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Kaptain K, Ulsøe ML, Dreyer P. Surgical perioperative pathways-Patient experiences of unmet needs show that a person-centred approach is needed. J Clin Nurs 2019; 28:2214-2224. [PMID: 30786078 DOI: 10.1111/jocn.14817] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 02/05/2019] [Accepted: 02/09/2019] [Indexed: 11/30/2022]
Abstract
AIM To explore patients' and healthcare professionals' experiences of patients' surgical pathways in a perioperative setting. BACKGROUND Elective surgical pathways have improved over the past decades due to fast-track programmes, but patients desire more personalised and coordinated care and treatment. There is little knowledge of how healthcare professionals' collaboration and communication affect patients' pathways. DESIGN The overall framework was complex intervention method. A phenomenological-hermeneutic approach was used for data analyses. COREQ checklist was used as a guideline to secure accurate and complete reporting of the study. METHODS Field observations (120 hr) and semi-structured interviews (24 patients) were undertaken during 2016-2017. Healthcare professionals involved in the pathways were interviewed: (a) 13 single interviews and (b) 13 focus group interviews (37 healthcare professionals) were conducted. The Consolidated Criteria for Reporting Qualitative Research checklist was used. RESULTS Patients asked for individualised information adapted to their life and illness experiences. Furthermore, healthcare professionals need access to a quick overview of individual patients and their perioperative pathway in the electronic patient journal (EPJ). Agreements made with patients did not always reach the right receiver, there was poor interpersonal communication and the complex teamwork between many healthcare professionals made pathways incoherent and uncoordinated. Healthcare professionals who had the time to talk about other subjects than the disease with smiles and good humour gave patients a feeling of security. CONCLUSION Patients wanted to be treated as individuals, but often they received standard treatment. Healthcare professionals had the intention of treating patients individually, but the EPJ and information provided to patients were not easy to access. RELEVANCE TO CLINICAL PRACTICE Visible information about the patient's whole pathway could improve healthcare professionals' care and treatment. In addition, systematic feedback from patients' could make it possible to adjust information, care and treatment to achieve a more coherent pathway. Particular attention needs to be paid to how electronic healthcare systems can underpin relational coordination in pathways.
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Affiliation(s)
- Kirsten Kaptain
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus N, Denmark
| | - Marie-Louise Ulsøe
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus N, Denmark
| | - Pia Dreyer
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus N, Denmark.,Institute of Public Health, Section of Nursing, University of Aarhus, Aarhus C, Denmark
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Abstract
OBJECTIVES To conduct a systematic review of qualitative studies which explore health professionals' experiences of and perspectives on the enhanced recovery after surgery (ERAS) pathway. DESIGN Systematic review of qualitative literature using a qualitative content analysis. Literature includes the experiences and views of a wide range of multidisciplinary team and allied health professional staff, to incorporate a diverse range of clinical and professional perspectives. DATA SOURCES PsycINFO, Medline, CINAHL and PubMed were searched in May 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES The searches included relevant qualitative studies across a range of healthcare contexts. We included studies published from 2000 to 2017, as an appropriate time frame to capture evidence about ERAS after implementation in the late 1990s. Only studies published in the English language were included, and we included studies that explicitly stated that they used qualitative approaches. DATA EXTRACTION AND SYNTHESIS Literature searches were conducted by the first author and checked by the second author: both contributed to the extraction and analysis of data. Studies identified as relevant were assessed for eligibility using the Critical Appraisal Skills Programme guidance. RESULTS Eight studies were included in the review, including studies in six countries and in four surgical specialties. Included studies focus on health professionals' experiences of ERAS before, during and after implementation in colorectal surgery, gastrointestinal surgery, abdominal hysterectomy and orthopaedics. Five main themes emerged in the analysis: communication and collaboration, resistance to change, role and significance of protocol-based care, and knowledge and expectations. Professionals described the importance of effective multidisciplinary team collaboration and communication, providing thorough education to staff and patients, and appointing a dedicated champion as means to implement and integrate ERAS pathways successfully. Evidence-based guidelines were thought to be useful for improvements to patient care by standardising practices and reducing treatment variations, but were thought to be too open to interpretation at local levels. Setting and managing 'realistic' expectations of staff was seen as a priority. Staff attitudes towards ERAS tend to become more favourable over time, as practices become successfully 'normalised'. Strengths of the review are that it includes a wide range of different studies, a variety of clinical populations, diversity of methodological approaches and local contexts. Its limitation is the inclusion of a small number of studies, although these represent six countries and four surgical specialties, and so our findings are likely to be transferable. CONCLUSIONS Staff feel positive about the implementation of ERAS, but find the process is complex and challenging. Challenges can be addressed by ensuring that multidisciplinary teams understand ERAS principles and guidelines, and communicate well with one another and with patients. Provision of comprehensive, coherent and locally relevant information to health professionals is helpful. Identifying and recruiting local ERAS champions is likely to improve the implementation and delivery of ERAS pathways. PROSPERO REGISTRATION NUMBER CRD42017059952.
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Affiliation(s)
- Rachel Cohen
- Department of Population Health Sciences, Centre for Academic Mental Health, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Protocol for process evaluation of evidence-based care pathways: the case of colorectal cancer surgery. INT J EVID-BASED HEA 2019; 16:145-153. [PMID: 30095534 DOI: 10.1097/xeb.0000000000000149] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND AIM Care pathways are complex interventions, consisting of multiple 'active ingredients', to structure care processes around patient needs. Numerous studies have reported improved outcomes after implementation of care pathways. The structure-process-outcome framework and the context-mechanism-outcome framework both suggest that outcomes can only be achieved through a certain process within a context or structure. To understand how and why care pathways are effective, understanding of both this process and context is necessary. The aim of this article is to propose a study protocol to evaluate the implementation process of evidence-based care pathways, including the influence of the context. This protocol is explained by applying it to the implementation of a colorectal cancer surgery pathway in an international setting. METHODS The Medical Research Council (MRC) guidance on process evaluations for complex interventions is used as the basis for the protocol. The key components of process evaluation are intervention, context, implementation, mechanisms of impact and outcomes. In process evaluations, these components are studied using quantitative and qualitative methods. Among them are patient record analysis, questionnaires, on-site visits and interviews. DISCUSSION To guide our methodological choices, the MRC guidance for process evaluations of complex interventions, and published protocols for process evaluations of complex interventions were used. Our protocol is now tailored for the process evaluation of evidence-based care pathways and provides researchers and clinicians methods and tools, as well as a worked example, that can be used to study the process of care pathway implementation. As a result, healthcare professionals will be informed on context factors and implementation processes that can facilitate the implementation of care pathways, improving quality and effectiveness of care processes.
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Agarwal R, Rajanbabu A, P V N, Goel G, Madhusudanan L, U G U. A prospective study evaluating the impact of implementing the ERAS protocol on patients undergoing surgery for advanced ovarian cancer. Int J Gynecol Cancer 2019; 29:605-612. [PMID: 30833445 DOI: 10.1136/ijgc-2018-000043] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/03/2018] [Accepted: 08/31/2018] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Information on the benefits of enhanced recovery after surgery (ERAS) when applied to advanced ovarian cancer() is minimal. The study objectives were to prospectively evaluate whether the implementation of ERAS in AOC patients improves post-operative recovery, and reduces the length of hospital stay (LOHS), without increasing the readmission rate or surgery-related complications; and to investigate ERAS protocol compliance. METHODS This was a prospective interventional study carried out at a single university teaching hospital. Patients undergoing laparotomy for advanced ovarian cancer (stages IIb-IV) from March 2017 to February 2018 were managed using an ERAS protocol. The conventional management (CM) period extended from January 2016 to December 2016. The primary outcome was reduction in LOHS. Secondary outcomes were ERAS protocol compliance, incidence of post-operative complications, and readmission rate. RESULTS The CM and ERAS groups each comprised 45 patients. Both the groups were comparable in terms of clinicopathological and operative characteristic. Median LOHS of the full cohort, primary debulking cohort, interval debulking cohort, staging surgery cohort (all 6 vs 4 days; p<0.001), and complex cytoreductive surgery cohort (5 vs 4 days; p=0.019) were significantly reduced in the ERAS group. The overall compliance for the ERAS protocol was 90.6%. Occurrence of moderate or severe (17.8% vs 0%; p=0.003) and ≥grade 2 extended Clavein-Dindo complications (22.2% vs 0%; p=0.001); and hospital stay due to occurrence of complications (31.1% vs 2.2%; p<0.001) were also significantly reduced in the ERAS group. There was no difference in the 30-day readmission rates. CONCLUSION The results from our investigation suggest that the ERAS program can be successfully implemented in advanced ovarian cancer patients even in low-resource settings provided the program is modified to meet local needs so as not to increase healthcare costs.
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Affiliation(s)
- Reshu Agarwal
- Department of Gynaecologic Oncology, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India
| | - Anupama Rajanbabu
- Department of Gynaecologic Oncology, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India
| | - Nitu P V
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India
| | - Gaurav Goel
- Department of Gynaecologic Oncology, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India
| | - Lipi Madhusudanan
- Department of Gynaecologic Oncology, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India
| | - Unnikrishnan U G
- Department of Biostatistics, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India
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Implementing Our Microsurgical Breast Reconstruction Enhanced Recovery after Surgery Pathway: Consensus Obstacles and Recommendations. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e1855. [PMID: 30859019 PMCID: PMC6382235 DOI: 10.1097/gox.0000000000001855] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 05/08/2018] [Indexed: 11/25/2022]
Abstract
Enhanced recovery after surgery pathways are well established in other surgical specialties but are relatively new in plastic surgery. These guidelines focus on improving patient care by incorporating evidence-based recommendations. Length of stay is shorter, and overall hospital costs are lower without compromising patient satisfaction. When care is standardized, ambiguity is removed and physician acceptance is improved. Yet, implementation can be challenging on an institutional level. The Johns Hopkins microsurgical breast reconstruction team identified areas of dogmatic dissonance during 3 focus groups to formalize an enhanced recovery pathway for microsurgical breast reconstruction. Six microsurgeons used nominal group technique to reach consensus. Four discussion points were identified: multidisciplinary buy-in, venous thromboembolism (VTE) chemophylaxis, early feeding, and dietary restrictions. Evidence-based recommendations and our enhanced recovery after surgery protocol are provided.
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Martin D, Roulin D, Grass F, Addor V, Ljungqvist O, Demartines N, Hübner M. A multicentre qualitative study assessing implementation of an Enhanced Recovery After Surgery program. Clin Nutr 2018; 37:2172-2177. [DOI: 10.1016/j.clnu.2017.10.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 10/03/2017] [Accepted: 10/25/2017] [Indexed: 12/18/2022]
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Li Z, Zhao Q, Bai B, Ji G, Liu Y. Enhanced Recovery After Surgery Programs for Laparoscopic Abdominal Surgery: A Systematic Review and Meta-analysis. World J Surg 2018; 42:3463-3473. [PMID: 29750324 DOI: 10.1007/s00268-018-4656-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols or laparoscopic technique has been applied in various surgical procedures. However, the clinical efficacy of combination of the two methods still remains unclear. Thus, our aim was to assess the role of ERAS protocols in laparoscopic abdominal surgery. METHODS We performed a systematic literature search in various databases from January 1990 to October 2017. The results were analyzed according to predefined criteria. RESULTS In the present meta-analysis, the outcomes of 34 comparative studies (15 randomized controlled studies and 19 non-randomized controlled studies) enrolling 3615 patients (1749 in the ERAS group and 1866 in the control group) were pooled. ERAS group was associated with shorter hospital stay (WMD - 2.37 days; 95% CI - 3.00 to - 1.73; P 0.000) and earlier time to first flatus (WMD - 0.63 days; 95% CI - 0.90 to - 0.36; P 0.000). Meanwhile, lower overall postoperative complication rate (OR 0.62; 95% CI 0.51-0.76; P 0.000) and less hospital cost (WMD 801.52 US dollar; 95% CI - 918.15 to - 684.89; P 0.000) were observed in ERAS group. Similar readmission rate (OR 0.73, 95% CI 0.52-1.03, P 0.070) and perioperative mortality (OR 1.33; 95% CI 0.53-3.34; P 0.549) were found between the two groups. CONCLUSIONS ERAS protocol for laparoscopic abdominal surgery is safe and effective. ERAS combined with laparoscopic technique is associated with faster postoperative recovery without increasing readmission rate and perioperative mortality.
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Affiliation(s)
- Zhengyan Li
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China.
| | - Qingchuan Zhao
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China.
| | - Bin Bai
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China
| | - Gang Ji
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China
| | - Yezhou Liu
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China
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Robertson TR, Eldridge NE, Rattray ME, Roberts SJ, Desbrow B, Marshall AP, Ali AB, Hickman IJ. Early oral feeding after colorectal surgery: A mixed methods study of knowledge translation. Nutr Diet 2018; 75:345-352. [PMID: 30187634 DOI: 10.1111/1747-0080.12473] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/02/2018] [Accepted: 08/06/2018] [Indexed: 12/28/2022]
Abstract
AIM Evidence-based guidelines recommend early oral feeding (EOF) as prescription of an unrestricted diet within 24 hours after colorectal surgery. The present study aimed to understand local postoperative feeding practices after colorectal surgery; identify barriers to EOF implementation; select, tailor and implement stakeholder engagement strategies to facilitate EOF uptake; and evaluate changes to practice. METHODS A longitudinal, mixed methods study was undertaken, guided by the knowledge-to-action framework. Phase 1 assessed the nature of the problem using postoperative diet Audits 1 and 2. In Phase 2, staff interviews identified barriers to EOF implementation. Results from Phases 1 and 2 were fed back to inform Phase 3 strategies. Knowledge uptake was monitored in Audits 3 and 4. Phase 4 evaluated outcomes from Audit 5. RESULTS In Phase 1, median time to commencement of full diet was postoperative Days 4 and 3 in Audits 1 and 2, respectively. Phase 2 identified EOF barriers, including disparities in diet upgrade practices and variable understanding of hospital diets. In Phase 3, planned strategies were implemented to improve EOF (i) educational session describing local hospital diets; (ii) consultant decision to prescribe a full diet on operation notes; and (iii) educational sessions with nursing staff describing changes to EOF practice. In Phase 4, median time to commencement of full diet improved to postoperative Day 0. Patients prescribed a full diet on operation notes increased from 0% to 82%. CONCLUSIONS The present study successfully identified and overcame local barriers to improve EOF practices to align with guideline recommendations.
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Affiliation(s)
- Tayla R Robertson
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Naomi E Eldridge
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Megan E Rattray
- School of Allied Health Sciences, Griffith University, Gold Coast, Queensland, Australia
| | - Shelley J Roberts
- School of Allied Health Sciences, Griffith University, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.,Gold Coast Health, Gold Coast, Queensland, Australia
| | - Ben Desbrow
- School of Allied Health Sciences, Griffith University, Gold Coast, Queensland, Australia
| | - Andrea P Marshall
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.,Gold Coast Health, Gold Coast, Queensland, Australia
| | - Azmat B Ali
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ingrid J Hickman
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
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Abstract
A growing body of evidence suggests that the implementation of an enhanced recovery after surgery (ERAS) clinical pathway can accelerate recovery and reduce length of stay through the use of a multimodal program that includes guidelines for optimal pain relief, stress reduction, early nutrition, and early mobilization. The article discusses the importance of the nursing body in improving institutional compliance to ERAS clinical pathway measures and describes specific nursing barriers observed in the ERAS implementation in an academic medical center.
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Francis NK, Walker T, Carter F, Hübner M, Balfour A, Jakobsen DH, Burch J, Wasylak T, Demartines N, Lobo DN, Addor V, Ljungqvist O. Consensus on Training and Implementation of Enhanced Recovery After Surgery: A Delphi Study. World J Surg 2018; 42:1919-1928. [PMID: 29302724 DOI: 10.1007/s00268-017-4436-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Enhanced 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. METHODS A 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. RESULTS An 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. CONCLUSIONS We 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.
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Affiliation(s)
- Nader K Francis
- Department of Colorectal Surgery, Yeovil District Hospital Foundation Trust, Higher Kingston, Yeovil, Somerset, BA21 4AT, UK.
- Faculty of Science, University of Bath, Wessex House 3.22, Bath, BA2 7AY, UK.
| | - Thomas Walker
- Department of Colorectal Surgery, Yeovil District Hospital Foundation Trust, Higher Kingston, Yeovil, Somerset, BA21 4AT, UK
| | - Fiona Carter
- South West Surgical Training Network, ERAS-UK, Yeovil, Somerset, BA20 2RH, UK
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), Rue de Bugnon 46, 1011, Lausanne, Switzerland
| | - Angela Balfour
- NHS Lothian Western General Hospital, Crewe Road, Edinburgh, EH4 2XU, Scotland
| | - Dorthe Hjort Jakobsen
- Section of Surgical Pathophysiology 4074, Rigshospitalet, Blegdamsvej 9, 2100 Kbh Ø, Copenhagen, Denmark
| | - Jennie Burch
- Head of Gastrointestinal Nurse Education, Academic Institute, St Mark's Hospital, London, HA1 3UJ, UK
| | - Tracy Wasylak
- Strategic Clinical Networks, Alberta Health Services, Edmonton, AB, Canada
- Faculty of Nursing, University of Calgary, 10301 Southport Lane SW, Calgary, AB, T2W1S7, Canada
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), Rue de Bugnon 46, 1011, Lausanne, Switzerland
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Valerie Addor
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), Rue de Bugnon 46, 1011, Lausanne, Switzerland
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, Örebro University, 701 85, Orebro, Sweden
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Satisfaction survey after an ERAS (Enhanced Recovery After Surgery) protocol in colorectal elective surgery in patients over 70 years of age. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2018. [DOI: 10.1097/cj9.0000000000000061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Cintorino D, Ricotta C, Bonsignore P, Di Francesco F, Li Petri S, Pagano D, Tropea A, Checchini G, Tuzzolino F, Gruttadauria S. Preliminary Report on Introduction of Enhanced Recovery After Surgery Protocol for Laparoscopic Rectal Resection: A Single-Center Experience. J Laparoendosc Adv Surg Tech A 2018; 28:1437-1442. [PMID: 29733252 DOI: 10.1089/lap.2018.0234] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Laparoscopic rectal surgery seems to improve postoperative recovery of patients who undergo surgery for rectal cancer. The aim of this study was to evaluate preliminary results of implementation of enhanced recovery after surgery (ERAS) protocol for laparoscopic rectal resection (LRR) for cancer at our institute. MATERIALS AND METHODS We conducted a retrospective analysis of prospectively collected data. Patients who underwent LRR for cancer at our institute after introduction of enhanced recovery protocol were compared with a control group of patients who previously underwent surgery with traditional protocol. Primary endpoints evaluated were length of stay (LOS) and rates of complications and readmissions. RESULTS We studied 150 consecutive patients, 56 operated with the traditional approach and 94 according to ERAS protocol. The mean (range) LOS was 10 (4-27) days for patients in control group versus 8.5 (3-32) days for patients in the ERAS group (P = .0823). No evidence of a different rate (P = .227) of complications was registered between the two groups. One patient in each group was readmitted. CONCLUSIONS The introduction of the ERAS protocol in LRR for cancer at our institute led to an initial reduction in hospital LOS, without increase in morbidity or readmission rate compared with our previous experience with traditional protocol.
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Affiliation(s)
- Davide Cintorino
- 1 Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| | - Calogero Ricotta
- 1 Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| | - Pasquale Bonsignore
- 1 Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| | - Fabrizio Di Francesco
- 1 Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| | - Sergio Li Petri
- 1 Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| | - Duilio Pagano
- 1 Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| | - Alessandro Tropea
- 1 Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| | - Giuliana Checchini
- 1 Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| | - Fabio Tuzzolino
- 2 Research Office, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
| | - Salvatore Gruttadauria
- 1 Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione)/UPMC Italy, Palermo, Italy
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Using the Normalization Process Theory to qualitatively explore sense-making in implementation of the Enhanced Recovery After Surgery programme: "It's not rocket science". PLoS One 2018; 13:e0195890. [PMID: 29668717 PMCID: PMC5906013 DOI: 10.1371/journal.pone.0195890] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 04/02/2018] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION The Enhanced Recovery After Surgery programme (ERAS) is an approach to the perioperative care of patients encompassing multiple interventions and involving a wide range of different actors. It can thus be defined as a complex intervention. Despite the strength of the evidence-base in its support, the implementation of ERAS has been slow. This paper specifically explores the utility of Normalization Process Theory (NPT) as a methodological framework to aid exploration of ERAS implementation, with a focus on the core NPT construct coherence. METHODS AND MATERIALS The study employed qualitative methods guided by NPT. Semi-structured interviews were conducted with twenty-six healthcare professionals working in three specialities (thoracic, colorectal, head and neck) in a UK hospital. Data were analysed using an adapted Framework Approach. RESULTS Coherence, or sense-making work, was key to successful implementation and demonstrated in the importance of participants believing in ERAS both as an individual and as a team. In order to invest in ERAS individuals needed to be able to differentiate its practices favourably with those enacted pre-implementation (differentiation). Participants also needed to understand their specific tasks and responsibilities (individual specification) and build a shared understanding (communal specification), resolving differences in planning meetings. Belief in the worth of ERAS was often aligned to evidence for its effectiveness or benefit to patients (internalization), so implementing ERAS therefore 'made sense'. Sense-making work had strong links with aspects of implementation related to other NPT constructs including resource issues such as funding for data collection and feedback (reflexive monitoring: systemization) and failure to replace key staff members (collective action: skill set workability). CONCLUSIONS NPT was found to be a valuable heuristic device to employ in the exploration of ERAS implementation processes. NPT was useful in facilitating recognition of the importance of coherence work to successful implementation. However despite participants' strong beliefs in the worth of ERAS, it was in translating these beliefs into action that barriers were encountered, highlighting the interconnectedness of NPT constructs and the complicated nature of implementing complex interventions.
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Joris J, Léonard D, Slim K. How to implement an enhanced recovery programme after colorectal surgery? Acta Chir Belg 2018; 118:73-77. [PMID: 29334849 DOI: 10.1080/00015458.2018.1427841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Although the concept of enhanced recovery after surgery was introduced more than 20 years ago, its implementation in daily practice still remains difficult. RESULTS This article addresses bottlenecks and barriers to the development of enhanced recovery programme (ERP). Barriers to the implementation are multifactorial and are raised by the different actors of these programmes: surgeons, anaesthetists, nurses, patients. Solutions and steps that must be respected to succeed in introducing ERP in an hospital are proposed. CONCLUSIONS Large-scale implementation of ERP continues to face mainly lack of trust and communication. Solutions exist and are based particularly on team work and interdisciplinary collaboration.
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Affiliation(s)
- Jean Joris
- Department of Anaesthesiology, Anaesthesia and Intensive Care, CHU Liège, ULiège, Liège, Belgium
- GRACE: Groupe francophone de Réhabilitation Améliorée après ChirurgiE, Beaumont, France
| | - Daniel Léonard
- GRACE: Groupe francophone de Réhabilitation Améliorée après ChirurgiE, Beaumont, France
- Colorectal Surgery Unit, Cliniques Universitaires Saint-Luc, UCL, Brussels, Belgium
| | - Karem Slim
- GRACE: Groupe francophone de Réhabilitation Améliorée après ChirurgiE, Beaumont, France
- Service of Digestive Surgery, University Hospital Estaing, Clermont-Ferrand, France
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Krajcer Z, Ramaiah VG, Henao EA, Metzger DC, Nelson WK, Moursi MM, Rajasinghe HA, Al-Dallow R, Miller LE. Perioperative Outcomes From the Prospective Multicenter Least Invasive Fast-Track EVAR (LIFE) Registry. J Endovasc Ther 2017; 25:6-13. [DOI: 10.1177/1526602817747871] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose: To determine the feasibility, perioperative resource utilization, and safety of a fast-track endovascular aneurysm repair (EVAR) protocol in well-selected patients. Methods: Between October 2014 and May 2016, the LIFE (Least Invasive Fast-track EVAR) registry ( ClinicalTrials.gov identifier NCT02224794) enrolled 250 patients (mean age 73±8 years; 208 men) in a fast-track EVAR protocol comprised of bilateral percutaneous access using the 14-F Ovation stent-graft, no general anesthesia, no intensive care unit (ICU) admission, and next-day discharge. The primary endpoint was major adverse events (MAE) through 30 days. The target performance goal for the MAE endpoint was 10.4%. Results: Vascular access, stent-graft delivery, and stent-graft deployment success were 100%. A total of 216 (86%) patients completed all elements of the fast-track EVAR protocol. Completion of individual elements was 98% for general anesthesia avoidance, 97% for bilateral percutaneous access, 96% for ICU avoidance, and 92% for next-day discharge. Perioperative outcomes included mean procedure time of 88 minutes, median blood loss of 50 mL, early oral nutrition (median 6 hours), early mobilization (median 8 hours), and short hospitalization (median 26 hours). Fast-track EVAR completers had shorter procedure time (p<0.001), less blood loss (p=0.04), faster return to oral nutrition (p<0.001) and ambulation (p<0.01), and shorter hospital stay (p<0.001). With 241 (96%) of the 250 patients returning for the 30-day follow-up, the MAE incidence was 0.4% (90% CI 0.1% to 1.8%), significantly less than the 10.4% performance goal (p<0.001). No aneurysm rupture, conversion to surgery, or aneurysm-related secondary procedure was reported. There were no type III endoleaks and 1 (0.4%) type I endoleak. Iliac limb occlusion was identified in 2 (0.8%) patients. The 30-day hospital readmission rate was 1.6% overall. Conclusion: A fast-track EVAR protocol was feasible in well-selected patients and resulted in efficient perioperative resource utilization with excellent safety and effectiveness.
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Affiliation(s)
| | | | | | | | | | | | | | - Raed Al-Dallow
- SIH Memorial Hospital of Carbondale, Carbondale, IL, USA
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Coxon A, Nielsen K, Cross J, Fox C. Implementing enhanced recovery pathways: a literature review with realist synthesis. Hosp Pract (1995) 2017; 45:165-174. [PMID: 28679348 DOI: 10.1080/21548331.2017.1351858] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 07/04/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Enhanced Recovery Pathways (ERPs) are an increasingly popular, evidenced-based approach to surgery, designed to improve patient outcomes and reduce costs. Despite evidence demonstrating the benefits of these pathways, implementation and adherence have been inconsistent. METHODS Using realist synthesis, this review explored the current literature surrounding the implementation of ERPs in the UK. Knowledge consolidation between authors and consulting with field experts helped to guide the search strategy. Relevant medical and social science databases were searched from 2000 to 2016, as well as a general web search. A total of 17 papers were identified, including original research, reviews, case studies and guideline documents. Full texts were analysed, cross-examined, and data extracted and synthesised. RESULTS Several implementation strategies were identified, including the contexts in which these operated, the subsequent mechanisms of action that were triggered, and the outcome patterns they produced. Context-Mechanism-Outcome (CMO) configurations were generated, tested, and refined. These were grouped to develop two programme theories concerning ERP implementation, one related to the strategy of consulting with staff, the other with appointing a change agent to coordinate and drive the implementation process. These theories highlight instances in which implementation could be improved. CONCLUSION Current literature in ERP research is primarily focussed on measuring patient outcomes and cost effectiveness, and as a result, important detail regarding the implementation process is often not reported or described robustly. This review not only provides recommendations for future improvements in ERP implementation, but also highlights specific areas of focus for furthering ERP implementation research.
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Affiliation(s)
- Astrid Coxon
- a University of East Anglia Faculty of Medicine and Health Sciences , Norwich Medical School University of East Anglia , Norwich , UK
| | - Karina Nielsen
- b Management School, Institute of Work Psychology Sheffield , University of Sheffield , Sheffield , UK
| | - Jane Cross
- a University of East Anglia Faculty of Medicine and Health Sciences , Norwich Medical School University of East Anglia , Norwich , UK
| | - Chris Fox
- a University of East Anglia Faculty of Medicine and Health Sciences , Norwich Medical School University of East Anglia , Norwich , UK
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Herbert G, Sutton E, Burden S, Lewis S, Thomas S, Ness A, Atkinson C. Healthcare professionals' views of the enhanced recovery after surgery programme: a qualitative investigation. BMC Health Serv Res 2017; 17:617. [PMID: 28859687 PMCID: PMC5580205 DOI: 10.1186/s12913-017-2547-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 08/15/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The Enhanced Recovery After Surgery (ERAS) programme is an approach to the perioperative care of patients which aims to improve outcomes and speed up recovery after surgery. Although the evidence base appears strong for this programme, the implementation of ERAS has been slow. This study aimed to gain an understanding of the facilitating factors and challenges of implementing the programme with a view to providing additional contextual information to aid implementation. The study had a particular focus on the nutritional elements as these have been highlighted as important. METHODS The study employed qualitative research methods, guided by the Normalisation Process Theory (NPT) to explore the experiences and opinions of 26 healthcare professionals from a range of disciplines implementing the programme. RESULTS This study identified facilitating factors to the implementation of ERAS: alignment with evidence based practice, standardising practice, drawing on the evidence base of other specialties, leadership, teamwork, ERAS meetings, patient involvement and education, a pre-operative assessment unit, staff education, resources attached to obtaining The Commissioning for Quality and Innovation (CQUIN) money, the ward layout, data collection and feedback, and adapting the care pathway. A number of implementation challenges were also identified: resistance to change, standardisation affecting personalised patient care, the buy-in of relevant stakeholders, keeping ERAS visible, information provision to patients, resources, palatability of nutritional drinks, aligning different ward cultures, patients going to non-ERAS departments, spreading the programme within the hospital, differences in health issue, and utilising a segmental approach. CONCLUSIONS: The findings presented here provide useful contextual information from diverse surgical specialties to inform healthcare providers when implementing ERAS in practice. Addressing the challenges and utilising the facilitating factors identified in this study, could speed up the rate at which ERAS is adopted, implemented and embedded.
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Affiliation(s)
- Georgia Herbert
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK.
| | - Eileen Sutton
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK
| | - Sorrel Burden
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK.,School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Stephen Lewis
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK.,Derriford Hospital, Plymouth, UK
| | - Steve Thomas
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK.,Oral and Maxillofacial Surgery, University of Bristol, Bristol, UK
| | - Andy Ness
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK
| | - Charlotte Atkinson
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK
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Roulin D, Najjar P, Demartines N. Enhanced Recovery After Surgery Implementation: From Planning to Success. J Laparoendosc Adv Surg Tech A 2017; 27:876-879. [PMID: 28759314 DOI: 10.1089/lap.2017.0347] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Enhanced Recovery After Surgery (ERAS®) is an evidence-based approach in perioperative care. The implementation and translation of ERAS pathways into clinical practice requires a certain investment in time and money. A multidisciplinary team must be gathered and should undergo training according to the ERAS Implementation Program. Close attention to financial aspects of implementation, including projecting return on investment, is necessary in today's cost-conscious healthcare environment. Despite frequently encountered barriers and resistance to change, the common objective of reducing complications should overcome these barriers, so that every patient benefits from the most appropriate perioperative care.
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Affiliation(s)
- Didier Roulin
- 1 Department of Visceral Surgery, Lausanne University Hospital (CHUV) , Lausanne, Switzerland
| | - Peter Najjar
- 2 Department of Surgery, Brigham and Women's Hospital/Harvard Medical School , Boston, Massachusetts
| | - Nicolas Demartines
- 1 Department of Visceral Surgery, Lausanne University Hospital (CHUV) , Lausanne, Switzerland
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Michard F, Gan T, Kehlet H. Digital innovations and emerging technologies for enhanced recovery programmes. Br J Anaesth 2017; 119:31-39. [DOI: 10.1093/bja/aex140] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Are we ready for the ERAS protocol in colorectal surgery? Wideochir Inne Tech Maloinwazyjne 2017; 12:7-12. [PMID: 28446926 PMCID: PMC5397552 DOI: 10.5114/wiitm.2017.66672] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 03/02/2017] [Indexed: 12/21/2022] Open
Abstract
Introduction Modern perioperative care principles in elective colorectal surgery have already been established by international surgical authorities. Nevertheless, barriers to the introduction of routine evidence-based clinical care and changing dogmas still exist. One of the factors is the surgeon. Aim To assess perioperative care trends in elective colorectal surgery among general surgery consultants in surgical departments in Malopolska Voivodeship, Poland. Material and methods An anonymous standardized 20-question questionnaire was developed based on ERAS principles and sent out to Malopolska Voivodeship general surgery departments. Answers of general surgery consultants showed the level of acceptance of elements of perioperative care. Results The overall response rate was 66%. Several elements (antibiotic and antithrombotic prophylaxis, postoperative oxygen therapy, no nasogastric tubes) had quite a high acceptance rate. On the other hand, most crucial surgical perioperative elements (lack of mechanical bowel preparation, preoperative oral carbohydrate loading, use of laparoscopy and lack of drains, early fluid and oral diet intake, early mobilization) were not followed according to evidence-based ERAS protocol recommendations. Surgeons were not willing to change their practice, but were supportive of changes in anesthesiologist-dependent elements of perioperative care, such as restrictive fluid therapy, use of transversus abdominis plane blocks, etc. Conclusions Many elements of perioperative care in elective colorectal surgery in Malopolska Voivodeship are still dictated by dogma and are not evidence-based. The level of acceptance of many important ERAS protocol elements is low. Surgeons are ready to accept only changes that do not interfere with their practice.
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Enhanced Recovery After Surgery in the Setting of the Perioperative Surgical Home. Int Anesthesiol Clin 2017; 55:135-147. [DOI: 10.1097/aia.0000000000000160] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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A Guide to Implementing Enhanced Recovery After Surgery Protocols: Creating, Scaling, and Managing a Perioperative Consult Service. Int Anesthesiol Clin 2017; 55:101-115. [DOI: 10.1097/aia.0000000000000163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Lau CSM, Chamberlain RS. Enhanced Recovery After Surgery Programs Improve Patient Outcomes and Recovery: A Meta-analysis. World J Surg 2016; 41:899-913. [DOI: 10.1007/s00268-016-3807-4] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Enhanced recovery implementation in colorectal surgery—temporary or persistent improvement? Langenbecks Arch Surg 2016; 401:1163-1169. [DOI: 10.1007/s00423-016-1518-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 09/27/2016] [Indexed: 01/02/2023]
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Ripollés-Melchor J, Casans-Francés R, Abad-Gurumeta A, Suárez-de-la-Rica A, Ramírez-Rodríguez JM, López-Timoneda F, Calvo-Vecino JM. Spanish survey on enhanced recovery after surgery. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:376-383. [PMID: 26796041 DOI: 10.1016/j.redar.2015.09.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 09/01/2015] [Accepted: 09/17/2015] [Indexed: 06/05/2023]
Abstract
INTRODUCTION The aim of this study was to determine the interest in ERAS protocols, and the extent to which clinicians are familiar with and apply these protocols during perioperative care. MATERIALS AND METHODS Free access survey hosted on the Spanish Society of Anesthesiology and Critical Care; Spanish Association of Surgeons and Spanish Society of Enteral and Parenteral nutrition and ERAS Spain (GERM) websites conducted between September and December 2014. RESULTS The survey was answered by 272 professionals (44.5% anaesthetists, 45.2% general surgeons) from 110 hospitals, 73% of whom had experience in ERAS protocols. Most (86.1%) had specific knowledge of ERAS protocols, whereas only 50.9% were familiar with ERAS recommendations and 42.4% with GERM recommendations. Most (73.1%) respondents reported that ERAS protocols are performed in their hospitals, mainly in colorectal surgery (93%), and 52.2% reported that GERM/ERAS recommendations are followed. Nearly all (95.5%) would be interested in the development of multidisciplinary national guidelines. Less than half (46.6%) perform preoperative nutritional assessment, albeit without a universal malnutrition screening method (56.8%). Preoperative loading with carbohydrate drinks is carried out in only 51.4% of cases; nasogastric tube and drainage are avoided (79.3%), prophylaxis for postoperative nausea and vomiting (73.4%), goal directed fluid therapy (73.3%), and active normothermia maintenance (87.4%) are performed. In most cases, mobilization (90.1%) and early feeding (87.9%) are performed. The leading causes of protocol failure are postoperative nausea and vomiting (46.5%) and ileus (58.9%). CONCLUSION Clinicians in Spain are familiar with fast track protocols, although there is no overall consensus, and hospitals do not adhere to existing guidelines. Overall compliance with the items of the protocol is adequate, although perioperative nutritional management is poor.
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Affiliation(s)
- J Ripollés-Melchor
- Department of Anesthesia, Infanta Leonor University Hospital, Complutense University of Madrid, Madrid, Spain.
| | - R Casans-Francés
- Department of Anesthesia, Lozano Blesa University Hospital, University of Zaragoza, Zaragoza, Spain
| | - A Abad-Gurumeta
- Department of Anesthesia, La Paz University Hospital, Madrid, Spain
| | | | - J M Ramírez-Rodríguez
- Department of Surgery, Lozano Blesa University Hospital, University of Zaragoza, Zaragoza, Spain
| | - F López-Timoneda
- Department of Anesthesia, Clínico San Carlos University Hospital, Complutense University of Madrid, Madrid, Spain
| | - J M Calvo-Vecino
- Department of Anesthesia, Infanta Leonor University Hospital, Complutense University of Madrid, Madrid, Spain
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Vignali A, Elmore U, Cossu A, Lemma M, Calì B, de Nardi P, Rosati R. Enhanced recovery after surgery (ERAS) pathway vs traditional care in laparoscopic rectal resection: a single-center experience. Tech Coloproctol 2016; 20:559-66. [PMID: 27262309 DOI: 10.1007/s10151-016-1497-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 02/21/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of this study was to compare the outcome of an enhanced recovery after surgery (ERAS) pathway with traditional perioperative care in laparoscopic rectal resection. METHODS A retrospective analysis of prospectively collected data was conducted. Single-center consecutive patients who underwent laparoscopic rectal surgery after an ERAS program were compared with patients who received traditional care over an 8-year period. Primary and total length of stay, and readmission, morbidity and mortality rates were analyzed. For ERAS group, the actual adherence to protocol was also evaluated. RESULTS Two hundred and ninety-seven patients, 162 in the ERAS group and 135 in conventional care, were studied. Median primary and total length of stay were significantly shorter in the ERAS group (9 vs 12 days; p = 0.0001; 10 vs 12 days; p = 0.01; respectively). The ERAS group experienced a faster recovery of bowel function than the traditional care group (p = 0.0001). A similar morbidity rate was observed in the two groups (32.3 % in ERAS vs 36.1 % in traditional care p = 0.41). Readmission rates were 4.9 % in the ERAS versus 1.5 % in the traditional care group (p = 0.19). There was no mortality in either group. Overall mean compliance with the ERAS protocol was 85.7 % (range 54.4-100 %). CONCLUSIONS The introduction of the ERAS protocol in laparoscopic rectal resection led to a reduction in primary and total length of hospital stay without an increase in morbidity or readmission rates when compared to traditional care.
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Affiliation(s)
- A Vignali
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Via Olgettina 60, 20132, Milan, Italy.
| | - U Elmore
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Via Olgettina 60, 20132, Milan, Italy
| | - A Cossu
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Via Olgettina 60, 20132, Milan, Italy
| | - M Lemma
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Via Olgettina 60, 20132, Milan, Italy
| | - B Calì
- Department of General and Minimally-Invasive Surgery, Humanitas Research Hospital, University of Milan, Rozzano, Milan, Italy
| | - P de Nardi
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Via Olgettina 60, 20132, Milan, Italy
| | - R Rosati
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Via Olgettina 60, 20132, Milan, Italy
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Alawadi ZM, Leal I, Phatak UR, Flores-Gonzalez JR, Holihan JL, Karanjawala BE, Millas SG, Kao LS. Facilitators and barriers of implementing enhanced recovery in colorectal surgery at a safety net hospital: A provider and patient perspective. Surgery 2016; 159:700-12. [DOI: 10.1016/j.surg.2015.08.025] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 08/20/2015] [Accepted: 08/22/2015] [Indexed: 01/14/2023]
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Page AJ, Gani F, Crowley KT, Lee KHK, Grant MC, Zavadsky TL, Hobson D, Wu C, Wick EC, Pawlik TM. Patient outcomes and provider perceptions following implementation of a standardized perioperative care pathway for open liver resection. Br J Surg 2016; 103:564-71. [DOI: 10.1002/bjs.10087] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/13/2015] [Accepted: 11/19/2015] [Indexed: 12/12/2022]
Abstract
Abstract
Background
Enhanced recovery after surgery (ERAS) pathways have been associated with improved perioperative outcomes following several surgical procedures. Less is known, however, regarding their use following hepatic surgery.
Methods
An evidence-based, standardized perioperative care pathway was developed and implemented prospectively among patients undergoing open liver surgery between 1 January 2014 and 31 July 2015. Perioperative outcomes, including length of hospital stay, postoperative complications and healthcare costs, were compared between groups of patients who had surgery before and after introduction of the ERAS pathway. Provider perceptions regarding the perioperative pathway were assessed using an online questionnaire.
Results
There were no differences in patient or disease characteristics between pre-ERAS (42 patients) and post-ERAS (75) groups. Although mean pain scores were comparable between the two groups, patients treated within the ERAS pathway had a marked reduction in opioid use on the first 3 days after surgery compared with those treated before introduction of the pathway (all P < 0·001). Duration of hospital stay was shorter in the post-ERAS group (median 5 (i.q.r. 4–7) days versus 6 (5–7) days in the pre-ERAS group; P = 0·037) and there was a lower incidence of postoperative complications (1 versus 10 per cent; P = 0·036). Implementation of the ERAS pathway was associated with a 40·7 per cent decrease in laboratory costs (−US $333; −€306, exchange rate 4 January 2016) and a 21·5 per cent reduction in medical supply costs (−US $394; −€362) per patient. Although 91·0 per cent of providers endorsed the ERAS pathway, 33·8 per cent identified provider aversion to a standardized protocol as the greatest hurdle to implementation.
Conclusion
The introduction of a multimodal ERAS programme following open liver surgery was associated with a reduction in opioid use, shorter hospital stay and decreased hospital costs. ERAS was endorsed by an overwhelming majority of providers.
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Affiliation(s)
- A J Page
- Department of Surgery, Johns Hopkins University School of Medicine, Maryland, USA
| | - F Gani
- Department of Surgery, Johns Hopkins University School of Medicine, Maryland, USA
| | - K T Crowley
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland, USA
| | - K H K Lee
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland, USA
| | - M C Grant
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Maryland, USA
| | - T L Zavadsky
- Department of Surgery, Johns Hopkins University School of Medicine, Maryland, USA
| | - D Hobson
- Department of Surgery, Johns Hopkins University School of Medicine, Maryland, USA
| | - C Wu
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Maryland, USA
| | - E C Wick
- Department of Surgery, Johns Hopkins University School of Medicine, Maryland, USA
| | - T M Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, Maryland, USA
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Steenhagen E. Enhanced Recovery After Surgery: It's Time to Change Practice! Nutr Clin Pract 2015; 31:18-29. [PMID: 26703956 DOI: 10.1177/0884533615622640] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Perioperative surgical care is undergoing a paradigm shift. Traditional practices such as prolonged preoperative fasting (nil by mouth from midnight), bowel cleaning, and reintroduction of oral nutrition 3-5 days after surgery are being shunned. These and other similar changes have been formulated into a protocol called Enhanced Recovery After Surgery (ERAS) pathway. It is a multimodal perioperative care pathway designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of an ERAS protocol include preoperative counseling, optimization of nutrition, standardized analgesic and anesthetic regimes, and early mobilization. The recent literature is heavily influenced by colorectal surgery, but the principles are now being applied to a wide range of disciplines. As they challenge traditional surgical doctrine, the implementation of ERAS guidelines has been slow, despite the significant body of evidence indicating that ERAS guidelines may lead to improved outcomes.
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Affiliation(s)
- Elles Steenhagen
- Internal Medicine and Dermatology, Department of Dietetics, University Medical Center Utrecht, the Netherlands
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Development of an Enhanced Recovery After Surgery Guideline and Implementation Strategy Based on the Knowledge-to-action Cycle. Ann Surg 2015; 262:1016-25. [DOI: 10.1097/sla.0000000000001067] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Pędziwiatr M, Kisialeuski M, Wierdak M, Stanek M, Natkaniec M, Matłok M, Major P, Małczak P, Budzyński A. Early implementation of Enhanced Recovery After Surgery (ERAS®) protocol - Compliance improves outcomes: A prospective cohort study. Int J Surg 2015; 21:75-81. [PMID: 26231994 DOI: 10.1016/j.ijsu.2015.06.087] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 03/29/2015] [Accepted: 06/28/2015] [Indexed: 12/16/2022]
Abstract
Enhanced Recovery After Surgery protocol in colorectal surgery allows shortening length of hospital stay and reducing complication rate. Despite the clear guidelines and conclusive evidence their full implementation and putting them into daily practice meets certain difficulties, especially in the early stage. The aim of the study was to analyse the course of implementation of the ERAS protocol into daily practice on the basis of adherence to the protocol. Group included 92 patients (43F/49M) with colorectal cancer submitted to laparoscopic resection during the years 2013-2014. Perioperative care in all of them based on ERAS protocol consisting of 16 items. Its principles and discharge criteria were based on the guidelines of the ERAS Society guidelines. The entire analysed group of patients was divided into 3 subgroups (30 patients) depending on the time from ERAS protocol implementation. We analysed the compliance with the protocol and its influence on length of hospital stay, postoperative complications and readmission rate in different subgroups. The average compliance with the protocol differed significantly between groups and was 65% in group 1, 83.9% in group 2 and 89.6% in group 3. The compliance with subsequent protocol elements was different. The length of stay and complication rate was statistically different in analysed subgroups. The whole group demonstrated an inverse correlation between compliance and length of stay. This analysis leads to the conclusion that the introduction of the ERAS protocol is a gradual process, and its compliance at the level of 80% or more requires at least 30 patients and the period of about 6 months. The initial derogation from the assumed proceedings is inevitable and should not discourage further action. Particular emphasis in the initial stage should be put on continuous training of personnel of all specialties and continuous evaluation of the results.
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Affiliation(s)
- Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University, Krakow, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumor Surgery, Kopernika 21, 31-501 Kraków, Poland.
| | - Mikhail Kisialeuski
- 2nd Department of General Surgery, Jagiellonian University, Krakow, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumor Surgery, Kopernika 21, 31-501 Kraków, Poland
| | - Mateusz Wierdak
- 2nd Department of General Surgery, Jagiellonian University, Krakow, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumor Surgery, Kopernika 21, 31-501 Kraków, Poland
| | - Maciej Stanek
- 2nd Department of General Surgery, Jagiellonian University, Krakow, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumor Surgery, Kopernika 21, 31-501 Kraków, Poland
| | - Michał Natkaniec
- 2nd Department of General Surgery, Jagiellonian University, Krakow, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumor Surgery, Kopernika 21, 31-501 Kraków, Poland
| | - Maciej Matłok
- 2nd Department of General Surgery, Jagiellonian University, Krakow, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumor Surgery, Kopernika 21, 31-501 Kraków, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University, Krakow, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumor Surgery, Kopernika 21, 31-501 Kraków, Poland
| | - Piotr Małczak
- Students' Scientific Society of 2nd Department of General Surgery, Jagiellonian University, Kopernika 21, 31-501 Kraków, Poland
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University, Krakow, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumor Surgery, Kopernika 21, 31-501 Kraków, Poland
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Gotlib Conn L, McKenzie M, Pearsall EA, McLeod RS. Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: a process evaluation of champions' experiences. Implement Sci 2015; 10:99. [PMID: 26183086 PMCID: PMC4504167 DOI: 10.1186/s13012-015-0289-y] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 07/02/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Enhanced 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. METHODS A 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. RESULTS Fifty-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. CONCLUSIONS Successful 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.
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Affiliation(s)
- Lesley Gotlib Conn
- Evaluative Clinical Sciences, Trauma, Emergency and Critical Care Research Program, Sunnybrook Research Institute, 2075 Bayview Ave., Room K3W-28, Toronto, ON, M4N 3M5, Canada.
| | - Marg McKenzie
- Department of Surgery, Mount Sinai Hospital Joseph and Wolf Lebovic Health Complex, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
| | - Emily A Pearsall
- Department of Surgery, Mount Sinai Hospital Joseph and Wolf Lebovic Health Complex, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
| | - Robin S McLeod
- Department of Surgery, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, M5T 1P5, Canada.
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The use of artificial neural networks to predict delayed discharge and readmission in enhanced recovery following laparoscopic colorectal cancer surgery. Tech Coloproctol 2015; 19:419-28. [PMID: 26084884 DOI: 10.1007/s10151-015-1319-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 04/24/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND Artificial neural networks (ANNs) can be used to develop predictive tools to enable the clinical decision-making process. This study aimed to investigate the use of an ANN in predicting the outcomes from enhanced recovery after colorectal cancer surgery. METHODS Data were obtained from consecutive colorectal cancer patients undergoing laparoscopic surgery within the enhanced recovery after surgery (ERAS) program between 2002 and 2009 in a single center. The primary outcomes assessed were delayed discharge and readmission within a 30-day period. The data were analyzed using a multilayered perceptron neural network (MLPNN), and a prediction tools were created for each outcome. The results were compared with a conventional statistical method using logistic regression analysis. RESULTS A total of 275 cancer patients were included in the study. The median length of stay was 6 days (range 2-49 days) with 67 patients (24.4 %) staying longer than 7 days. Thirty-four patients (12.5 %) were readmitted within 30 days. Important factors predicting delayed discharge were related to failure in compliance with ERAS, particularly with the postoperative elements in the first 48 h. The MLPNN for delayed discharge had an area under a receiver operator characteristic curve (AUROC) of 0.817, compared with an AUROC of 0.807 for the predictive tool developed from logistic regression analysis. Factors predicting 30-day readmission included overall compliance with the ERAS pathway and receiving neoadjuvant treatment for rectal cancer. The MLPNN for readmission had an AUROC of 0.68. CONCLUSIONS These results may plausibly suggest that ANN can be used to develop reliable outcome predictive tools in multifactorial intervention such as ERAS. Compliance with ERAS can reliably predict both delayed discharge and 30-day readmission following laparoscopic colorectal cancer surgery.
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84
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Segelman J, Nygren J. Evidence or eminence in abdominal surgery: Recent improvements in perioperative care. World J Gastroenterol 2014; 20:16615-16619. [PMID: 25469030 PMCID: PMC4248205 DOI: 10.3748/wjg.v20.i44.16615] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 07/23/2014] [Accepted: 09/19/2014] [Indexed: 02/06/2023] Open
Abstract
Repeated surveys from Europe, the United States, Australia, and New Zealand have shown that adherence to an evidence-based perioperative care protocol, such as Enhanced Recovery After Surgery (ERAS), has been generally low. It is of great importance to support the implementation of the ERAS protocol as it has been shown to improve outcomes after a number of surgical procedures, including major abdominal surgery. However, despite an increasing awareness of the importance of structured perioperative management, the implementation of this complex protocol has been slow. Barriers to implementation involve both patient- and staff-related factors as well as practice-related issues and resources. To support efficient and successful implementation, further educational and structural measures have to be made on a national or regional level to improve the standard of general health care. Besides postoperative morbidity, biological and physiological variables have been quite commonly reported in previous ERAS studies. Little information, however, has been obtained on cost-effectiveness, long-term outcomes, quality of life and patient-related outcomes, and these issues remain important areas of research for future studies.
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85
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Barker LA, Crowe TC. Nutritional management of gastrointestinal surgical patients in Victoria's public hospitals. Nutr Diet 2014. [DOI: 10.1111/1747-0080.12145] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Lisa A. Barker
- Nutrition and Dietetics; Monash Health; Clayton Victoria Australia
- School of Exercise and Nutrition Sciences; Deakin University; Burwood Victoria Australia
| | - Timothy C. Crowe
- Nutrition and Dietetics; Monash Health; Clayton Victoria Australia
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Hughes M, Coolsen MME, Aahlin EK, Harrison EM, McNally SJ, Dejong CHC, Lassen K, Wigmore SJ. Attitudes of patients and care providers to enhanced recovery after surgery programs after major abdominal surgery. J Surg Res 2014; 193:102-10. [PMID: 25066187 DOI: 10.1016/j.jss.2014.06.032] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 06/07/2014] [Accepted: 06/18/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is a well-established pathway of perioperative care in surgery in an increasing number of specialties. To implement protocols and maintain high levels of compliance, continued support from care providers and patients is vital. This survey aimed to assess the perceptions of care providers and patients of the relevance and importance of the ERAS targets and strategies. MATERIALS AND METHODS Pre- and post-operative surveys were completed by patients who underwent major hepatic, colorectal, or oesophagogastric surgery in three major centers in Scotland, Norway, and The Netherlands. Anonymous web-based and article surveys were also sent to surgeons, anesthetists, and nurses experienced in delivering enhanced recovery protocols. Each questionnaire asked the responder to rate a selection of enhanced recovery targets and strategies in terms of perceived importance. RESULTS One hundred nine patients and 57 care providers completed the preoperative survey. Overall, both patients and care providers rated the majority of items as important and supported ERAS principles. Freedom from nausea (median, 10; interquartile range [IQR], 8-10) and pain at rest (median, 10; IQR, 8-10) were the care components rated the highest by both patients and care providers. Early return of bowel function (median, 7; IQR, 5-8) and avoiding preanesthetic sedation (median, 6; IQR, 3.75-8) were scored the lowest by care providers. CONCLUSIONS ERAS principles are supported by both patients and care providers. This is important when attempting to implement and maintain an ERAS program. Controversies still remain regarding the relative importance of individual ERAS components.
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Affiliation(s)
- Michael Hughes
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom.
| | - Marielle M E Coolsen
- Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands
| | - Eirik K Aahlin
- Department of Gastrointestinal Surgery, University Hospital Northern Norway and Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Ewen M Harrison
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Stephen J McNally
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - C H C Dejong
- Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands
| | - Kristoffer Lassen
- Department of Gastrointestinal Surgery, University Hospital Northern Norway and Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Stephen J Wigmore
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
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