H&N Laryngectomy ERAS Pathway - Bedside Notes Version 2

Head & Neck Surgery Laryngectomy
Enhanced Recovery Programme

Bed End Chart for Staff use
This chart is to be used as a prompt for compliance with the patient pathway and
an audit tool it does not replace medical notes
Please ensure this document accompanies the patient at all times, and is used
during nursing handover and ward rounds.
October 2015 (version 2:0)
Admission Date: ______________

PATIENT DETAILS
NOK CONTACT INFORMATION
Head & Neck Surgery Laryngectomy Enhanced Recovery Programme

Bed End Chart V1.0
Neck dissection (ND)
Yes
ND Type (details) Lt Rt
Flap Reconstruction
No

Yes
No
Yes
No
Hemi
Total
Primary Tracheoesophageal Puncture
Yes
No
Salivary Fistula Tube
Yes
No
Enteral feeding
Yes
No
Carbohydrate loading
Yes
No
Tracheostomy
Yes
No
Type of tube Make: Size:
Head and Neck Consultant Name
Clinical Nurse Specialist Name
Admission Date
Planned Discharge Date
Actual Discharge Date
Delayed discharge cause
Donor Site
Thyroidectomy
Thyroidectomy procedure
airway
wound
Medical
Equipment
Other

Bed End Chart V1.0
Clinic: Pre-admission Assessment

Information:
0 Surgical plan confirmed
____________________________________
Operation discussed
0 Enhanced recovery concept explained
0 Patient encouraged to increase activity levels

0
Patient information leaflet provided
Dietician:
0 Dietician review
0
Nutritional status assessed
Feeding plan confirmed with consultant (e.g. NG feed or if PEG to be placed)
Discuss nutritional supplements, if indicated
Preload feeding discussed
Post-op nutrition discussed
SALT:
0 SALT review
PHYSIOTHERAPIST:
0 Physiotherapy review
ANAESTHETIST: Contact Dr B Patel or scheduled anaesthetist via Hazel Still (Ext 4116)
0 Reviewed in MDT
or
0 Anaesthetic pre-assessment clinic
CLINICAL NURSE SPECIALIST:
Reviewed by CNS
Patient assessed for risk of ETOH withdrawal
Detox regimen if appropriate
Alert ENT team
If smoker consider smoking cessation & refer Smoking Cessation Team
Consider risk of delayed discharge
At risk?
YES 0 NO 0
If yes, refer to Discharge Co-ordinator (below). Date: _____________________

Karen.parr@nhs.net and leave message on extension 4519 0

Bed End Chart V1.0
Pre-operative surgical checklist

0 Clerking
0 Imaging available (MRI / CT / PET)
0 Pre-op blood results available (FBC / U&E / Coag)
0 G&S: 2 samples required, one of which must be within 7 days.
(Cross match 2 units only if Hb <10 or antibodies or significant blood loss anticipated)
0 ECG
0 Drug chart Cross off ACE Inhibitor (if applicable) night before surgery
0 Mark surgical site
0 Consent
0 TEDS
0 Ensure preload prescribed:
2 sachets in 800mls water at 21.00 - evening prior to surgery
1 sachet in 400mls water at 05.30 - morning of surgery
0 If diabetic, follow standard DM pre-op guidance as per trust protocol (red book)
0 Confirm ICU bed booked
Morning of surgery:
0 Patient to be ready for theatre 07.30 on morning of surgery

Deviation:

Bed End Chart V1.0
Anaesthesia
0 Lines: Arterial line, consider Femoral CVC if required
0 Standard anaesthetic technique with remifentanil infusion
0 LiDCO: Optimise cardiac output - goal directed fluid management, as per protocol for
duration of operation
0 Aim lactate <2mmol/l

0 Give first dose of antibiotics (augmentin or ciprofloxacin & metronidazole if pen. allergic)
0 Give first dose of Dexamethasone 8mg
0 Prescribe/sign for regular Paracetamol 1g iv/po 8 hrly
0 Write up prn Tramadol 50-100mg 6 hrly iv/po (if not given, document why)
0 Write up prn Cyclizine and Ondansetron
0 VTE prophylaxis (LMWH - commence evening of surgery if surgeon in agreement)

Deviation:

Bed End Chart V1.0

Bed End Chart V1.0
Post Operative Recovery & ICU/Clandon admission

Post-op Day Zero
Date & Time: _____________
Notes: __________________________________________________________________________
________________________________________________________________________________
Airway
Patient will come to ICU with ETT/tracheostomy/laryngectomy tube - confirm and label spare
tracheostomy inner tube on admission
Chest XR check NG position if present
Check tube secured, humidified oxygen and secretions suctioned
Circulation
Continue GDFT with LiDCO overnight if on ICU
Maintain:
MAP 70 - 80mmHg
lactate <2mmol/l
Hb >80g/l (>100g/l if CVS co-morbidity)
If MAP low, consider Outreach / ICU referral

Post-operative care
Nurse slightly head up at 45
Laryngectomy heated, humidified oxygen, site checked at least once/shift, suction

once/shift or as necessary, TOP observation
VTE prophylaxsis/anticoagulation as prescribed
Monitor drains, ensure vacuum present (revac as appropriate)
Ensure saliva fistula tube in situ (contact ENT on bleep 0500 if concerned)
Check topical lidocaine spray prescribed to aid tolerance of salivary fistula tube
Check antibiotics prescribed (total 7 day course)
Deviation:

Bed End Chart V1.0
ITU / ADU / Ward
Post-op Day One
Date & Time ______________
Nursing:
Transfer to Clandon Ward as able
Remove arterial and (femoral) central venous lines before ward transfer
Laryngectomy (care as per day zero)
Monitor drain & urine output
Doctors:
0 Consider change to laryngectomy tube after discussion with surgeon

0
Ensure antibiotics prescribed and given and consider steroids if appropriate
Analgesia as prescribed. Consider uptitrating if required
Ensure antiemetics and anti reflux medication prescribed
LMWH until discharge
Confirm presence and tolerance of salivary fistula tube
Monitor drain output and presence of vacuum
Discuss with surgeon re: water soluble contrast swallow assessment for day 7
Feeding:
Commence standard feeding regimen following surgical review: Increase rate (and
reduce IVI) as per protocol
Record blood sugars, bowel movement
Mobilisation/Physio:
0 Chest physio
0
Transfer out of bed/mobilise as able
morning
afternoon 0
SALT:
0 Review, airway assessment, laryngectomy tube removal plus stoma obs if appropriate
0 Education

Bed End Chart V1.0
ITU / ADU / Ward
Post-op Day Two
Date & Time: _____________
Nursing:
Transfer out of bed & encourage to sit out in chair
TWOC
Doctors:
Consider neck drain(s) removal if <30ml + surgeon approval
Ensure antibiotics prescribed and given
Ensure antiemetics anti reflux medication prescribed
Feeding:
Continue feeding regime via NG tube
Record BMs and bowel movement
Physio/Mobilisation:
Chest physio
Neck / Shoulder physio as appropriate (if drains out)
Mobilise as able with physio:
Laryngectomy (care as per day 0)
Morning
Afternoon 0
SALT:
Education, support and manage stoma care
Social:
0
0
Review by discharge coordinator to identify problems and target discharge date

Family update as necessary

Bed End Chart V1.0
ITU / HDU / Ward
Post-op Day Three
Date & Time _____________
Nursing:
Doctors:
Consider neck drain removal if <30ml & still in situ
Feeding:
Aim to meet full nutritional requirements via NG
Record BMs and bowels
Chest physio
Mobilise independently
or as able with physio:
Morning
Laryngectomy (care as per day 0)
Afternoon 0
SALT:
Social:
Ensure review by discharge coordinator to identify problems

Bed End Chart V1.0
ITU / HDU / Ward
Post-op Day Four
Date & Time _____________
Nursing:
Doctors:
Feeding:
Full nutritional requirements via NG
Chest physio
Mobilise independently
or as able with physio:
Morning
Afternoon 0
Rehabilitation will be continued until the patient is mobilising independently.
SALT:
Social:
0
Review target discharge date
10

Bed End Chart V1.0
ITU / HDU / Ward
Post-op Day Five
Date & Time: _____________
Nursing:
0
Encourage independence
Doctors:
0
General reassurance
Consider removal of sutures if surgeon in agreement
Feeding:
NG feed
Chest physio continued until the patient is independent maintaining own chest
Rehabilitation to be continued until patient mobilising independently.
SALT:
Social:
0
11

Bed End Chart V1.0
ITU / HDU / Ward
Post-op Day Six
Date & Time: _____________
Nursing:
0
Doctors:
0
General reassurance
Feeding:
NG feed
Continue until independent
SALT:
Social:
0
12

Bed End Chart V1.0
ITU / HDU / Ward
Post-op Day Seven
Date & Time: _____________
Nursing:
Doctors:
Ensure water soluble contrast swallow assessment completed today
Stop antibiotics completion of 7 days
Consider removal of clips (alternate)
Examine stoma
Feeding:
Eating and drinking if swallow test passed
0
0

Eating and drinking if swallow test passed - monitor
SALT:
Social:
Consider fitness for discharge
Home help/social service referrals as appropriate
13

Bed End Chart V1.0
ITU / HDU / Ward
Post-op Day Eight
Date & Time: _____________
Nursing:
Doctors:
Check oral intake
Consider removal of remaining clips
Examine stoma
Feeding:
Oral feed (NGT removal as able)
Shoulder and neck function assessed
SALT:
0
0
0
0

Monitor eating and drinking
Change TOP if indicated
Voice prosthesis management
Social:
14

Bed End Chart V1.0
ITU / HDU / Ward
Post-op Day Nine
Date & Time: _____________
Nursing:
Doctors:
Check oral intake
Examine stoma
Feeding:
Oral feed
SALT:
0
0
0

Airway and voice prosthesis management
Encourage independence and laryngectomy self care
Social:
Chase home help/social service referrals
15

Bed End Chart V1.0
ITU / HDU / Ward
Post-op Day Ten
Date & Time: _____________
Nursing:
0
0
Doctors:
Discharge care information to patient
Confirm follow-up plans
Check stoma
Feeding:
Oral feed
SALT:
0
0
0

Social:
0
0
Discharge planning
16

Bed End Chart V1.0
ITU / HDU / Ward
Post-op Day Eleven
Date & Time: _____________
Nursing:
Doctors:
Feeding:
Oral feed
SALT:
0
0
0

Social:
0
0
Discharge planning
17

Bed End Chart V1.0
ITU / HDU / Ward
Post-op Day Twelve
Date & Time: _____________
Nursing:
Doctors:
Feeding:
Oral feed
SALT:
0
0
0

18

Bed End Chart V1.0
ITU / HDU / Ward
Post-op Day Thirteen
Date & Time: _____________
Nursing:
Doctors:
Feeding:
Oral feed
SALT:
0
0
0

Encourage independence and laryngectomy self caring
19

Bed End Chart V1.0
ITU / HDU / Ward
Post-op Day Fourteen
Date & Time: _____________
DISCHARGE CHECKLIST
0
Ensure self caring in context of laryngectomy
Home suction and laryngectomy equipment in place
Discharge medication:
Follow up appointment and out patient plan
Ward and emergency contact details
Analgesia/regular medications
20

H&N Laryngectomy ERAS Pathway - Bedside Notes Version 2

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Head & Neck Surgery Laryngectomy

Enhanced Recovery Programme

NOK CONTACT INFORMATION

Head & Neck Surgery Laryngectomy Enhanced Recovery Programme

Neck dissection (ND)

Primary Tracheoesophageal Puncture

Salivary Fistula Tube

Type of tube Make: Size:

Head and Neck Consultant Name

Clinical Nurse Specialist Name

Planned Discharge Date

Actual Discharge Date

Delayed discharge cause

Head & Neck Surgery Laryngectomy Enhanced Recovery Programme

Clinic: Pre-admission Assessment

0 Enhanced recovery concept explained

0 Patient encouraged to increase activity levels

Patient information leaflet provided

Nutritional status assessed

Feeding plan confirmed with consultant (e.g. NG feed or if PEG to be placed)

Discuss nutritional supplements, if indicated

Preload feeding discussed

Post-op nutrition discussed

0 Anaesthetic pre-assessment clinic

CLINICAL NURSE SPECIALIST:

Patient assessed for risk of ETOH withdrawal

Detox regimen if appropriate

Alert ENT team

If smoker consider smoking cessation & refer Smoking Cessation Team

Consider risk of delayed discharge

If yes, refer to Discharge Co-ordinator (below). Date: _____________________

Head & Neck Surgery Laryngectomy Enhanced Recovery Programme

Pre-operative surgical checklist

Head & Neck Surgery Laryngectomy Enhanced Recovery Programme

0 Aim lactate <2mmol/l

Head & Neck Surgery Laryngectomy Enhanced Recovery Programme

Head & Neck Surgery Laryngectomy Enhanced Recovery Programme

Post Operative Recovery & ICU/Clandon admission

Date & Time: _____________

Chest XR check NG position if present

Check tube secured, humidified oxygen and secretions suctioned

Continue GDFT with LiDCO overnight if on ICU

If MAP low, consider Outreach / ICU referral

Nurse slightly head up at 45

Laryngectomy heated, humidified oxygen, site checked at least once/shift, suction

VTE prophylaxsis/anticoagulation as prescribed

Monitor drains, ensure vacuum present (revac as appropriate)

Check antibiotics prescribed (total 7 day course)

Head & Neck Surgery Laryngectomy Enhanced Recovery Programme

ITU / ADU / Ward

Post-op Day One

Date & Time ______________

Transfer to Clandon Ward as able

Laryngectomy (care as per day zero)

Monitor drain & urine output

0 Consider change to laryngectomy tube after discussion with surgeon

Ensure antibiotics prescribed and given and consider steroids if appropriate

Analgesia as prescribed. Consider uptitrating if required

Ensure antiemetics and anti reflux medication prescribed

LMWH until discharge

Confirm presence and tolerance of salivary fistula tube

Monitor drain output and presence of vacuum