mmol/L) (3.89 - 10 mmol/L) (>10 mmol/L)
Discussion
Figure 2 Percentage of blood glucose values classified as either hyper-, eu-, or hypo-glycaemic in patients Ample data show the benefit of IV insulin
treated perioperatively with GIPPr (A) or subcutaneous (B) insulin. Data are further analysed to show infusion protocols in patients undergoing
percentage of blood glucose values during the pre-op, intra-op, PACU, and post-op periods (C). cardiac or vascular procedures, yet there is
relatively little prospective or retrospective
was 4.52% (Figure 2B). In addition, the (5 of 110 readings) and post-operative outcomes data in general surgical patients.
ability of the healthcare provider to maintain (5 of 58 readings) periods (Figure 2C). Our retrospective chart review demonstrates
acceptable blood glucose ranges was However, proportionally more instances of that use of the GIPPr maintained CBG
improved in the GIPPr group, with 85.40% hypoglycaemia occurred in the SC group, values while patients transferred through
of all readings between 3.89 - 10mmol/L with episodes of hypoglycaemia occurring in multiple hospital services and levels of
(Figure 2A), as compared to only 50.68% of 4 of 32 patients and 5 CBGs falling below care during the perioperative period. More
all readings in the SC group (Figure 2B). 3.11mmol/L in 2 patients. importantly, in patients treated with the
GIPPr, no perioperative episodes of severe
Rare instances of hypoglycaemia in the We also wanted to determine whether hypoglycaemia (<2.78mmol/L) were
GIPPr-treated patients were found pre- multiple hand-offs among providers would observed. Hyperglycaemia, while relatively
operatively (8 of 849 readings) and post- impair the GIPPr in maintaining glycaemic more common than hypoglycaemia, rarely
operatively (1 of 243 readings) (Figure control. This effect was not observed; large produced values in excess of 12.78
2C). These episodes occurred in 5 of the shifts in the percentage of hypoglycaemic, mmol/L. This is in contrast to the SC
93 patients investigated, and no CBGs fell euglycaemic, and hyperglycaemic CBGs group, in which five episodes of severe
below 3.11mmol/L. Hypoglycaemia in the were not seen between locations. Abnormal hypoglycaemia were observed and 60
SC group also occurred in the pre-operative high and low glucose values did not occur

October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589 225

CLINICAL FEATURE
A novel glucose-insulin infusion maintains perioperative
glycaemic control through multiple transitions of care
Continued
Figure 3 Mean blood glucose values for patients treated with the GIPPr. I&D (irrigation and debridement)
versus amputation, p=0.01 repeated measures analysis. The interaction between subgroup and perioperative
period was not statistically significant, p=0.49
episodes of blood glucose being in excess
of 12.78mmol/L.
Maintenance of blood glucose within a
narrow range can be labour-intensive. The
algorithm’s titration nomogram based on
whole or half units enables patients to
transition through different levels of care. Of
note, nursing ratios may vary from one unit
to the next and the GIPPr maintained stable
glycaemia in high-risk patients, irrespective
of changes in the intensity and experience
level of nursing staff.
Limitations of our study include its
observational nature and small sample
size, although this is a necessary first
step in performing any hospital quality
improvement initiative. It is the usual
practice at our hospital that diabetic
patients undergoing an operative procedure
are maintained on intravenous insulin
therapy. Because this is now standard of
care at our institution, it is not possible to
create a prospective, randomised trial, as
the nursing staff experience on the GIPPr
protocol would confound the results. A
comparison of insulin protocols across
institutions is also not possible; patients
at our country-sponsored teaching hospital
often lack health insurance and/or reliable
access to preventative diabetes care and,
therefore, present with more advanced
complications of diabetes and/or acute
uncontrolled hyperglycaemia. Therefore, a
comparison was made with patients who
were selected to continue on subcutaneous
226
insulin, despite the potential allocation
bias. It was likely that patients chosen to
continue subcutaneous insulin did not
have severe hyperglycaemia preoperatively,
yet they still manifested higher rates
of hyperglycaemia and hypoglycaemia.
Therefore, we feel that any potential
allocation bias in our study would have
skewed the results to favour subcutaneous
insulin injections. In fact, GIPPr was still
found to be superior to subcutaneous
insulin despite its use among patients with
more severe preoperative hyperglycaemia
Anecdotal discussions with nurses at our
institution indicated that many were able
to commit the algorithm to memory and
liked the ability to titrate infusions based
on whole or half-unit increments without
referring back to a paper or computer-based
nomogram. Adjustments of the dextrose
and insulin infusions can be performed
simultaneously based on a single CBG
value, such that nurses felt the GIPPr was
no more labour-intensive than managing a
single infusion. Dissemination of the GIPPr
protocol to other resource-constrained
hospitals may be beneficial, because it does
not require purchase of expensive devices
beyond standard infusion equipment.
Additionally, the GIPPr’s flexible algorithm
accommodates patients with extreme
obesity and insulin resistance.
Based on the data presented in the current
study, we conclude the GIPPr to be superior
to subcutaneous glucose management
October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589
for improved prevention of both hyper and
hypoglycaemic events. While head-to-head
comparison with other institutional insulin
infusion protocols has not been conducted
and may not be feasible, we believe the
current GIPPr protocol to be simple, safe,
and easy-to-use, even during multiple
transfers of care, in sick diabetic patients
vulnerable to hypoglycaemia and stressful
physiologic conditions including active
infection, inflammation and surgery. This
GIPPr can be used in other clinical settings
and for other types of surgery safely and
successfully.
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Furnary AP, Gao G, Grunkemeier GL et al 2003
Continuous insulin infusion reduces mortality
in patients with diabetes undergoing coronary
artery bypass grafting Journal of Thoracic and
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Furnary AP, Wu Y, Bookin SO 2004 Effect of
hyperglycaemia and continuous intravenous
insulin infusions on outcomes of cardiac surgical
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Goldberg PA, Siegel MD, Russell RR et al 2004
Experience with the continuous glucose monitoring
system in a medical intensive care unit Diabetes
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Inzucchi SE, Rosenstock J 2005 Counterpoint.
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Utilization of a computerized intravenous insulin
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Society of Thoracic Surgeons practice guideline
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with diabetes mellitus and acute myocardial
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Markovitz LJ, Wiechmann RJ, Harris N et al
2002 Description and evaluation of a glycaemic
management protocol for patients with diabetes
undergoing heart surgery Endocrine Practice 8 (1)
10-18
Moghissi ES, Korytkowski MT, DiNardo M et al 2009
American Association of Clinical Endocrinologists
and American Diabetes Association consensus
statement on inpatient glycaemic control Endocrine
Practice 15 (4) 353-69
Noordzij PG, Boersma E, Schreiner F et al 2007
Increased preoperative glucose levels are associated
with perioperative mortality in patients undergoing
noncardiac, nonvascular surgery European Journal
of Endocrinology 156 (1) 137-42
Osburne RC, Cook CB, Stockton L et al 2006
Improving hyperglycaemia management in the
intensive care unit: preliminary report of a
nurse-driven quality improvement project using a
redesigned insulin infusion algorithm The Diabetes
Educator 32 (3) 394-403
Raju TA, Torjman MC, Goldberg ME 2009
Perioperative blood glucose monitoring in the
general surgical population Journal of Diabetes
Science and Technology 3 (6) 1282-7
Robertshaw HJ, McAnulty GR, Hall GH 2004
Strategies for managing the diabetic patient Best About the authors
Practices & Research Clinical Anaesthesiology 18
(4) 631-43
Nora Renthal
Simmons D, Morton K, Laughton SJ, Scott DJ 1994 MD, PhD
A comparison of two intravenous insulin regimens
among surgical patients with insulin-dependent Childen’s Medical Center of Dallas, Dallas, Texas
diabetes mellitus The Diabetes Educator 20 (5)
Erin D. Roe
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MD, MBA
Sullivan EE 2007 Hand-off communication Journal
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Trence DL, Kelly JL, Hirsch IB 2003 The rationale Center, Dallas, Texas
and management of hyperglycaemia for in-patients
with cardiovascular disease: time for change Beverley Adams-Huet
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Southwestern Medical Center, 5323 Harry Hines
Van den Berghe G, Wouters P, Weekers F, 2001
Boulevard, Dallas, Texas
Intensive insulin therapy in the critically ill patients
The New England Journal Medicine 345 (19) 1359-
Philip Raskin
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No competing interests declared
therapy in critical care: a review of 12 protocols
Diabetes Care 30 (4) 1005-11
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Editor
Karen McCutcheon, Teaching Fellow,
School of Nursing and Midwifery, Queen’s
University Belfast
Review Panel
Angela Cobbold, Senior Lecturer,
Allied Health & Medicine, Faculty
of Health, Social Care & Education,
Anglia Ruskin University
Felicia Cox, Senior Nurse, Pain
Management, Royal Brompton & Harefield
NHS Foundation Trust
Marie Digner, Matron/Clinical Lead,
Outpatients, Royal Bolton Hospital
Luke Ewart, Senior Lecturer/Pathway
Director Pre-reg ODP, Canterbury Christ
Church University
Jill Ferbrache, Practice Educator,
Aberdeen Royal Infirmary
Dr Theofanis Fotis, Senior Lecturer School
of Nursing & Midwifery, University of
Brighton
Eleanor Freeman, Theatre Sister and
Education Lead Scrub, Theatres, Queen
Elizabeth Hospital, Gateshead
Lois Hamlin, Former Senior Lecturer,
Director, Postgraduate Programs,
University of Technology, Sydney, Australia
Adrian Jones, Orthopaedic Surgical Care
Practitioner, Trauma & Orthopaedic
Department, Norfolk & Norwich University
NHS Trust
Moyra Journeaux, Clinical Educator/
Lecturer, Harvery Besterman Education
Centre, Jersey General Hospital
Sue Lord, Head of Department, Allied
Health and Medicine, Faculty of Health &
Social Care, Anglia Ruskin University
Andy Mardell, Former Practice Educator,
Main Theatres, University Hospital of
Wales, Cardiff
Daphne Martin, Nurse Lecturer, Pathway
Leader Specialist Practice in Anaesthetic
Nursing, School of Nursing and Midwifery,
Queen’s University Belfast
Shirley Martin, Surgical Care Practitioner
and Robotics Specialist Nurse, St Mary’s
NHS Trust
Lucy Mitchell, Psychology Research
Assistant, University of Aberdeen
Amanda Parker, Director of Nursing,
Queen Victoria Hospital NHS Foundation
Trust, West Sussex
Eloise Pearson, Lecturer, School of
Nursing & Midwifery, University of Dundee
Susan Pirie, Practice Educator, East Surrey
Hospital, Redhill
Julie Quick, Surgical Care Practitioner, Day
Unit Theatres, Manor Hospital, Walsall
Paul Rawling, Senior Lecturer, ODP
Education, Edge Hill University, Ormskirk
Julie Seed, Trainee Surgical Care
Practitioner, Royal Preston Hospital
Susan Tame, Lecturer, University of Hull
Vanessa Tuthill, Clinical Coordinator,
Royal Berkshire Hospital
Dr Linda Walker, Divisional Nurse Surgery,
Cardiff and Vale University Local Health
Board
Dr Stephen T Webb,  Consultant in
Intensive Care & Anaesthesia, Papworth
Hospital NHS Foundation Trust
Paul Wicker, Head of Perioperative
Studies, Edge Hill University, Ormskirk
and Visiting Professor at Nanjing Medical
University, China
Marilyn Williams, Senior Lecturer, School
of Health, University of Wolverhampton
(retired)

October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589 227

CLINICAL FEATURE
KEYWORDS Enhanced recovery / Accelerated recovery / Fast-track surgery / Orthopaedics / Hip arthroplasty / Knee arthroplasty

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication January 2013.

Enhanced recovery
after surgery (ERAS): an
orthopaedic perspective
by Jonathan J E White, Robert Houghton-Clemmey and Paul Marval
Correspondence address: Jonathan J E White, Department of Trauma and Orthopaedic Surgery, Royal Derby Hospital, Uttoxeter New Road, Derby, DE22 3NE.
Email:jonathan.white1@nhs.net

Enhanced recovery after surgery (ERAS) is a programme that aims to improve the care of elective
surgical patients. Accelerated care pathways are delivered using a multidisciplinary approach,
leading to reduced lengths of hospital stay, improved quality of treatment, and better outcomes.
These programmes have gained considerable popularity in orthopaedics recently, however their
widespread adoption remains to be seen. This article highlights the key evidence concerning
ERAS in orthopaedic surgery.

Introduction
Enhanced recovery or ‘fast-track’ surgical
pathways have gained considerable
momentum over recent years. A concept
pioneered by Danish surgeon Henrik Kehlet
in 1997 (Kehlet 1997), it was originally
intended as a method for treating patients
following colonic surgery (Kehlet 1997,
Basse et al 2000) through the benefit of
multimodal intervention. The aim of an
enhanced recovery programme is to improve
the care of elective surgical patients with
the use of standardised, multi-professional
care pathways. These pathways cover
every aspect of a patient’s surgical journey,
from the preoperative phase through to
discharge. The key principle is to accelerate
postoperative recovery and thus reduce
the length of hospital stay, improve patient
experience, and achieve enhanced clinical
outcomes.
Although the process of enhanced recovery
was initially developed and intended for
use in colorectal surgical pathways, its
scope has widened to encompass other
surgical specialties. Many of the ideas
and strategies remain the same, with
necessary adaptation and change as
required. Orthopaedic surgery, particularly
elective hip and knee arthroplasty, is one
such specialty where enhanced recovery
programmes are being instituted and
developed quite rapidly. The purpose of this
review article is to describe what is meant
by enhanced recovery after surgery (ERAS),
how these pathways are structured within
an orthopaedic setting, and the benefits
provided to patients and the NHS.
What is enhanced recovery
after surgery (ERAS)?
Enhanced recovery after surgery aims to
improve patient outcomes and speed up
recovery after surgery. The programme
focuses on optimising every step of a
patient’s surgical pathway and develops
patients that are active participants in their
own recovery process. The philosophy is
that the provision of adequate education
prior to surgery, along with an optimal
anaesthetic and analgesic plan, will allow
patients to mobilise earlier. Patients are
then able to achieve physiotherapy goals
earlier and progress more rapidly compared
to traditional time frames. This allows for
earlier discharge, reduced length of hospital
stay, and an inevitable reduction in hospital-
related complications. The ultimate aim
is that all patients achieve a safe earlier
discharge date than previously, including
those with chronic illnesses, with the same
quality of outcome.
There is no consensus definition of ERAS
within the literature, and numerous monikers
exist, all describing the same characteristic
pathway. Examples include ‘Accelerated
Rehabilitation’, ‘Fast-track’, and ‘Rapid
Recovery’ (Berend et al 2004, Schwenk &
Muller 2005, Isaac et al 2005). Despite the
lack of a formal definition, there are four key
elements that characterise an enhanced
recovery programme (NHS Institute for
Innovation and Improvement 2008):
1. Optimised preoperative care
• Thorough preoperative assessment,
including consultation with an
anaesthetist, to optimise
general health and co-morbidities
• Education and counselling, to manage
patient expectations
• Identification and coordination
of essential resources and discharge
requirements
2. Reduced physical stress of surgery
• Minimally invasive surgical techniques
with smaller incisions
• Reduced surgical times
• Optimised anaesthetic techniques (i.e.
short-acting spinal anaesthetic with
a light general anaesthetic or regional
blocks)
• Maintenance of normovolaemia and
normothermia

228 October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589


Quality of care is improved and patients are more active in
3. Enhanced postoperative comfort
• Infiltration of local anaesthetic around
joints to reduce postoperative pain and
allow for earlier mobilisation
• Regular and effective analgesia
• Prophylaxis for nausea and vomiting
4. Optimised postoperative care
• Emphasise re-introduction of normal are employed and there is an emphasis
feeding and hydration
• Early mobilisation
• Promotion of ‘wellness’ and return to
normality – early removal of catheter, to return to ‘normality’ as soon as possible
drips and drains, and independence postoperatively (e.g. free of any catheters,
with washing and dressing
• Clear discharge and post-discharge
arrangements
Specific considerations in
orthopaedic surgery
Enhanced recovery may have taken form
within colorectal surgery, but the use
of multidisciplinary clinical pathways in
orthopaedics is not new. Integrated pathways
have been used worldwide and accounts of
their use in hip and knee arthroplasty patients
have been published for over a decade
(Dowsey et al 1999). There is a considerable
amount of evidence in the literature to
demonstrate the efficacy of these pathways
in reducing length of hospital stay with either
improved (Dowsey 1999, Vanhaecht et al
2005) or unchanged outcomes (Brunenberg
et al 2005, Walter et al 2007) compared with
conventional rehabilitation. They have also
been shown significantly to reduce the cost
of rehabilitation post large joint arthroplasty
(Brunenberg et al 2005, Walter et al 2007),
and to enable more patients to be discharged
back to their usual place of residence rather
than to rehabilitation facilities (Walter et
al 2007). Meta-analyses of the effects
of instituting specific clinical pathways
have generated the consensus that their
introduction significantly improves the quality
of care for patients (Khan et al 2008, Barbieri
et al 2009).
The introduction and subsequent adoption
of enhanced clinical pathways in orthopaedic
surgery has shown further improvement
in postoperative outcomes coupled with
October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589
their own recovery
increased patient satisfaction. Enhanced
recovery programmes are very similar to
integrated care pathways, and often use these
as a starting point. ERAS aims to couple the
two best practices of organisation of care and
clinical management, whilst focusing strongly
on best evidence. Patients, and particularly
their families, are used as useful resources
in planning and managing their own recovery
and care. Standardised surgical methods
on optimised analgesic, fluid and diet
management, with the overall aim of getting
postoperative patients to mobilise more
quickly. The patient is actively encouraged
lines etc and wearing their own clothes
rather than hospital gowns). Quality of care is
improved and patients are more active in their
own recovery.
ERAS has demonstrated continued reductions
in length of stay, without any evidence
of increased complications (Berend et al
2004, Isaac et al 2005, den Hertzog 2012,
McDonald et al 2012). These benefits
are universal, and confer an advantage
regardless of the patient’s preoperative
condition (Dwyer et al 2012). The improved
gains in rehabilitative efficiency also bestow
a considerable economic incentive to
orthopaedic units. Multimodal optimisation is
an important part of this process and is often
achieved via preoperative patient seminars
or clinics, run by nursing staff and therapy
services. These have been shown to be
beneficial and can help to reduce length of
stay, achieve earlier ambulation, and allow for
discharge back to a usual place of residence
(Dowsey et al 1999). McGregor et al (2004)
were able to show that patients who received
a preoperative leaflet and rehabilitation
advice prior to a total hip replacement spent
on average three days less in hospital than
those that received standard care. They also
required less postoperative occupational
therapy. Siggeirsdottir et al (2005) evaluated
the effects of preoperative and postoperative
education programmes and home visits from
an outpatient team. They concluded that the
length of hospital stay can be significantly
shortened if perioperative education is
coupled with home based rehabilitation and
nursing after discharge, whilst improving
quality of life and maintaining patient safety.
CLINICAL FEATURE
The beneficial effects of relational
coordination within a multidisciplinary team
are well established. This involves frequent,
timely, and accurate communication between
the core disciplines involved in the care of
patients undergoing total joint arthroplasty
(doctors, nurses, physiotherapists,
occupational therapists, and social workers),
in order to achieve shared goals. Gittell et
al (2000) found that relational coordination
significantly improved patients’ quality
of care, reducing postoperative pain and
length of hospital stay, whilst improving
postoperative function. Important aspects
of multidisciplinary team working included
frequent communication, strength of shared
goals and mutual respect amongst healthcare
providers. All of these are part of a well
designed enhanced recovery service. The
benefits of multimodal optimisation and
relational coordination even go beyond total
joint arthroplasty in orthopaedics, and may
be associated with a decline in postoperative
morbidity in patients with proximal hip
fractures (Macfie et al 2012).
The improvements to quality of care and
postoperative efficiency that are gained
by implementing ERAS programmes are
thought to be largely due to the underlying
organisational structure. If the patient
pathway is well-structured and highly
standardised, with developmental input from
all members of the multidisciplinary team,
then improvements to patient care are likely
to manifest (Khan et al 2008). Clinicians
lead the development of enhanced recovery
programmes through partnership with
anaesthetists, senior nurses, physiotherapists,
pharmacists, surgical trainees and experts
in acute pain management. The channels
of communication and understanding that
develop as a result of these partnerships
lend themselves to the success of enhanced
recovery, and differentiate ERAS pathways
from their traditional counterparts.
Development of ERAS
programmes
The NHS Institute for Innovation and
Improvement (2008) has highlighted three
key factors that help the development of ERAS
programmes. The first is staff training, and
there are five particular areas to focus on:
1. Knowledge of the evidence regarding
accelerated postoperative recovery
229
CLINICAL FEATURE

Enhanced recovery after surgery (ERAS): an orthopaedic perspective

Continued

2. Changing the mindset to one where Figure 1 The Enhanced Recovery Surgical Pathway (Enhanced Recovery Partnership 2012)
patients are active in their own recovery
process and aiming to achieve a sense of
‘normality’ on the ward
3. Standardised surgical techniques
4. Standardised anaesthetic protocols (e.g.
spinal anaesthetic and local nerve block)
5. Consistent implementation of the protocol
by all members involved in the patient’s
surgical journey.

The second factor is consistent processes and

room layout. Actions and procedures should
be conducted in the same way, every time
so that they become second nature to staff.
Wards and workspaces should have a logical
design and effective organisation to help
improve efficiency.

The third factor is the use of procedure

specific care plans and guidance, normally
provided at a preadmission clinic or
preoperative education class. Figure 1
demonstrates a generic enhanced recovery
pathway, as described by the Enhanced
Recovery Partnership (ERP 2012). Figure 2
describes a more specific standardised
protocol used in our institution to deliver ERAS
after elective hip and knee replacements.
Care plans should educate patients on what
to expect on each day of their surgical journey
including when their target discharge date is.
The entire process should be explained to the
patient and additional information should be
provided by physiotherapists such as the use
of crutches and exercises to practise at home
prior to admission. In this way patients have
a check or reminder for their own care, with
realistic goals and expectations.
The three factors described by the NHS
Institute for Innovation and Improvement are
welcome suggestions, as ERAS remains to
be universally adopted amongst orthopaedic
departments in the United Kingdom. The
reasons for this slow uptake may be due to a
lack of awareness or reluctance to introduce
new, evidence-based practice. This seems
very unlikely however, as most healthcare
providers aim to keep up to date and are
keen to promote best practice (Knos et al
2009). The more plausible answer is that
departments have difficulty organising and
co-ordinating such changes and generating
the necessary lines of communication
*Shared Decision Making (SDM)
between the various health care disciplines
(Maessen et al 2007). This can be very
difficult in orthopaedics due to the large
number of procedures performed. In contrast
to this, the implementation of ERAS in
colorectal surgery has been more widespread,
however the procedural tally is comparatively
smaller (130,842 primary total hip and knee
replacements were completed within the UK
in 2010-2011 compared to 39,431colectomy
and excision of rectum procedures (HES
2011)).
The widespread adoption of ERAS in
orthopaedic surgery is yet to be seen, and
its national uptake is slow to progress.
Much of the outcome data has come from a
restricted number of institutions, and within
these centres, it tends to be selected teams
that have adopted enhanced recovery.
Despite its proven results, there are still
areas of the programme that require further
development. The two latest meta-analyses
on the efficacy of physiotherapy post total hip
arthroplasty/total knee arthroplasty (THA/
TKA) have concluded that the postoperative
physiotherapy exercise either does not work
or is not very effective (Minns Lowe et al
2007, 2009). It is suggested that this may
be because exercise is of too little intensity,
or is offered too late after surgery. Bandholm
& Kehlet (2012) proposed that the focus
should be changed to earlier initiated and
more intensive physiotherapy, in order to
reduce the early loss of muscle strength
and function postoperatively. The earlier
discharge of patients in ERAS programmes
puts more demand on outreach physiotherapy
services, suggesting that the availability of
such services is imperative (Smith et al 2012),
which in turn creates a new challenge for
departmental commissioning. There are

230 October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589

 CLINICAL FEATURE

The improvements to quality of care and postoperative efficiency that are

gained by implementing ERAS programmes are thought to be largely
due to the underlying organisational structure

Figure 2 An example of an orthopaedic enhanced recovery programme

• Surgeon buys into the pathway; promotes it to the patient

Orthopaedic elective clinic
• Patient listed for surgery (identified on the operation list as ‘enhanced’)
• Introductory letter provided on enhanced recovery programme
• Patient given estimated discharge date (approx day 2/3 post-op)
• Booked onto education class
• Comorbidities optimised (via possible anaesthetic assessment)

Education class • Delivered by nurse, PT and OT

(approx 4 weeks pre-op) • Explanation of surgery, anaesthetic, PT and OT goals
• Therapy screening; crutches and exercises provided

• Omit potent BP tablets – last dose before surgery (morning or evening)

Preoperative assessment • Prescription for gabapentin - to start night before surgery
(approx 2 weeks pre-op) • Two carbohydrate drinks (night before and by 6am morning of surgery)
• Pre-printed sticker on prescription chart for antibiotics and analgesics

Day of surgery • Premedication prescribed and given – paracetamol and gabapentin

• Oxycontin 10mg prescribed for post-op analgesia
(Ward admission)
• Fluids taken up to 2 hours pre-op

• Combined partial spinal (opiate-free) and light GA

• Selective catheterisation (>80yrs, diuretics, patient request, prostatic
symptoms, renal impairment)
• No nerve blocks
Operating theatre • Local anaesthetic: 100mls 0.125% chirocaine into joint capsule and
subcutaneous tissues
• Restrictive intra-operative fluids
• Standard enhanced recovery analgesic plan prescribed
• Provisional discharge medication prescribed
• Opsite dressing applied
• Cryocuff for knee replacements
• Post op note – ‘home when safe’ – to allow nurse delegated discharge

• Patients to be labelled as ‘ER’ if completing whole programme to allow

consistent nursing, PT and OT management
• IVI discontinued when patient drinking and BP stable
• Aim to mobilise 2-6 hours after return to ward as allowed by patient stability
• Remove knee bandage after 4 hours
Post-op ward • Early mobility and sitting out promotes patients’ confidence and reduces
(Nurses/PT/OT familiar with general joint stiffness (e.g. toilet visits)
programme) • PT/nurses to ensure cryocuff remains cold (and instruct patient on use)
• If present remove catheter early day 1
• Patient discharged once PT/OT goals achieved and feels confident
• Ward contact details provided
• Routine outpatient PT referral for TKR

• THR/TKR phone call within 5-7 days

Post-discharge • TKR PT visit if required
• 6 week follow-up clinic

BP – blood pressure; ER – enhanced recovery; GA – general anaesthetic; IVI –intravenous infusion; OT – occupational therapist; PT –
physiotherapist; THR – total hip replacement; TKR – total knee replacement

October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589 231

CLINICAL FEATURE
Enhanced recovery after surgery (ERAS): an orthopaedic perspective
Continued
also suggestions that early discharge shifts
the burden of healthcare to a rehabilitation
setting, however this has not been proved
(Berend et al 2004).
As enhanced recovery programmes become
universally established within orthopaedics,
it is logical to predict a dissemination of
practice into other areas of the specialty.
The vast majority of the published material
on ERAS describes its use for total hip and
knee replacements. Reilly et al (2005)
were able to show that ERAS is beneficial
in the treatment of patients undergoing
unicompartmental knee replacement and
Macfie et al (2012) demonstrated the
benefits in those with fractured neck of femur.
These results suggest great possibilities for
enhanced recovery in other arthroplastic
procedures, such as those involving the upper
limb, and for revision surgery as well. It is
a proven mode of practice, with significant
improvements in the outcomes and quality of
care that patients receive. It is also financially
beneficial to hospital institutions, and to the
health service as a whole.
References
Bandholm T, Kehlet H 2012 Physiotherapy
exercise after fast-track total hip and knee
arthroplasty: time for reconsideration? Archives
of Physical Medicine and Rehabilitation 93 (7)
1292-4
BarbieriA, Vanhaecht K, Van Herck P et al 2009
Effects of clinical pathways in joint replacement:
a meta-analysis BMC Medicine 7 32
Basse L, HjortJakobsen D, Billesbolle P et al 2000
A clinical pathway to accelerate recovery after
colonic resection Annals of Surgery 232 (1) 51-7
Berend KR, Lombardi AV, Mallory TH 2004 Rapid
recovery protocol for per-operative care of total
hip and total knee replacement patients Surgical
Tecnology International 13 239-47
Brunenberg D, van Steyn M, Sluimer J et al 2005
Joint recovery programme versus usual care. An
economic evaluation of a clinical pathway for
joint replacement surgery Medical Care 43 (10)
1018-26
den Hertzog A, Gliesche K, Timm J et al 2012
Pathway-controlled fast-track rehabilitation after
total knee arthroplasty: a randomised prospective
clinical study evaluating the recovery pattern,
drug consumption, and length of stay Archives of
Orthopaedic Trauma Surgery 132 (8) 1153-63
Dowsey MM, Kilgour ML, Santamaria NM, Choong
PF 1999 Clinical pathways in hip and knee
arthroplasty: a prospective randomised controlled
study Medical Journal of Australia 170 59-62
232
Dwyer AJ, Tarassoli P, Thomas W, Porter P
2012 Enhanced recovery program in total hip
arthroplasty Indian Journal of Orthopaedics 46
(4) 407-12
Enhanced Recovery Partnership 2012 The
enhanced recovery surgical pathway Available
from: www.improvement.nhs.uk/documents/
ER_Pathway2012.pdf [Accessed March 2013]
Gittell J, Fairfield K, Bierbaum B et al 2000
Impact of relational coordination on quality of
care, postoperative pain and functioning and
length of stay Medical Care 38 (8) 807-19
Hospital Episodes Statistics 2011 Total procedures
and interventions 2010-2011 Available
from: www.hesonline.nhs.uk/Ease/servlet/
ContentServer?siteID=1937&categoryID=210
[Accessed March 2013]
Isaac D, Faode T, Phong L et al 2005 Accelerated
rehabilitation after total knee replacement Knee
12 (5) 346-50
Kehlet H 1997 Multimodal approach to control
postoperative pathophysiology and rehabilitation
British Journal of Anaesthesia 78 606-17
Khan F, Ng L, Gonzalez S, Hale T, Turner-Stokes L
2008 Multidisciplinary rehabilitation programmes
following joint replacement at the hip and knee
in chronic arthropathy Cochrane Database
Systematic Review CD004957
Knos AM, Vermeulen H, Legemate DA, Ubbink DT
2009 Attitudes, awareness, and barriers regarding
evidence-based surgery among surgeons and
surgical nurses World Journal of Surgery 33
1348-55
Macfie D, Zadeh RA, Andrews M et al 2012
Perioperative multimodal optimisation in patients
undergoing surgery for fractured neck of femur
Surgeon 10 (2) 90-4
Maessen J, Dejong C, Hausel J et al 2007 A
protocol is not enough to implement an enhanced
recovery programme for colorectal resection
British Journal of Surgery 94 (2) 224-31
McDonald DA, Siegmeth R, Deakin AH et al 2012
An enhanced recovery programme for primary
total knee arthroplasty in the United Kingdom –
follow up at one year Knee 19 (5) 525-9
McGregor A, Rylands H, Owen A et al 2004 Does
preoperative hip rehabilitation advice improve
recovery and patient satisfaction? Journal of
Arthroplasty 19 464-8
Minns Lowe CJ, Barker KL, Dewey M, Sackley CM
2007 Effectiveness of physiotherapy exercise after
knee arthroplasty for osteoarthritis: systematic
review and meta-analysis of randomised
controlled trials British Medical Journal 335
7624
Minns Lowe CJ, Barker KL, Dewey ME, Sackley
CM 2009 Effectiveness of physiotherapy exercise
following hip arthroplasty for osteoarthritis:
a systematic review of clinical trials BMC
Musculoskeletal Disorders 10 98
NHS Institute for Innovation and Improvement
2008 Enhanced recovery programme
Available from: www.institute.nhs.uk/
quality_and_service_improvement_tools/quality_
and_service_improvement_tools/enhanced_
recovery_programme.html [Accessed March 2013]
October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589
Reilly K, Beard D, Barker K et al 2005 Efficacy
of an accelerated recovery protocol for Oxford
unicompartmental knee arthroplasty – a
randomised controlled trial Knee 12 (5) 341-57
Schwenk W, Muller JM 2005 What is ‘fast-track’
surgery? Deutsche Medizinische Wochenschrift
130 (10) 536-40
Siggeirsdottir K, Olafsson O, JonssonJr H et
al 2005 Short hospital stay augmented with
education and home-based rehabilitation
improves function and quality of life after hip
replacement Acta Orthopaedica 76 (4) 555-62
Smith TO, McCabe C, Lister S et al 2012
Rehabilitation implications during the
development of the Norwich Enhanced Recovery
Programme (NERP) for patients following total
knee and total hip arthroplasty Orthopaedic
Traumatology and Surgical Research 98 (5)
499-505
Vanhaecht K, Sermeus W, Tuerlinckx G et al
2005 Development of a clinical pathway for total
knee arthroplasty and the effect on length of
stay and in-hospital functional outcome Acta
Orthopaedica Belgium 71 439-44
Walter F, Bass N, Bock G, Markel D 2007 Success
for clinical pathways for total joint arthroplasty in
a community hospital Clinical Orthopaedics and
Related Research 457 133-7
About the authors
Jonathan J E White
BSc (Hons), MBBS, MRCS
CT2 Doctor, Department of Trauma and Orthopaedic
Surgery, Royal Derby Hospital
Robert Houghton-Clemmey
BSc (Hons), MBBS, FRCS (TR&Orth)
Pulvertaft Upper Limb Fellow, Pulvertaft Hand
Centre, Royal Derby Hospital
Paul Marval
BMedSci, BMBS, FRCA
Consultant Anaesthetist, Royal Derby Hospital
No competing interests declared
Members can search all issues of the BJPN/JPP
published since 1998 and download articles free of
charge at www.afpp.org.uk.
Access is also available to non-members who pay a
small fee for each article download.
 CLINICAL FEATURE
KEYWORDS Social media / Social network / Facebook

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication February 2013.

The issues surrounding

social network sites
and healthcare
professionals
by Taraneh Azizi
Correspondence address: Main Theatres, Kent and Canterbury Hospital, Ethelbert Road, Canterbury, Kent, CT1 3NG. Email: taranehazizi@nhs.net

This article discusses issues surrounding online social networking, and the implications of the
use of these sites by healthcare professionals. The article provides guidance to healthcare
professionals, as the increased use of sites like Facebook and Twitter have the potential to bring
risks to healthcare. Use of these websites can be a very grey area, and boundaries need to be
clearly set to ensure protection of service users and healthcare staff alike.
Introduction but the healthcare profession needs to be The issues affect all healthcare staff and
aware of the pitfalls to using these sites. trainees, including student practitioners
Facebook and Twitter are some of the who cannot rely on their student status
most popular and heavily used websites
of the modern day, with Facebook having Healthcare professionals and or inexperience to excuse them from
inappropriate social networking. A major
over 1 billion users as of October 2012 social media problem with sites like Facebook is that
(Zuckerberg 2012). These are social there can be a false sense of security,
Social network sites, if used inappropriately,
network sites which provide an open service and individuals can assume that their
can have great implications for healthcare
where anybody that has a valid email privacy settings are such that others
professionals, as there is a very large
address can register and use the website cannot see certain things on their profile or
number of people with a Facebook or
which connects people from all over the ‘wall’. However, even ensuring maximum
Twitter account. Facebook alone has hit
world. Users can create personal profiles protection does not eliminate the possibility
saying where they are from, where they a user base of a billion people in recent
of Facebook ‘friends’ feeling compelled
work and how they are feeling that day by months. This is transforming the way in
to report incidents that they may find
writing on their ‘status’. Users can even which information is accessed and shared.
inappropriate or offensive (Smith 2012).
list family members including children and However, it also raises concerns due to
partners, so that people on their ‘friends the recreational element of use with these
Healthcare professionals should be
list’ can be redirected to others’ profiles websites.
reminded that Facebook is still in the
as well. Events can be created and photos public domain, and as such there is always
uploaded where users can ‘tag’ friends and It has become apparent, through an the risk of public awareness. Therefore
family so that it is clear who is who. Users increasing number of public and high nothing in relation to their work, patients or
can even add their current location and profile cases in the media, that not all professional experiences should be shared
link it to the person they are with, so that healthcare professionals realise how in this way. The implications are not just
others know where they are and what they quickly information can be spread and the for the confidential work that they do, but
are doing. risks associated with their actions online also for the patients they care for. There are
or through a social network. Healthcare serious concerns for patient confidentiality
Regardless of age, gender, religion or workers must always consider whether their and patient safety if staff disclose
profession, a great number of individuals status, comments and photographs are in information, regardless of whether or not it
own a Facebook or Twitter account. Social line with their duty of confidentiality and was deliberate. Most questionable postings
network sites do provide good opportunities their professional code of conduct (Griffith and disclosures among nursing staff are
to share information and can contain 2012). typically done unintentionally (Ross 2012).
educational resources that are helpful, Releasing information such as a diagnosis/

October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589 233

CLINICAL FEATURE
The issues surrounding social network sites and healthcare
professionals
Continued
condition, hospital and even nicknames or
abbreviations can be seen as a breach of
confidentiality. Any personal data is also not
to be disclosed under any circumstances.
The Department of Health (2006) define
personal data as: ‘an individual’s name,
address, age, religion, race, gender and
physical, mental or sexual health’.
Another problem that healthcare
professionals need to consider is the
innocent provision of their place of work
on their Facebook profiles. As a sole factor,
is not necessarily a problem. However,
along with a status or comments they
might write regarding something in the
workplace, or something they write on
a colleague’s profile, it can link specific
cases to specific people at specific dates
and times. Healthcare workers need to be
aware of these risks before it is too late and
confidentiality has already been breached,
and the information is in the public domain.
Health professionals can also be tempted
to share experiences that may be emotional
or upsetting to them, but this risks giving
identifiable information. Discussion
of specific cases should be avoided,
regardless of whether or not names were
mentioned. It may always be possible to
relate the information back to a patient
and/or the professional, and this is how a
seemingly ‘innocent’ posting can actually
violate privacy issues.
Legal implications
It does not stop there. Healthcare
professionals have a duty imposed on
them by law. This duty of care exists where
patients could be or are affected by acts
or omissions of the people involved in
their care (Pirie 2012). Confidentiality is
protected by data protection law, which
is set by common law and statutory law.
Healthcare workers have a fiduciary duty
towards their patients, which is the highest
standard of care in law. Interestingly,
the law does not give special allowance
for trainees or students when assessing
liability. Courts state that the people who
are learning a skill must exercise the same
standard of care as those who are already
proficient in that skill (Huxtable-Goy 2012).
This may be assumed to apply mainly to
doctors, but also includes registrants of
the Nursing and Midwifery Council (NMC)
and Health and Care Professions Council
(HCPC).
234
The risks can be seen when it is considered
that a ‘friend’ of a ‘friend’ on Facebook
perhaps knew or could identify a patient
that may be being discussed, even where
no names were mentioned. The nature
of social media is such that this is not an
unlikely situation, and is actually highly
possible, particularly in localised areas.
As a healthcare professional, consider the
implications and effects that this would
have on the relevant profession due to
public awareness of something that had
been found through Facebook. It could
easily happen to anybody.
Code of conduct
Operating Department Practitioners
(ODPs) and Registered Nurses have an
obligation to work at a standard set by
their respective regulatory body as part of
their professional registration. They are
professionally accountable to the regulator,
which is a normal part of professional
healthcare practice (Pirie 2012). The NMC
(2011) has issued specific advice to nurses
regarding expected behaviour when using
social network sites. This is definitely
the way forward to promote awareness
of these issues, as it makes it very clear
that nurses must uphold the reputation of
their profession at all times. The NMC also
advises that conduct online is judged in
the same way as work and private life, and
that this is applicable to all forms of online
communication.
The HCPC (2011) has also focused on
standards in relation to social network sites,
and stated that they will take action against
registrants if confidential information about
a service user has been posted on their
blog or Facebook page. They also mention
that they have no problem with registrants
expressing views and opinions online,
but that comments should not breach
confidentiality or be offensive. In addition,
anything posted should be within the
professional standards set for registrants.
Healthcare practitioners have a professional
duty of confidence not to disclose
information gained in a professional
capacity to a third party, and this
includes by inappropriate use of social
networking sites (Griffith 2012). The NMC
and HCPC have clear guidelines in their
documentation that are directly applicable
to social network sites. The standards
October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589
required of pre-registration individuals
(students) are no different. The guidelines
state clearly that all practitioners should:
• always respect the confidentiality of your
service users
• not knowingly give out any personal or
confidential information to anyone who
is not entitled to access it
• keep high standards of personal
conduct
• make sure that your behaviour does
not damage public confidence in your
profession (HCPC 2012)
• respect people’s right to confidentiality
• make the care of people your first
concern, treating them as individuals
and respecting their dignity
• be open and honest, act with integrity
and uphold the reputation of your
profession
• always act lawfully, whether those
laws relate to your professional practice
or personal life (NMC 2008).
Registered practitioners should
remember to set an example to their
peers and the students that they mentor.
Along with student practitioners,
they should act responsibly as they are still
bound by a professional code of conduct
and their fitness to practice and their
suitability to the healthcare profession
can be called into question by their
employer or educational institution.
All relevant healthcare professionals
should abide by their respective code
of conduct at all times to demonstrate
compliance with their duty of care and to
assume responsibility for their own actions.
Consequences
Nurses have been dismissed from duty
because of Facebook related incidents and
there are many articles and reports that
have shown that healthcare professionals
are clearly not as aware as they should
be with the risks of social networking,
or the risks that they carry from their
interaction with these sites (BBC 2011).
There are serious implications for staff
who breach their duty of care through data
confidentiality and healthcare professionals
should familiarise themselves with their
employment contracts and ensure that they
do not engage in conduct that breaches
the contractual relationship between the
employee and the trust or organisation that

The NMC and HCPC have clear guidelines in their documentation that are
directly applicable to social network sites
they work for. Inappropriate use of social
networking sites falls under NHS trust
disciplinary procedures on the grounds of
’breach of confidentiality’ and ’conduct that
brings the trust’s name into disrepute’.
Employees will be investigated and can be
suspended, downgraded and ultimately
dismissed under these points (Local NHS
Trust 2012).
Furthermore, registration from regulatory
bodies can be suspended or terminated
based on the outcome of these disciplinary
processes. The nature of Facebook is such
that it is in the public domain, and therefore
access to information is not as ‘private’ as
people think, and there is always the risk of
public awareness. This could pose a major
risk to patient safety, privacy and dignity – a
major concern at a national level where the
NHS is already struggling with other issues.
The issues are not just within healthcare, as
the recent Sally Bercow Twitter posts have
shown. The viral nature of social networking
most certainly has its problems and this
is becoming a most apparent issue in the
modern day. As Twitter is not legally liable
for what appears on the site, individuals,
irrespective of profession, need to think
about what they are writing. The law sees
social network sites as a platform rather
than a publisher, so care needs to be
taken when posting statuses, comments or
‘Tweets’ online (Channel 4 2012).
The latest media coverage of social
network mishaps makes it evident that
individuals are not being careful enough,
and are creating compromising situations
for the people involved. The Sally Bercow
tweets breached government and political
boundaries, as well as legal breaches of
data confidentiality, where the name of
an underage girl who was supposed to be
protected by law, was made public. The
issues are becoming more and more serious
with each new story that gains coverage in
the press, and it is the responsibility of each
individual to ensure that they are not doing
anything that has the potential to risk the
safety of themselves or another in any way.
Conclusion
Social networking has positive factors and
benefits many individuals for educational
or professional purposes, but also invokes
the desire to respond (Coates 2012).
October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589
Healthcare professionals should consider
the following table of DOs and DON’Ts in
order to ensure professional behaviour
appropriate to their regulatory body codes
of conduct (Table 1).
There is a clear need for education and
guidance on how healthcare professionals
should use social network sites. Managers
in healthcare settings need to promote
education and awareness of these issues
to make sure that staff are unlikely to make
mistakes online. This could be achieved
by discussing the issues around social
networking as a current issue through staff
training days and audit sessions. It is often
assumed that young people are the main
‘culprits’ as they are the ones presumed to
generally engage with social network sites.
This is not necessarily the case, and it can be
seen from the Facebook user base that the
older generation, parents and more are also
DO DON’T
Make a distinction between
your personal and
professional life
Use social media for
educational purposes
Set your privacy settings as
high as possible and
minimise friends/followers
Think before you type –
should you be writing
what you are about to write?
Be honest – deleted
comments or statuses
can actually be retrieved
Treat everything online as
public, permanent and
shared
Follow workplace policy for
both staff and students
Table 1 Adapted from Odom-Forren 2012 and NMC 2011
CLINICAL FEATURE
using social media.
Local trust policy contains clear disciplinary
guidelines that ’inappropriate use of social
network sites’ is a dismissible offence, yet
there is not always distinct policy to indicate
what is or is not classed as appropriate
use of these sites. This does not mean that
healthcare professionals have a loophole
for excuse or ignorance, but reiterates the
need for every healthcare individual to take
the necessary steps to ensure that they
are fully aware of how they engage with
the sites. Similarly, larger organisations
and companies need to be careful about
information that they use on public forums
or social media so that they are not in a
position where they are found negligent
through breach of data protection or related
legal issues.
Be lulled by a false sense of
security or the sense that
your comments are private
Discuss patients, colleagues
or locations
Upload or take photos of you,
your colleagues or your
patients at work
Comment on anything you
see colleagues writing
– avoid any involvement
whatsoever
Give medical advice via
social media
Use social network sites to
raise or escalate concerns or
whistle blow
Use social networks to build
or pursue relationships with
current or former patients
235
CLINICAL FEATURE
The issues surrounding social network sites and healthcare
professionals
Continued
Social network sites are a common platform
for interaction online with friends, family
and colleagues. However healthcare
professionals must consider the possibility
that their comments or photos could be
inappropriate and not in line with the
standards expected of them from regulatory
bodies. Whilst the implications are not
limited to them, healthcare staff do carry a
great responsibility and accountability for
their patients which if broken, could result
in dismissal, criminal charges or regulatory
body sanctions.
Greater awareness can be achieved through
better in-house education and learning for
healthcare professionals. With so many
people now using social network sites,
there may even be the need for inclusion
of the issues surrounding these sites within
hospital e-learning and data confidentiality
training, which is mandatory for all staff
members within the healthcare setting.
References
BBC News 2011 Nottingham nurse sacked
over Facebook photo Available from: www.
bbc.co.uk/news/uk-england-nottingham-
shire-15492092?print=true [Accessed March 2013]
Channel 4 News 2012 Do we need a ‘green cross
code’ for Twitter? Available from: www.channel4.
com/news/twitter-sally-bercow-contempt-lord-
mcalpine-schoolgirl [Accessed March 2013]
Coates T 2012 Don’t just tick it, talk it! Tweeted
by Tracy Coates in reference to the surgical
checklist Journal of Perioperative Practice 22
(7) 210
Department of Health 2006 NHS Code of
Practice: Part 1 London, DH
236
Griffith R 2012 Duty of confidence and the use of
social networking sites British Journal of Nursing
21 (16) 988-9 About the author
Health and Care Professions Council 2012 Taraneh Azizi
BSc (Hons)
Guidance on conduct and ethics for students
Available from: www.hpc-uk.org/assets/ Operating Department Practitioner, Main Theatres,
documents/10002C16Guidanceonconductandeth- Kent and Canterbury Hospital
icsforstudents.pdf [Accessed March 2013]
Student SIG Lead, Association for Perioperative
Practice
Health Professions Council 2011 Focus on stand-
ards – social networking sites In: Focus. Health No competing interests declared
Professions Council Newsletter 34 3
Huxtable-Goy A 2012 Indemnity and liability [Lec-
ture given to BSc operating department practice Members can search all issues of the BJPN/JPP
Year 3] October published since 1998 and download articles free of
charge at www.afpp.org.uk.
Local NHS Trust 2012 Disciplinary procedure Access is also available to non-members who pay a
small fee for each article download.
(Anonymised)
Nursing and Midwifery Council 2008 The code:
Standards of conduct, performance and
ethics for nurses and midwives Available from:
www.nmc-uk.org/Documents/Standards/The-
code-A4-20100406.pdf [Accessed March 2013]
Nursing and Midwifery Council 2011 Regulators
act to prevent nurses and midwives getting into
trouble on Facebook Available from: www.nmc-
uk.org/Press-and-media/Latest-news/Regulator-
acts-to-prevent-nurses-and-midwives-getting-into-
trouble-on-Facebook/ [Accessed March 2013]
Odom-Forren J 2012 Responsible social networking
Journal of PeriAnesthesia Nursing 27 (1) 61-3
Pirie S 2012 Legal and professional issues for the
perioperative practitioner Journal of Periopera-
tive Practice 22 (2) 57-62
Ross J 2012 Social networking: possible risks to
nurses Journal of PeriAnesthesia Nursing 27 (3)
212-3
Smith B 2012 Social networking and professional
pitfalls International Journal of Orthopaedic
and Trauma Nursing EDITORIAL 16 63-4
Zuckerberg M 2012 One billion people on Face-
book Available from: http://newsroom.fb.com/
News/457/One-Billion-People-on-Facebook [Ac-
cessed March 2013
October 2013 / Volume 23 / Issue 10 / ISSN 1750-4589
Instructions for authors
Please read these instructions carefully, as articles will only be accepted if they are in the correct
format, with references laid out as described below.
Administration
Receipt of manuscripts will be acknowledged, but not
letters or items of interest. Published authors will be
paid up to £200 for a full article (depending on the
length) and £10 for a letter. Author payments will be
made within six weeks of publication date. Articles
submitted must not be under consideration by any
other publication.
Competing interests
Competing and potentially competing interests must
be declared upon initial submission of your article.
Presentation
The usual length for a journal article is 2,500 to
3,000 words. Longer articles may be edited or
published in more than one part. All articles should
be typed using double line spacing with wide margins
on both sides of the page and leaving a space
between paragraphs.
Ideally the article should be submitted on CD or by
email. It should be saved in Microsoft Word.
The article should be accompanied by an abstract of
70 words maximum and a minimum of
three keywords.
More specific information on article types and
presentation is available from AfPP’s website: www.
afpp.org.uk/books-journals/Journal-of-Perioperative-
Practice/Write-for-JPP-link
The reviewing process
Each paper is reviewed by the editor and, if it is
judged suitable for this publication, it is then sent to
two referees for double blind peer review. Based on
their recommendations, the editor then decides
whether the paper should be accepted as it is,
revised or rejected.
If your paper is accepted, you will be asked to
complete and sign AfPP’s copyright form. Your paper
will then be allocated a publication date, usually
within six months. If revision is necessary, your
manuscript will be returned to you along with the
reviewers’ remarks and a new deadline will be agreed
upon for the re-submission of your paper.
Occasionally, papers are rejected. This is usually
because they are not suitable for the remit of this
journal. If your paper is rejected we will endeavour to
briefly explain the reasons why.
Reference list
Article – surname and initials of author(s), year of
publication, title of article, name of journal (in full and
in bold and italics), volume number, part number in
brackets and page numbers. For example:
O’ Regan P, Wills T 2009 The growth of
complimentary therapies: and their benefits in the
perioperative setting Journal of Perioperative
Practice 19 (11) 382-386
Book – surname and initials of author(s), year of
publication, name of book in bold, edition number if
applicable, first listed place of publication and name
of publisher. For example:
Cox F 2009 Perioperative Pain Management
Oxford, Wiley-Blackwell
Chapter in a book – surname and initials of chapter
author(s), year of publication, name of chapter,
initials and surname of editor(s), name of book in
bold, place of publication and name of publisher. For
example:
Chumbley G 2009 Patient-Controlled Analgesia. In:
Cox F (ed) Perioperative Pain Management Oxford,
Wiley-Blackwell
CD-ROM – surname and initials of author(s), year of
publication, title of CD-ROM in bold, version, date of
last update, if applicable, and supplier. For example:
Wilson SE 2006 Surgery [CD-ROM] Current Clinical
Strategies Publishing
Internet source – surname and initials of author(s) or
corporate author, year of online publication, title in
bold, version or date of last update if known,
location (URL), date accessed. For example:
National Patient Safety Agency 2007 PSA 21 Safer
Practice with Epidural Injections and Infusions
[online] Available from: www.npsa.nhs.uk/alerts-
and-directives/alerts/edidural-injections-and-
infusions/?locale=en [Accessed November 2009]
List to be in alphabetical order. Differentiate between
works published in the same year by the same
author(s) by labelling them a, b, c. Do not use ‘et al’ in
the references unless there are more than seven
authors, in which case the first three should be listed
followed by ‘et al’.
Use minimum punctuation and capitalisation:
n No full stops at the end of entry
n No full stop after the author’s initials
n No brackets around the date
n No ampersands – authors’ names to be
separated by a comma.
For direct quotations of more than four words use a
new indented paragraph that is single-spaced with
the reference and page number at the end of the
quotation.
If one author is summarised by another then it should
be presented as ‘cited in’ eg: ‘…McGrath cited in
Marsh (2000) contends that …’ Here it would be
Marsh that appears in the reference list.
References in the text
The Journal of Perioperative Practice uses a modified
Harvard system of referencing.
Use the name and date separated by a space, eg:
(Symonds 2005). Use commas to separate several
entries eg: (Gilchrist 2004, Langer 2005, MacGill
2006). List references in chronological order. For
organisations, use initials in the text (DH 2008), and
spell out in your reference list (Department of Health
2008).
Link two authors by an ampersand and use ‘et al’ for
three or more authors, eg: ‘Bennett (2001) asserted…
however others disagreed (Davies & Holmes 2004)
and have been supported by research (Lee 2003,
Martyn et al 2004)’.
Illustrations
Digital photographs must be taken at maximum
resolution and supplied at 100% as original
unmodified jpegs, and supplied on CD or by email.
Photographs and CDs should be protected in
the post, enclosed in card. Please provide a key for
group shots.
All artwork should have a plain original without
lettering or numbering and a labelled copy.
Permission to reproduce illustrations must be
obtained by the author from the owner of the
copyright, usually the publisher. Written permission
should accompany the illustrations.
Checklist
n Include your full details: name, qualifications, job
title and place of work, telephone number and
email address.
n An abstract of around 70 words.
n At least three key words.
n A reference list in house style.
By post  to The Editor, JPP,
Daisy Ayris House, 42 Freemans Way,
Harrogate, HG3 1DH
By email  with a covering letter and
full details (address, work place etc)
to editor@afpp.org.uk
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