Emily Pearsall

A qualitative study to understand the barriers and enablers in implementing an enhanced recovery after surgery program.

OBJECTIVE Explore the barriers and enablers to adoption of an Enhanced Recovery after Surgery (ERAS) program by the multidisciplinary perioperative team responsible for the care of elective colorectal surgical patients. BACKGROUND ERAS programs include perioperative interventions that when used together have led to decreased length of stay while increasing patient recovery and satisfaction. Despite the known benefits of ERAS programs, uptake remains slow. METHODS Semistructured interviews were conducted with general surgeons, anesthesiologists, and ward nurses at 7 University of Toronto-affiliated hospitals to identify potential barriers and enablers to adoption of 18 ERAS interventions. Grounded theory was used to thematically analyze the transcribed interviews. RESULTS Nineteen general surgeons, 18 anesthesiologists, and 18 nurses participated. The mean time of each interview was 18 minutes. Lack of manpower, poor communication and collaboration, resistance to change, and patient factors were cited by most as barriers. Discipline-specific issues were identified although most related to resistance to change. Overall, interviewees were supportive of implementation of a standardized ERAS program and agreed that a standardized guideline based on best evidence; standardized order sets; and education of the staff, patients, and families are essential. CONCLUSIONS Multidisciplinary perioperative staff supported the implementation of an ERAS program at the University of Toronto-affiliated hospitals. However, major barriers were identified, including the need for patient education, increased communication and collaboration, and better evidence for ERAS interventions. Identifying these barriers and enablers is the first step toward successfully implementing an ERAS program.

Development of an Enhanced Recovery After Surgery Guideline and Implementation Strategy Based on the Knowledge-to-action Cycle.

Background: Enhanced Recovery After Surgery (ERAS) protocols have been shown to increase recovery, decrease complications, and reduce length of stay. However, they are difficult to implement. Objective: To develop and implement an ERAS clinical practice guideline (CPG) at multiple hospitals. Methods: A tailored strategy based on the Knowledge-to-action (KTA) cycle was used to develop and implement an ERAS CPG at 15 academic hospitals in Canada. This included an initial audit to identify gaps and interviews to assess barriers and enablers to implementation. Implementation included development of an ERAS guideline by a multidisciplinary group, communities of practice led by multidiscipline champions (surgeons, anesthesiologists, and nurses) both provincially and locally, educational tools, and clinical pathways as well as audit and feedback. Results: The initial audit revealed there was greater than 75% compliance in only 2 of 18 CPG recommendations. Main themes identified by stakeholders were that the CPG must be based on best evidence, there must be increased communication and collaboration among perioperative team members, and patient education is essential. ERAS and Pain Management CPGs were developed by a multidisciplinary team and have been adopted at all hospitals. Preliminary data from more than 1000 patients show that the uptake of recommended interventions varies but despite this, mean length of stay has decreased with low readmission rates and adverse events. Conclusions: On the basis of short-term findings, our results suggest that a tailored implementation strategy based on the KTA cycle can be used to successfully implement an ERAS program at multiple sites.

Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: a process evaluation of champions’ experiences

BackgroundEnhanced recovery after surgery (ERAS) is a multimodal evidence-based approach to patient care that has become the standard in elective colorectal surgery. Implemented globally, ERAS programmes represent a considerable change in practice for many surgical care providers. Our current understanding of specific implementation and sustainability challenges is limited. In January 2013, we began a 2-year ERAS implementation for elective colorectal surgery in 15 academic hospitals in Ontario. The purpose of this study was to understand the process enablers and barriers that influenced the success of ERAS implementation in these centres with a view towards supporting sustainable change.MethodsA qualitative process evaluation was conducted from June to September 2014. Semi-structured interviews with implementation champions were completed, and an iterative inductive thematic analysis was conducted. Following a data-driven analysis, the Normalization Process Theory (NPT) was used as an analytic framework to understand the impact of various implementation processes. The NPT constructs were used as sensitizing concepts, reviewed against existing data categories for alignment and fit.ResultsFifty-eight participants were included: 15 surgeons, 14 anaesthesiologists, 15 nurses, and 14 project coordinators. A number of process-related implementation enablers were identified: champions’ belief in the value of the programme, the fit and cohesion of champions and their teams locally and provincially, a bottom-up approach to stakeholder engagement targeting organizational relationship-building, receptivity and support of division leaders, and the normalization of ERAS as everyday practice. Technical enablers identified included effective integration with existing clinical systems and using audit and feedback to report to hospital stakeholders. There was an overall optimism that ERAS implementation would be sustained, accompanied by concern about long-term organizational support.ConclusionsSuccessful ERAS implementation is achieved by a complex series of cognitive and social processes which previously have not been well described. Using the Normalization Process Theory as a framework, this analysis demonstrates the importance of champion coherence, external and internal relationship building, and the strategic management of a project’s organization-level visibility as important to ERAS uptake and sustainability.

Enhanced Recovery After Surgery: Implementation Strategies, Barriers and Facilitators

Numerous reports have documented the effectiveness of Enhanced Recovery after Surgery (ERAS) pathways in improving recovery and decreasing morbidity and length of stay. However, there is also increasing evidence that ERAS® guidelines are difficult to adopt and require the commitment of all members of the perioperative team. Multiple barriers related to limited hospital resources (financial, staffing, space restrictions, and education), active or passive resistance from members of the perioperative team, and lack of data and/or education have been identified. Thus, ERAS® guidelines require a tailored implementation strategy to increase adherence.

Fundamentals of Patient Preparation for the Operating Room in the Twenty-First Century

Preoperative preparation is essential in order to optimize outcomes and decrease complications, mortality, and length of stay of the surgical patient. With the adoption of the concept of enhanced recovery after surgery, there is an increased emphasis on the preoperative phase of care recognizing that if patients are in optimal condition preoperatively, they are more likely to recover more quickly postoperatively. Patient education is also an important part of their care as there is also an increased emphasis on self-management in ERAS protocols.

Executive Summary: Enhanced Recovery After Surgery: Best Practice Guideline for Care of Patients With a Fecal Diversion.

Enhanced Recovery After Surgery (ERAS) is a multimodal program developed to decrease postoperative complications, improve patient safety and satisfaction, and promote early discharge. In the province of Ontario, Canada, a standardized approach to the care of adult patients undergoing elective colorectal surgery (including benign and malignant diseases) was adopted by 15 hospitals in March 2013. All colorectal surgery patients with or without an ostomy were included in the ERAS program targeting a length of stay of 3 days for colon surgery and 4 days for rectal surgery. To ensure the individual needs of patients requiring an ostomy in an ERAS program were being met, a Provincial ERAS Enterostomal Therapy Nurse Network was established. Our goal was to develop and implement an evidence-based, ostomy-specific best practice guideline addressing the preoperative, postoperative, and discharge phases of care. The guideline was developed over a 3-year period. It is based on existing literature, guidelines, and expert opinion. This article serves as an executive summary for this clinical resource; the full guideline is available as Supplemental Digital Content 1 (available at: http://links.lww.com/JWOCN/A36) to this executive summary.

Overcoming Barriers to the Implementation of an Enhanced Recovery After Surgery Program

While there is support for implementation of enhanced recovery after surgery programs, many barriers exist. The most commonly cited barriers of ERPs are time and personnel restrictions, limited hospital resources, resistance from members of the perioperative team, necessity of engagement of the whole perioperative multidisciplinary team, lack of education, patients’ social and cultural values, and institutional barriers. The most commonly cited enablers are a standardized guideline based on best evidence, standardized pre- and postoperative order sets, education for the entire perioperative multidisciplinary team, patients and families, and a hospital ERP champion. The literature suggests that various implementation strategies must be used in order to increase uptake. Common strategies include identification of local champions (nursing, anesthesia, and surgery), engagement of surgical residents, development of standardized materials (order sets, care pathways, guidelines, etc), development of educational tools (posters, reminiders, slide decks), educational booklet and video, audit and feedback, and eliciting support from hospital administration.