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The impact of an enhanced recovery pathway on nursing workload: A retrospective cohort study ☆

BACKGROUND & AIMS The importance of nursing for surgical patients has been frequently underestimated. The success of enhanced recovery programs after surgery (ERAS) depends on preferably complete fulfillment of the protocol and nurses are an important part of it. Due to the additional nursing action required, such protocols are suspected to increase the nursing workload. The aim of the present study was to observe and measure objectively nursing workload before, during and after systematic implementation of a comprehensive enhanced recovery pathway in colorectal surgery. METHODS The program ERAS was introduced systematically in our tertiary academic centre 2011, since then our experience is based on more than 1500 ERAS patients. Nursing workload was prospectively assessed for all patients on a routine basis by means of a standardized and validated point system (PRN). In a retrospective cohort study, we compared nursing workload based on prospective data before, during and after ERAS implementation and correlated nursing workload to the compliance with the ERAS protocol. RESULTS The study cohort included 50 patients before ERAS implementation (2010) and 69 (2011) and 148 (2012) consecutive patients after implementation; the baseline characteristics of the 3 groups were similar. Mean PRN values were 61.2 ± 19.7 per day in 2010 and decreased to 52.3 ± 13.7 (P = 0.005) and 51.6 ± 18.6 (P < 0.002) in 2011 and 2012, respectively. Increasing compliance with the ERAS protocol was significantly correlated to decreasing nursing workload (ρ = -0.42; P < 0.001). CONCLUSIONS Nursing workload is--against a common belief--decreased by systematic implementation of enhance recovery protocol. The higher the compliance with the pathway, the lower the burden for the nurses!

Impact of weekday surgery on application of enhanced recovery pathway: a retrospective cohort study

Objective To compare the enhanced recovery after surgery (ERAS) protocol compliance and clinical outcomes depending on the weekday of surgery. Settings Cohort of consecutive non-selected patients undergoing elective colorectal surgery from January 2012 to March 2015. This retrospective analysis of our prospective database compared patients operated early in the week (Monday and Tuesday) with patients operated in the second half (late: Thursday, Friday). Primary outcome measures Compliance with the ERAS protocol, functional recovery, complications and length of stay. Results Demographic and surgical details were similar between the early (n=352) and late groups (n=204). Overall compliance with the ERAS protocol was 78% vs 76% for the early and late groups, respectively (p=0.009). Significant differences were notably prolonged urinary drainage and intravenous fluid infusion in the late group. Complication rates and length of stay, however, were not different between surgery on Monday or Tuesday and surgery on Thursday or Friday. Conclusions Application of the ERAS protocol showed only minor differences for patients operated on early or late during the week, and clinical outcomes were similar. A fully implemented ERAS programme appears to work also over the weekend.

Consensus on Training and Implementation of Enhanced Recovery After Surgery: A Delphi Study

BackgroundEnhanced Recovery After Surgery (ERAS) is widely accepted in current surgical practice due to its positive impact on patient outcomes. The successful implementation of ERAS is challenging and compliance with protocols varies widely. Continual staff education is essential for successful ERAS programmes. Teaching modalities exist, but there remains no agreement regarding the optimal training curriculum or how its effectiveness is assessed. We aimed to draw consensus from an expert panel regarding the successful training and implementation of ERAS.MethodsA modified Delphi technique was used; three rounds of questionnaires were sent to 58 selected international experts from 11 countries across multiple ERAS specialities and multidisciplinary teams (MDT) between January 2016 and February 2017. We interrogated opinion regarding four topics: (1) the components of a training curriculum and the structure of training courses; (2) the optimal framework for successful implementation and audit of ERAS including a guide for data collection; (3) a framework to assess the effectiveness of training; (4) criteria to define ERAS training centres of excellence.ResultsAn ERAS training course must cover the evidence-based principles of ERAS with team-oriented training. Successful implementation requires strong leadership, an ERAS facilitator and an effective MDT. Effectiveness of training can be measured by improved compliance. A training centre of excellence should show a willingness to teach and demonstrable team working.ConclusionsWe propose an international expert consensus providing an ERAS training curriculum, a framework for successful implementation, methods for assessing effectiveness of training and a definition of ERAS training centres of excellence.

Guidelines for Perioperative Care in Esophagectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations

IntroductionEnhanced recovery after surgery (ERAS) programs provide a format for multidisciplinary care and has been shown to predictably improve short term outcomes associated with surgical procedures. Esophagectomy has historically been associated with significant levels of morbidity and mortality and as a result routine application and audit of ERAS guidelines specifically designed for esophageal resection has significant potential to improve outcomes associated with this complex procedure.MethodsA team of international experts in the surgical management of esophageal cancer was assembled and the existing literature was identified and reviewed prior to the production of the guidelines. Well established procedure specific components of ERAS were reviewed and updated with changes relevant to esophagectomy. Procedure specific, operative and technical sections were produced utilizing the best current level of evidence. All sections were rated regarding the level of evidence and overall recommendation according to the evaluation (GRADE) system.ResultsThirty-nine sections were ultimately produced and assessed for quality of evidence and recommendations. Some sections were completely new to ERAS programs due to the fact that esophagectomy is the first guideline with a thoracic component to the procedure.ConclusionsThe current ERAS society guidelines should be reviewed and applied in all centers looking to improve outcomes and quality associated with esophageal resection.

Application of an enhanced recovery pathway for ileostomy closure: a case–control trial with surprising results

AbstractBackgroundEnhanced recovery after surgery (ERAS) protocols have been widely validated in colorectal surgery; however, few data exist on loop ileostomy closure. The aim of this study was to compare clinical outcomes before and after introduction of ERAS for loop ileostomy closure.MethodsData on outcomes after loop ileostomy closure were retrospectively collected before ERAS was applied at our department (control group). These results were compared to results of patients undergoing loop ileostomy closure within the original colorectal ERAS pathway (ERAS 1 group); after analysis of these results, adaptations were made to the ERAS pathway regarding the postoperative diet, and this second category of patients was analyzed (ERAS 2 group).ResultsForty-eight patients in the control group were compared to 46 ERAS 1 and 69 ERAS 2 patients. First stool was significantly faster in ERAS 2 group versus control and ERAS 1 group [median 1 (range 1–2) days vs 2 (2–3) days p value 0.01]. The incidence of vomiting increased from 26% in the control group to 45% in ERAS 1 group, and then decreased to 29% in the ERAS 2 group (p value 0.41). Length of stay was significantly shorter during the ERAS 2 protocol: median 4 (range 3–6) days versus 5 (4–8) days in the control group (p value < 0.01).ConclusionsAfter application of the ‘colorectal’ ERAS pathway to loop ileostomy closure, results were initially not improved. Minor corrections were sufficient to avoid increased incidence of vomiting and to allow for reduced hospital stay. Uncritical extrapolation of an ERAS colorectal protocol to other types of surgery should be monitored and needs audit for corrections.

Feasibility of early postoperative mobilisation after colorectal surgery: a retrospective cohort study

BACKGROUND Enhanced Recovery After Surgery (ERAS) guidelines advocate early postoperative mobilisation to counteract catabolic changes due to immobilisation and maintain muscle strength. The present study aimed to assess compliance to postoperative mobilisation according to ERAS recommendations. MATERIALS AND METHODS This is a retrospective cohort study on consecutive colorectal surgical procedures treated within an established ERAS protocol within a single center between May 2011 and May 2017. Demographics, surgical details, ERAS related items and surgical outcome were prospectively assessed in a dedicated database and compared between ambulant patients (at least 6 h out of bed at postoperative day (POD) 1) vs. patients not meeting the target (delayed mobilisation). Risk factors for decreased postoperative mobilisation were identified through multivariable logistic regression. RESULTS 1170 patients were retained. 676 patients (58%) did not mobilise as recommended by ERAS protocol at POD1. Emergency operation (Odds Ratio (OR) 0.40; 95% Confidence Interval (CI) 0.18-0.91, p = 0.028), age > 70 years (OR 0.69; 95% CI 0.47-1.00, p = 0.050) and intraoperative total fluids > 2000 mL (OR 0.59; 95% CI 0.37-0.93, p = 0.025) were independent risk factors for delayed mobilisation. Patients with delayed mobilisation had significantly more overall (Clavien grade IV) (55% vs. 29%, p=<0.001), major (Clavien grade IIIb-V) (16% vs. 7%, p=<0.001) and respiratory (12% vs. 4%, p=<0.001) complications, as well as longer length of stay (12 ± 14 vs. 6±7days, p=<0.001). CONCLUSIONS More than half of patients did not mobilise as recommended by ERAS guidelines. Emergency surgery, advanced age and fluid overload were independent risk factors for delayed mobilisation, which was associated with increased postoperative complications.