Original articleA multicentre qualitative study assessing implementation of an Enhanced Recovery After Surgery program☆
Introduction
Enhanced Recovery After Surgery (ERAS) pathways reduce overall morbidity, length of hospital stay and costs by incorporating multimodal optimization of perioperative care in colorectal, upper gastrointestinal, liver and pancreatic surgery, and more recently in urology, gynaecology and orthopaedic surgery [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11].
Previous research assessed adherence to the protocol and improvement of clinical outcomes to evaluate completeness and success of ERAS implementation [12], [13], [14]. In daily clinical practice, it may be complex to introduce and apply simultaneously a relatively high number of new interventions among many providers and across hospital services [15]. Qualitative studies allow to define those barriers and provide multidimensional additional information [16]. Implementation challenges have been attributed to a variety of key areas, namely related to patient, staff, practice and resources [17]. Therefore, evidence-based principles of ERAS are not widely adopted and implementation is lagging way behind the evidence [18].
The present survey aimed to analyse the reasons and motivations that made centres decide to implement ERAS as well as difficulties encountered and challenges during implementation. Secondly, the relevance and importance of postoperative recovery targets and perioperative care items were assessed as well.
Section snippets
Study design and participants
A multicentre qualitative study was conducted among ERAS teams from centres in Switzerland (n = 16) and Sweden (n = 14) that had implemented ERAS principles by participating in the ERAS Society Implementation Program (www.erassociety.org [2], [19]). Each centre had an ERAS coordinator on site. At least one member of the surgical, nursing and anaesthetic team, considered as trained in ERAS, was asked to participate in each institution. This survey concerned all different surgical specialities.
Demographics
Seventy-seven out of 146 experts completed the survey yielding a response rate of 52.7%. Fifty-eight responses were from Swiss participants (response rate 63%) and 19 from Swedish participants (response rate 37%). Demographics of responding experts are summarized in Table 1. Response rate was not significantly different between specialities (surgeons 65%, anaesthesiologists 65% and nurses 57%, p = 0.790).
Reasons for ERAS implementation
The main reasons for initiating the ERAS implementation were the following expected
Discussion
This survey among professionals involved in and leading ERAS pathways in their local hospital is one of the first analysing the motivation and difficulties of ERAS implementation in daily clinical practice. Some interesting discrepancies but also similarities of view between subjective feeling of ERAS care providers have been highlighted. In fact, implementation required important changes of clinical practice in order to achieve improved outcomes, and the amount of work and energy should not be
Conflict of interest
OL founded and owns stock in Encare AB, registered in Sweden that manages the ERAS Interactive Audit System. No other conflict of interest.
Funding source
None.
Statement of authorship
All the authors contributed to the work and approved the final version of the manuscript. Particularly, contributions were: study design: DM, MH, OL, ND; Data collection: DM, DR, FG, VA; Data analyses and interpretation: DM, DR, FG, VA, OL, ND, MH; Manuscript draughting: DM, DR, FG, MH; Critical revision of the manuscript: DM, DR, FG, VA, OL, ND, MH.
Acknowledgements
The authors wish to thank the participants who answered the survey anonymously in the different ERAS centres in Switzerland and Sweden.
References (44)
- et al.
Guidelines for perioperative care after radical cystectomy for bladder cancer: enhanced Recovery After Surgery (ERAS((R))) society recommendations
Clin Nutr
(2013) - et al.
Enhanced recovery after urological surgery: a contemporary systematic review of outcomes, key elements, and research needs
Eur Urol
(2016) - et al.
Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: enhanced Recovery After Surgery (ERAS(R)) Society recommendations–Part I
Gynecol Oncol
(2016) - et al.
Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations–Part II
Gynecol Oncol
(2016) - et al.
Implementation costs of an enhanced recovery after surgery program in the United States: a financial model and sensitivity analysis based on experiences at a quaternary academic medical center
J Am Coll Surg
(2016) - et al.
Fast-track protocols in colorectal surgery
Surg J R Coll Surg Edinb Irel
(2011) - et al.
Enhanced Recovery After Surgery (ERAS) multimodal programme as experienced by pancreatic surgery patients: findings from an Italian qualitative study
Int J Surg
(2015) - et al.
Facilitators and barriers of implementing enhanced recovery in colorectal surgery at a safety net hospital: a provider and patient perspective
Surgery
(2016) - et al.
Attitudes of patients and care providers to enhanced recovery after surgery programs after major abdominal surgery
J Surg Res
(2015) - et al.
Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations
Clin Nutr
(2012)
Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials
World J Surg
Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery
Br J Surg
Enhanced recovery protocols for major upper gastrointestinal, liver and pancreatic surgery
Cochrane Database Syst Rev
Guidelines for perioperative care for liver surgery: enhanced recovery After surgery (ERAS) society recommendations
World J Surg
The use of Enhanced Recovery After Surgery (ERAS) principles in Scottish orthopaedic units–an implementation and follow-up at 1 year, 2010-2011: a report from the Musculoskeletal Audit, Scotland
Arch Orthop Trauma Surg
An economic evaluation of the Enhanced Recovery after Surgery (ERAS) multisite implementation program for colorectal surgery in Alberta
Can J Surg J Can de Chir
Structured synchronous implementation of an enhanced recovery program in elective colonic surgery in 33 hospitals in The Netherlands
World J Surg
Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol
Anesth Analg
Enhanced recovery implementation in colorectal surgery-temporary or persistent improvement?
Langenbecks Arch Surg
Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: a process evaluation of champions' experiences
Implement Sci
Basics of qualitative research: techniques and procedures for developing grounded theory
A qualitative study assessing the barriers to implementation of enhanced recovery after surgery
World J Surg
Cited by (32)
Health Professionals Perception of Enhanced Recovery After Surgery: A Scoping Review
2022, Journal of Perianesthesia NursingCitation Excerpt :Several healthcare workers do not regard ERAS as a significant change because some of the protocols have already been implemented in daily practice, however, numerous health workers are unfamiliar with the program.7,24,25 Therefore, healthcare worker's knowledge of ERAS must be improved, because an inadequate understanding of the program will hinder its effective implementation.14,26,27 A study conducted in Korea regarding the implementation of ERAS in gastric cancer surgery showed most doctors were well acquainted with the protocol, however, most of these doctors failed to implement the program.28
Perioperative nutrition: Recommendations from the ESPEN expert group
2020, Clinical NutritionCitation Excerpt :Not only are there challenges in developing an evidence base for interventions, but also in the implementation of this evidence once established. One area in which implementation lags behind the evidence base for its practice is ERAS protocols in surgery, with a multicenter qualitative study finding the main barriers to implementation being time restraints, a reluctance to change and the logistics of setup [209]. Another topic is that of fasting guidelines in enterally fed in critical care patients.
Enhanced recovery after surgery (ERAS) pathway for microendoscopy-assisted minimally invasive transforaminal lumbar interbody fusion
2020, Clinical Neurology and NeurosurgeryCitation Excerpt :This retrospective cross-sectional study complies with strengthening the reporting of observational studies in epidemiology (STROBE) criteria [21]. The most important post-surgery goals assessed in this study are the ability to mobilize as early as possible and adequate pain control [22]. When compared with those in control group, the perioperative indicators, including operative time, intraoperative EBL, length of stay, postoperative NSAID usage and ambulation recovery time, improve remarkably in observation group.
Elderly patients over 70 years benefit from enhanced recovery programme after colorectal surgery as much as younger patients
2020, Journal of Visceral SurgeryCitation Excerpt :Together these data suggest that it is not necessary to use a different protocol for elderly. Use of several protocols can complicate the adherence to the protocols by the whole team while sustainability of ERP remains a challenge even in teams acquired for ERP [26–28]. Rather we favour one identical protocol for all patients with reasoned application of each item depending on patient medical or surgical contraindications regardless of the age of the patient.
Day Admission Surgery Program in a Prospective Payment System: What Are the Financial Incentives?
2024, Health Services Insights
- ☆
Presented to the 5th ERAS Society World Congress, May 2017, Lyon, France; published in abstract form as Clinical Nutrition ESPEN (Volume 19, June 2017, Pages 81). Presented as a poster to the 104th Annual Congress of the Swiss Society of Surgery, June 2017, Bern, Switzerland; published in abstract form as Swiss Knife 2017; 14: special edition.