A qualitative study assessing the barriers to implementation of enhanced recovery after surgery. World J Surg. 2014;38:1374-1380. [PMID: 24385194 DOI: 10.1007/s00268-013-2441-7]

The efficacy and safety of enhanced recovery after surgery (ERAS) Program in laparoscopic distal gastrectomy: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Although ERAS Program had some advantages in laparoscopic distal gastrectomy (LDG), its efficacy and safety remained unclear. We conducted a systematic review and meta-analysis to assess the efficacy and safety of the ERAS group and the traditional care (TC) group in LDG.

METHODS

Multiple databases were retrieved from 1 January 2000 to 30 April 2023. The risk ratio (RR), standardized mean difference (SMD) and their 95% confidence interval (CI) were used to estimate the results.

RESULTS

Our meta-analysis contained 17 randomized controlled trials (RCTs) studies, which comprised 1468 patients. Regarding efficacy, the ERAS group had significantly shorter postoperative time to first flatus (SMD = -1.29 [95% CI: -1.68, -0.90]), shorter time to first defecation (SMD = -1.26 [95% CI: -1.90, -0.61]), shorter hospital stays (SMD = -0.99 [95% CI: -1.34, -0.63]), and lower hospitalization costs (SMD = -1.17 [95% CI: -1.86, -0.48]) compared to the TC group. Furthermore, in the ERAS group, C-reactive protein levels were lower on postoperative days 1, 3 or 4, and 7; albumin levels were higher on postoperative days 3 or 4 and 7; and interleukin-6 levels were lower on postoperative days 1 and 3. Regarding safety, the overall postoperative complication rate was lower in the ERAS group (RR: 0.76 [95% CI: 0.60, 0.97]), but there was no significant difference in the individual postoperative complication rate. Other indicators were also not statistically significant.

CONCLUSION

The combination of ERAS Program with laparoscopy surgery was safe and effective for the perioperative management of patients with distal gastric cancer.

Clinicians' perceptions of "enhanced recovery after surgery" (ERAS) protocols to improve patient safety in surgery: a national survey from Australia

BACKGROUND

Surgical patients are at risk of postoperative complications, which may lead to increased morbidity, mortality, hospital length-of-stay and healthcare costs. Enhanced Recovery After Surgery (ERAS®) protocols are evidence-based and have demonstrated effectiveness in decreasing complications and associated consequences. However, their adoption in Australia has been limited and the reason for this is unclear. This study aimed to describe clinicians' perceptions of ERAS protocols in Australia.

METHODS

A national online survey of anaesthetists, surgeons and nurses was undertaken. Invitations to participate were distributed via emails from professional colleges. The 30-item survey captured respondent characteristics, ERAS perceptions, beliefs, education and learning preferences and future planning considerations. The final question was open-ended for elaboration of perceptions of ERAS. Descriptive and inferential statistics were used to describe and compare group differences across disciplines relative to perceptions of ERAS.

RESULTS

The sample included 178 responses (116 nurses, 65.2%; 36 surgeons, 20.2%; 26 anaesthetists, 14.6%) across six states and two territories. More than half (n = 104; 58.8%) had used ERAS protocols in patient care, and most perceived they were 'very knowledgeable' (n = 24; 13.6%) or 'knowledgeable' (n = 71; 40.3%) of ERAS. However, fewer nurses had cared for a patient using ERAS (p <.01) and nurses reported lower levels of knowledge (p <.001) than their medical counterparts. Most respondents agreed ERAS protocols improved patient care and financial efficiency and were a reasonable time investment (overall Md 3-5), but nurses generally recorded lower levels of agreement (p.013 to < 0.001). Lack of information was the greatest barrier to ERAS knowledge (n = 97; 62.6%), while seminars/lectures from international and national leaders were the preferred learning method (n = 59; 41.3%). Most supported broad implementation of ERAS (n = 130; 87.8%).

CONCLUSION

There is a need to promote ERAS and provide education, which may be nuanced based on the results, to improve implementation in Australia. Nurses particularly need to be engaged in ERAS protocols given their significant presence throughout the surgical journey. There is also a need to co-design implementation strategies with stakeholders that target identified facilitators and barriers, including lack of support from senior administration, managers and clinicians and resource constraints.

Lessons following implementation of a colorectal enhanced recovery after surgery (ERAS) protocol in a rural hospital setting

INTRODUCTION

Enhanced recovery after surgery (ERAS) programs have become increasingly popular in the management of patients undergoing colorectal resection. However, the validity of ERAS in rural hospital settings without intensive care facilities has not been primarily evaluated. This study aimed to assess an ERAS protocol in a rural surgical department based in Invercargill New Zealand.

METHODS

Ten years of prospectively collected data were analysed retrospectively from an ERAS database of all patients undergoing open, converted, or laparoscopic colorectal resections. Data were collected between two time periods: before the implementation of an ERAS protocol, from January 2011 to December 2013; as well as after the implementation of an ERAS protocol, from January 2014 to December 2020. The primary outcome measures were hospital length of stay (LOS) and LOS in the critical care unit (LOS-CCU). Secondary outcomes were compliance with ERAS protocol, mortality, readmission, and reoperation rates.

RESULTS

A total of 118 and 558 colorectal resections were performed in the pre-ERAS and ERAS groups respectively. A statistically significant reduction in hospital LOS was achieved from a median of 8 to 7 days (P = 0.038) when comparing pre-ERAS to ERAS groups respectively. Furthermore, a significant reduction in re-operation rates was observed (7.6% vs. 3% in the ERAS group, P = 0.033) which was seen without a rise in readmission rates (13.6% vs. 13.6% in the ERAS group).

CONCLUSION

The implementation of ERAS in a rural surgical setting is feasible, and these initial findings suggest ERAS adds value in optimizing the colorectal patient's surgical journey.

Obstetric and medical factors rather than psychosocial characteristics explain why eligible women do not complete the enhanced recovery after elective caesarean (EREC) pathway: A prospective cohort study

BACKGROUND

An Australian health-service implemented an 'enhanced recovery after elective caesarean' pathway with next-day discharge.

PROBLEM

Previous anecdotal reports indicated that a large percentage of eligible women were not discharged the next day and therefore were not regarded as having completed the pathway. Psychosocial factors were expected to be the leading reason for prolonged hospitalisation.

AIM

The study objectives were to: enumerate the percentage of women assessed as eligible for EREC who subsequently did not complete the pathway and the reasons; and to describe women's antenatal satisfaction with preparation, preferences, and perceived support. Women who completed the pathway versus those who did not were compared on antenatal biopsychosocial characteristics.

METHODS

This exploratory prospective cohort study enrolled consenting eligible women from antenatal clinics and used patient records and questionnaire data. Comparative statistical techniques were used.

FINDINGS

62 % of women did not complete the pathway, with medical and obstetric factors being the most common reasons (80 %). There was statistically significant evidence of lower antenatal stress levels for those who completed EREC (median=5) relative to those who did not (median=8; P = 0.035); although these findings may not be of clinical importance. Antenatally, 51 % of women felt prepared for early discharge, 36 % needed more information, 19 % disliked hospital, 93 % agreed that family togetherness after birth was important. Most agreed that staff (76 %) and family (67 %) supported the pathway.

CONCLUSION

This study indicated that a large percentage of women assessed as eligible did not complete EREC and that obstetric and medical factors, rather than psychosocial characteristics, largely explained this. This provides reassurance to clinicians and women that discharge home is working as intended and is useful for planning similar models of care. Higher stress levels in the antenatal period were demonstrated for women who did not complete EREC suggesting the need for further research into how to support these women.

Views and experiences of healthcare professionals and patients on the implementation of a 23-hour accelerated enhanced recovery programme: a mixed-method study

BACKGROUND

An accumulating body of research suggests that an accelerating enhanced recovery after colon surgery protocol is beneficial for patients, however, to obtain these effects, adherence to all elements of the protocol is important. The implementation of complex interventions, such as the Enhanced Recovery After Surgery protocol (ERAS), and their strict adherence have proven to be difficult. The same challenges can be expected in the implementation of the accelerated Enhanced Recovery Pathways (ERPs). This study aimed to understand the perspectives of both healthcare professionals (HCPs) and patients on the locally studied acCelerated enHanced recovery After SurgEry (CHASE) protocol.

METHODS

For this mixed-method study, HCPs who provided CHASE care and patients who received CHASE care were recruited using purposive sampling. Ethical approval was obtained by the Medical Ethical Committee of the Zuyderland Medical Centre (NL71804.096.19, METCZ20190130, October 2022). Semi-structured, in-depth, one-on-one interviews were conducted with HCPs (n = 13) and patients (n = 11). The interviews consisted of a qualitative and quantitative part, the protocol evaluation and the Measurement Instrument or Determinant of Innovations-structured questionnaire. We explored the perspectives, barriers, and facilitators of the CHASE protocol implementation. The interviews were audiotaped, transcribed verbatim and analysed independently by two researchers using direct content analysis.

RESULTS

The results showed that overall, HCPs support the implementation of the CHASE protocol. The enablers were easy access to the protocol, the relevance of the intervention, and thorough patient education. Some of the reported barriers included the difficulty of recognizing CHASE patients, the need for regular feedback, and the updates on the implementation progress. Most patients were enthusiastic about early discharge after surgery and expressed satisfaction with the care they received. On the other hand, the patients sometimes received different information from different HCPs, considered the information to be too extensive and few experienced some discomfort with CHASE care.

CONCLUSION

Bringing CHASE care into practice was challenging and required adaptation from HCPs. The experiences of HCPs showed that the protocol can be improved further, and the mostly positive experiences of patients are a motivation for this improvement. These results yielded practical implications to improve the implementation of accelerated ERPs.

An investigation on the compliance of perioperative practices using ERAS protocols and barriers to the implementation of the ERAS protocols in colorectal surgery

BACKGROUND

Although ERAS protocols have many benefits, there are some deficiencies in their understanding and implementation by healthcare professionals. The present study was conducted to investigate the compliance of the current perioperative practices of healthcare professional with the ERAS protocols and to assess barriers to the implementation of ERAS protocols in colorectal surgery.

METHODS

This cross-sectional descriptive study conducted in the surgical clinics and operating rooms of a training and research hospital between January 2020 and September 2020 included 110 physician and nurse members of surgical teams. Data were collected using the Questionnaire for Evaluating the Use of the ERAS Protocol and Identifying Barriers to Implementation in Colorectal Surgery.

RESULTS

The compliance of the current perioperative practices by healthcare professionals with the ERAS protocols ranged between 15.5% (routinely leaving nasogastric tubes in situ following colorectal resection) and 61.8% (being aware of the concept of balanced analgesia). Variables such as the healthcare professional's profession, title, years in practice and colorectal surgery experience led to a difference between them in terms of their compliance of the practices with the ERAS protocols (p < 0.05). Based on the healthcare professionals' comments about barriers to the implementation of the ERAS protocol, themes such as education, teamwork, communication and lack of resources were created.

CONCLUSION

Healthcare professionals' compliance level of the current perioperative practices with the ERAS protocols was mostly low. Barriers to the implementation of the ERAS protocols had a multi-factor structure that concerns the multidisciplinary team.

Experiences of interventions to reduce hospital stay for older adults following elective treatment: Qualitative evidence-synthesis

BACKGROUND AND OBJECTIVES

Hospitals streamline treatment pathways to reduce the length of time older adults admitted for planned procedures spend in hospital. However patient perspectives have been poorly evaluated. This systematic review aimed to understand the experiences of older patients, carers, families and staff of multi-component interventions intended to improve recovery following elective treatment.

RESEARCH DESIGN AND METHODS

Bibliographic databases searched in June 2021 included MEDLINE ALL, HMIC, CENTRAL, CINAHL, AMED and ProQuest Dissertations and Theses. We conducted citation searching and examined reference lists of reviews. Two reviewers independently undertook screening and data extraction, resolving disagreements through discussion. We used an adapted Wallace checklist for quality appraisal and meta-ethnography to synthesise data. Clinician, carer and patient views were incorporated throughout the review.

RESULTS

Thirty-five papers were included in the synthesis. Thirteen studies were conducted in the UK, with patient views the most frequently represented. We identified six overarching constructs: 'Home as preferred environment for recovery', 'Feeling safe', 'Individualisation of structured programme', 'Taking responsibility', 'Essential care at home' and 'Outcomes'.

DISCUSSION AND IMPLICATIONS

Findings explore the support patients, families and carers need throughout hospital admission, and may inform commissioning of services to ensure patients and carers receive appropriate follow-up support after hospital discharge. The findings may help hospital and community-based health and social care staff provide person-centred care based upon assessments of emotional and physical wellbeing of patients and family/carers. Research is needed to establish a core-set of patient-reported outcome measures which capture aspects of recovery which are meaningful to patients.

Enhanced Recovery after Surgery (ERAS) Implementation and Barriers among Healthcare Providers in France: A Cross-Sectional Study

The implementation of Enhanced Recovery After Surgery (ERAS) is a challenge for healthcare systems, especially in case of patients undergoing major surgery. Despite a proven significant reduction in postoperative complications and hospital lengths of stay, ERAS protocols are inconsistently used in real-world practice, and barriers have been poorly described in a cohort comprising medical and paramedical professionals. This study aims to assess the proportion of French healthcare providers who practiced ERAS and to identify barriers to its implementation amongst those surveyed. We conducted a prospective cross-sectional study to survey healthcare providers about their practice of ERAS using an online questionnaire. Healthcare providers were contacted through hospital requests, private hospital group requests, professional corporation requests, social networks, and personal contacts. The questionnaire was also designed to explore barriers to ERAS implementation. Identified barriers were allocated by two independent assessors to one of the fourteen domains of the Theoretical Domains Framework (TDF), which is an integrative framework based on behavior change theories that can be used to identify issues relating to evidence on the implementation of best practice in healthcare settings. One hundred and fifty-three French healthcare providers answered the online questionnaire (76% female, median age 35 years (IQR: 29 to 48)). Physiotherapists, nurses, and dieticians were the most represented professions (31.4%, 24.2%, and, 14.4%, respectively). Amongst those surveyed, thirty-one practiced ERAS (20.3%, 95%CI: 13.9 to 26.63). Major barriers to ERAS practice were related to the "Environmental context and resources" domain (57.6%, 95%CI: 49.5-65.4), e.g., lack of professionals, funding, and coordination, and the "Knowledge" domain (52.8%, 95%CI: 44.7-60.8), e.g., ERAS unawareness. ERAS in major surgery is seldom practiced in France due to the unfavorable environment (i.e., logistics issues, and lack of professionals and funding) and a low rate of procedure awareness. Future studies should focus on devising and assessing strategies (e.g., education and training, collaboration, institutional support, the development of healthcare networks, and leveraging telehealth and technology) to overcome these barriers, thereby promoting the wider implementation of ERAS.

[Modern Perioperative Care Concepts in Thoracic Surgery: Enhanced Recovery After Thoracic Surgery (ERATS)]

In modern perioperative care concepts, multimodal ERAS (Enhanced Recovery After Surgery) is a multimodal perioperative treatment concept for improving postoperative recovery of surgical patients after an operation. This is managed by the so-called ERAS Society and through which hospitals can also be officially certified. The focus of the ERAS concept is on uniform patient care from admission to discharge, with the aim of improving perioperative processes by implementing evidence-based protocols involving a multidisciplinary treatment team. In 2019, ERAS guidelines were published for the first time by the European Society of Thoracic Surgery (ESTS), in cooperation with the ERAS Society, for specific lung resection procedures, and these identified a total of 45 graduated recommendations or Enhanced Recovery Pathways (ERP). The implementation of ERAS concepts in thoracic surgery (ERATS = Enhanced Recovery After Thoracic Surgery) is intended to establish standardised perioperative procedures based on study results and/or expert recommendations. These recommendations take into account organisational aspects as well as thoracic surgical and anaesthesiological procedures, with the overriding goal of creating a structured treatment plan tailored to the patient. All these measures should result in a multimodal overall concept, which should primarily lead to an improved outcome after elective thoracic surgery and secondarily to shorter hospital stays with correspondingly lower costs.This review article describes basic ERAS principles and provides a compact presentation of the most important European ERAS recommendations from the authors' point of view, together with typical obstacles to the implementation of the corresponding ERATS program in German thoracic surgery.

Challenging issues of implementing enhanced recovery after surgery programs in South Korea

This review discusses the challenges of implementing enhanced recovery after surgery (ERAS) programs in South Korea. ERAS is a patient-centered perioperative care approach that aims to improve postoperative recovery by minimizing surgical stress and complications. While ERAS has demonstrated significant benefits, its successful implementation faces various barriers such as a lack of manpower and policy support, poor communication and collaboration among perioperative members, resistance to shifting away from outdated practices, and patient-specific risk factors. This review emphasizes the importance of understanding these factors to tailor effective strategies for successful ERAS implementation in South Korea's unique healthcare setting. In this review, we aim to shed light on the current status of ERAS in South Korea and identify key barriers. We hope to encourage Korean anesthesiologists to take a leading role in adopting the ERAS program as the standard for perioperative care. Ultimately, our goal is to improve the surgical outcomes of patients using this proactive approach.

Impact of enhanced recovery after surgery (ERAS) guidelines implementation in cesarean delivery: A systematic review and meta-analysis

BACKGROUND

Cesarean delivery rate is increasing, with no prediction of this rate to drop. Implementation of Early Recovery After Surgery (ERAS) program adapted to this high prevalent obstetrical surgical procedure proposes better peri-operative care achievement with improved maternal medical care, namely reduced morbidity, faster return to normal daily activities and improved impact on quality of life. Our aim was to analyze the outcomes of ERAS guidelines implementation in cesarean sections (CS).

MATERIAL AND METHODS

A systematic review was performed across 3 databases (MEDLINE (Pubmed), Scopus and Web of Science), with no time or language filters, for articles comparing outcomes on pregnant women who delivered via CS with ERAS guidelines implementation versus the traditional approach without ERAS implementation. Outcomes established: primary - hospital length of stay; secondary - opioid consumption, readmission rates and maternal complications (overall, surgical site infection and emetic morbidity). Statistical analyses were conducted using Review Manager 5.4 and its results were expressed as mean difference, standardized mean difference and odds ratio, with 95% of confidence intervals. This systematic review was reported according to the PRISMA statement.

RESULTS

This systematic review included 16 studies (3 randomized controlled trials (RCT), 4 prospective cohorts and 9 retrospective cohorts), with a pool analysis of 19,001 women (9752 with the traditional approach and 9249 following ERAS guidelines). Our results showed a significative decrease in length of hospital stay (MD: -13.78 h; CI 95 % -19.28 to -8.28; p < 0.00001) and opioid consumption (SMD: -0.91; CI 95 % -1.51 to -0.32; p = 0.003), with similar readmission rates (OR: 0.85; CI 95 % 0.50 to 1.44; p = 0.53) and maternal complications, namely: overall (OR: 0.87; CI 95 % 0.56 to 1.35; p = 0.53); surgical site infection (OR: 1.13; CI 95 % 0.72 to 1.77; p = 0.60) and emetic morbidity (OR: 0.78; CI 95 % 0.31 to 1.96; p = 0.60).

CONCLUSIONS

ERAS guidelines applied at CS management are associated with decreased length of stay and opioid consumption, without negatively impact on readmission rates and overall maternal complications, including surgical site infection and emetic morbidity. The reduced number of RCT studies and the heterogeneity of the studies (heterogeneous inter-study protocols) constitutes the major limitation of the evidence found. Still, these findings may be a foremost help to confirm the beneficial impact of an ERAS approach during peri-cesarean management.

Impact of interventions to improve recovery of older adults following planned hospital admission on quality-of-life following discharge: linked-evidence synthesis

Objectives

To understand the impact of multicomponent interventions to improve recovery of older adults following planned hospital treatment, we conducted two systematic reviews, one of quantitative and one of qualitative evidence, and an overarching synthesis. These aimed to: • understand the effect of multicomponent interventions which aim to enhance recovery and/or reduce length of stay on patient-reported outcomes and health and social care utilisation • understand the experiences of patients, carers and staff involved in the delivery of interventions • understand how different aspects of the content and delivery of interventions may influence patient outcomes.

Review methods

We searched bibliographic databases including MEDLINE ALL, Embase and the Health Management Information Consortium, CENTRAL, and Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database, conducted forward and backward citation searching and examined reference lists of topically similar qualitative reviews. Bibliographic database searches were completed in May/June 2021 and updated in April 2022. We sought primary research from high-income countries regarding hospital inpatients with a mean/median age of minimum 60 years, undergoing planned surgery. Patients experienced any multicomponent hospital-based intervention to reduce length of stay or improve recovery. Quantitative outcomes included length of stay and any patient-reported outcome or experience or service utilisation measure. Qualitative research focused on the experiences of patients, carers/family and staff of interventions received. Quality appraisal was undertaken using the Effective Public Health Practice Project Quality Assessment Tool or an adapted version of the Wallace checklist. We used random-effects meta-analysis to synthesise quantitative data where appropriate, meta-ethnography for qualitative studies and qualitative comparative analysis for the overarching synthesis.

Results

Quantitative review: Included 125 papers. Forty-nine studies met criteria for further synthesis. Enhanced recovery protocols resulted in improvements to length of stay, without detriment to other outcomes, with minimal improvement in patient-reported outcome measures for patients admitted for lower-limb or colorectal surgery. Qualitative review: Included 43 papers, 35 of which were prioritised for synthesis. We identified six themes: 'Home as preferred environment for recovery', 'Feeling safe', 'Individualisation of structured programme', 'Taking responsibility', 'Essential care at home' and 'Outcomes'. Overarching synthesis: Intervention components which trigger successful interventions represent individualised approaches that allow patients to understand their treatment, ask questions and build supportive relationships and strategies to help patients monitor their progress and challenge themselves through early mobilisation.

Discussion

Interventions to reduce hospital length of stay for older adults following planned surgery are effective, without detriment to other patient outcomes. Findings highlight the need to reconsider how to evaluate patient recovery from the perspective of the patient. Trials did not routinely evaluate patient mid- to long-term outcomes. Furthermore, when they did evaluate patient outcomes, reporting is often incomplete or conducted using a narrow range of patient-reported outcome measures or limited through asking the wrong people the wrong questions, with lack of longer-term evaluation. Findings from the qualitative and overarching synthesis will inform policy-making regarding commissioning and delivering services to support patients, carers and families before, during and after planned admission to hospital.

Study registration

This trial is registered as PROSPERO registration number CRD42021230620.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 130576) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 23. See the NIHR Funding and Awards website for further award information.

Noninvasive Bioelectronic Treatment of Postcesarean Pain: A Randomized Clinical Trial

Importance

Improved strategies are needed to decrease opioid use after cesarean delivery but still adequately control postoperative pain. Although transcutaneous electrical stimulation devices have proven effective for pain control after other surgical procedures, they have not been tested as part of a multimodal analgesic protocol after cesarean delivery, the most common surgical procedure in the United States.

Objective

To determine whether treatment with a noninvasive high-frequency electrical stimulation device decreases opioid use and pain after cesarean delivery.

Design, Setting, and Participants

This triple-blind, sham-controlled randomized clinical trial was conducted from April 18, 2022, to January 31, 2023, in the labor and delivery unit at a single tertiary academic medical center in Ohio. Individuals were eligible for the study if they had a singleton or twin gestation and underwent a cesarean delivery. Of 267 people eligible for the study, 134 (50%) were included.

Intervention

Participants were randomly assigned in a 1:1 ratio to a high-frequency (20 000 Hz) electrical stimulation device group or to an identical-appearing sham device group and received 3 applications at the incision site in the first 20 to 30 hours postoperatively.

Main Outcomes and Measures

The primary outcome was inpatient postoperative opioid use, measured in morphine milligram equivalents (MME). Secondary outcomes included pain scores, measured with the Brief Pain Inventory questionnaire (scale, 0-10, with 0 representing no pain), MME prescribed at discharge, and receipt of additional opioid prescriptions in the postpartum period. Normally distributed data were assessed using t tests; otherwise via Mann-Whitney or χ2 tests as appropriate. Analyses were completed following intention-to-treat principles.

Results

Of 134 postpartum individuals who underwent a cesarean delivery (mean [SD] age, 30.5 [4.6] years; mean [SD] gestational age at delivery, 38 weeks 6 days [8 days]), 67 were randomly assigned to the functional device group and 67 to the sham device group. Most were multiparous, had prepregnancy body mass index (calculated as weight in kilograms divided by height in meters squared) higher than 30, were privately insured, and received spinal anesthesia. One participant in the sham device group withdrew consent prior to treatment. Individuals assigned to the functional device used significantly less opioid medication prior to discharge (median [IQR], 19.75 [0-52.50] MME) than patients in the sham device group (median [IQR], 37.50 [7.50-67.50] MME; P = .046) and reported similar rates of moderate to severe pain (85% vs 91%; relative risk [RR], 0.77 [95% CI, 0.55-1.29]; P = .43) and mean pain scores (3.59 [95% CI, 3.21-3.98] vs 4.46 [95% CI, 4.01-4.92]; P = .004). Participants in the functional device group were prescribed fewer MME at discharge (median [IQR], 82.50 [0-90.00] MME vs 90.00 [75.00-90.00] MME; P < .001). They were also more likely to be discharged without an opioid prescription (25% vs 10%; RR, 1.58 [95% CI, 1.08-2.13]; P = .03) compared with the sham device group. No treatment-related adverse events occurred in either group.

Conclusions and Relevance

In this randomized clinical trial of postoperative patients following cesarean delivery, use of a high-frequency electrical stimulation device as part of a multimodal analgesia protocol decreased opioid use in the immediate postoperative period and opioids prescribed at discharge. These findings suggest that the use of this device may be a helpful adjunct to decrease opioid use without compromising pain control after cesarean delivery.

Determination of Knowledge and Attitudes of Cardiac Surgery Nurses Regarding the Enhanced Recovery After Surgery Protocol

PURPOSE

This study aimed to examine the knowledge and attitudes of cardiac surgery nurses regarding the enhanced recovery after surgery protocol.

DESIGN

This was a descriptive, cross-sectional study.

METHODS

The sample consisted of 50 nurses working in the cardiovascular surgery clinic of a university hospital in the province of Izmir, Turkey. A questionnaire consisting of three sections was prepared by the researchers to collect data. The first section of the form captured sociodemographic and descriptive characteristics; the second section examined the level of knowledge about the enhanced recovery protocol for cardiac surgery; the third section captured the nurses' attitudes regarding the enhanced recovery protocol. The questionnaire was distributed to the nurses and the research data were collected after a certain amount of time. Descriptive statistics, Mann-Whitney U test, Kruskal-Wallis test, and correlation analysis were used in the analysis of the data.

FINDINGS

The mean age of the nurses was 31.26 ± 6.74 (min = 23, max = 47); 78% were female; 76% had a bachelor's degree; 48% were employed in the intensive care unit. The mean score of the nurses regarding their level of knowledge on the enhanced recovery protocol for cardiac surgery was 18.70 ± 5.29 (min = 0.00, max = 28.00); the mean score regarding attitude toward the enhanced recovery protocol after surgery was 30.00 ± 3.86 (min = 12.00, max = 33.00). There was a positive, moderate, statistically significant correlation (r = 0.396, P = .005) between the mean knowledge level score and the mean attitude level score.

CONCLUSIONS

Results showed that nurses' knowledge was at a moderately positive level. Increasing the level of knowledge increased positive attitudes. Recommendations include disseminating protocol information and providing necessary training to increase positive attitudes in an effort to ensure protocol adherance.

ERAS programme in a Portuguese tertiary hospital: An audit of the first six months of implementation in elective colorectal surgery

INTRODUCTION AND OBJECTIVES

Enhanced Recovery After Surgery (ERAS) is a multimodal strategy designed to optimize postoperative recovery and reduce morbidity, length of hospital stay, and care costs. The aim of this study was to evaluate compliance and clinical outcomes 6 months of implementation of the program in scheduled colorectal surgery in a tertiary hospital.

MATERIAL AND METHODS

Data from 209 patients who underwent elective colorectal surgery were analysed. The first 102 patients (pre-ERAS group) who underwent surgery between January and May 2018, before the implementation of the program, were compared with the 107 patients treated between May and October 2019, after ERAS implementation. The main outcomes were patient education and counselling, use of intravenous fluids, early mobilization, incidence of postoperative nausea and vomiting, return of bowel function, length of stay, complications, mortality, and overall compliance.

RESULTS

The ERAS program was associated with a significant increase in patient education and counselling (p<0.001) and with a significant reduction in intra- and postoperative IV fluid administration (p=0.007 and p<0.001, respectively) and postoperative nausea or vomiting (17.6% vs 5.0%, p=0.007). Time to recovery of activities of daily living (5.29 vs 2.85 days; p<0.001), time to solid oral intake (6.21 vs 4.35 days; p<0.001), time to first flatus (2.41 vs 1.51 days; p<0.001) and defecation (3.35 vs 1.66 days; p<0.001) decreased with ERAS. There were no statistically significant differences in length of stay, complications, and mortality.

CONCLUSION

This study showed that the ERAS program improved perioperative outcomes and postoperative recovery in patients undergoing colorectal surgery in our hospital.

Issues in patients' experiences of enhanced recovery after surgery (ERAS) : a systematic review of qualitative evidence

OBJECTIVE

To explore patients' experiences of enhanced recovery after surgery (ERAS) and to identify issues in the implementation of ERAS from the patient's perspective.

DESIGN

The systematic review and qualitative analysis were based on the Joanna Briggs Institute's methodology for conducting synthesis.

DATA SOURCES

Relevant studies published in four databases, that is, Web of Science, PubMed, Ovid Embase and the Cochrane Library, were systematically searched, and some studies were supplemented by key authors and reference lists.

STUDY SELECTION

Thirty-one studies were identified, involving 1069 surgical patients enrolled in the ERAS programme. The inclusion and exclusion criteria were formulated based on the Population, Interest of phenomena, Context, Study design criteria recommended by the Joanna Briggs Institute to determine the scope of article retrieval. The inclusion criteria were as follows: ERAS patients' experiences; qualitative data; English language and published from January 1990 to August 2021.

DATA EXTRACTION

Data were extracted from relevant studies using the standardised data extraction tool from Joanna Briggs Institute Qualitative Assessment and Review Instrument for qualitative research.

DATA SYNTHESIS

The themes in the structure dimension are as follows: (1) patients cared about the timeliness of healthcare professionals' help; (2) patients cared about the professionalism of family care; and (3) patients misunderstood and worried about the safety of ERAS. The themes in the process dimension are as follows: (1) patients needed adequate and accurate information from healthcare professionals; (2) patients needed to communicate adequately with healthcare professionals; (3) patients hoped to develop a personalised treatment plan and (4) patients required ongoing follow-up services. The theme in the outcome dimension is as follows: patients wanted to effectively improve severe postoperative symptoms.

CONCLUSIONS

Evaluating ERAS from the patient's perspective can reveal the omissions and deficiencies of healthcare professionals in clinical care so that problems in patients' recovery process can be solved in a timely manner, reducing potential barriers to the implementation of ERAS.

PROSPERO REGISTRATION NUMBER

CRD42021278631.

Barriers and Facilitators in Implementation of an Esophagectomy Care Pathway: a Qualitative Analysis

INTRODUCTION

A new postoperative esophagectomy care pathway was recently implemented at our institution. Practice pattern change among provider teams can prove challenging; therefore, we sought to study the barriers and facilitators toward pathway implementation at the provider level.

METHODS

This qualitative study was guided by the Theoretical Domains Framework (TDF) to study the adoption and implementation of a post-esophagectomy care pathway. Sixteen in-depth interviews were conducted with providers involved with the pathway. Matrix analysis was used to analyze the data.

RESULTS

Providers included attending surgeons (n = 6), advanced practice providers (n = 8), registered dietitian (n = 1), and clinic staff (n = 1). TDF domains that were salient across our findings included knowledge, beliefs about consequences, social influences, and environmental context and resources. Identified facilitators included were electronic health record tools, such as note templates including pathway components and a pathway-specific order set, patient satisfaction, and preliminary data indicating clinical benefits such as a reduced anastomotic leak rate. The major barrier reported was a hesitance to abandon previous practice patterns, most prevalent at the attending surgeon level.

CONCLUSION

The TDF enabled us to identify and understand the individuals' perceived barriers and facilitators toward adoption and implementation of a postoperative esophagectomy pathway. This analysis can help guide and improve adoption of surgical patient care pathways among providers.

S136-operationalizing an enhanced recovery protocol after bariatric surgery: single institutional pilot experience forging data-driven standard work

BACKGROUND

Enhanced recovery protocols (ERPs) after metabolic and bariatric surgery (MBS) may help decrease length of stay (LOS) and postoperative nausea/vomiting but implementation is often fraught with challenges. The primary aim of this pilot study was to standardize a MBS ERP with a real-time data support dashboard and checklist and assess impact on global and individual element compliance. The secondary aim was to evaluate 30 day outcomes including LOS, hospital readmissions, and re-operations.

METHODS AND PROCEDURES

An ERP, paper checklist, and virtual dashboard aligned on MBS patient care elements for pre-, intra-, and post-operative phases of care were developed and sequentially deployed. The dashboard includes surgical volumes, operative times, ERP compliance, and 30 day outcomes over a rolling 18 month period. Overall and individual element ERP compliance and outcomes were compared pre- and post-implementation via two-tailed Student's t-tests.

RESULTS

Overall, 471 patients were identified (pre-implementation: 193; post-implementation: 278). Baseline monthly average compliance rates for all patient care elements were 1.7%, 3.7%, and 6.2% for pre-, intra-, and post-operative phases, respectively. Following ERP integration with dashboard and checklist, the intra-operative phase achieved the highest overall monthly average compliance at 31.3% (P < 0.01). Following the intervention, pre-operative acetaminophen administration had the highest monthly mean compliance at ≥ 99.1%. Overall TAP block use increased 3.2-fold from a baseline mean rate of 25.4-80.8% post-implementation (P < 0.01). A significant decrease in average intra-operative monthly morphine milligram equivalents use was noted with a 56% drop pre- vs. post-implementation. Average LOS decreased from 2.0 to 1.7 days post-implementation with no impact on post-operative outcomes.

CONCLUSION

Implementation of a checklist and dashboard facilitated ERP integration and adoption of process measures with many improvements in compliance but no impact on 30 day outcomes. Further research is required to understand how clinical support tools can impact ERP adoption among MBS patients.

A qualitative examination of barriers and facilitators of pediatric enhanced recovery protocol implementation among 18 pediatric surgery services

Background

Enhanced recovery protocols (ERPs) are an evidence-based intervention to optimize post-surgical recovery. Several studies have demonstrated that the use of an ERP for gastrointestinal surgery results in decreased length of stay, shortened time to a regular diet, and fewer administered opioids, while also trending toward lower complication and 30-day readmission rates. Yet, implementation of ERPs in pediatric surgery is lagging compared to adult surgery. The study’s purpose was to conduct a theory-guided evaluation of barriers and facilitators to ERP implementation at US hospitals with a pediatric surgery service.

Methods

We conducted semi-structured interviews at 18 hospitals with 48 participants, including pediatric surgeons, anesthesiologists, gastroenterologists, nurses, and physician assistants. Interviews were conducted online, audio-recorded, and transcribed verbatim. To identify barriers and facilitators to ERP implementation, we conducted an analysis using deductive logics based on the five Active Implementation Frameworks (AIFs).

Results

Effective practices (usable innovations) were challenged by a lack of compliance to ERP elements, and facilitators were having standardized protocols in place and organization support for implementation. Effective implementation (stages of implementation and implementation drivers) had widespread barriers to implementation across the stages from exploration to full implementation. Barriers included needing dedicated teams for ERP implementation and buy-in from hospital leadership. These items, when present, were strong facilitators of effective implementation, in addition to on-site, checklists, protected time to oversee ERP implementation, and order sets for ERP elements built into the electronic medical record. The enabling context (teams) focused on teams’ engagement in ERP implementation and how they collaborated to implement ERPs. Barriers included having surgical team members resistant to change or who were not bought into ERPs in pediatric practice. Facilitators included engaging a multi-disciplinary team and engaging patients and families early in the implementation process.

Conclusions

Barriers to ERP implementation in pediatric surgery highlighted can be addressed through providing guidelines to ERP implementation, team-based support for change management, and protocols for developing an ERP implementation team. Future steps are to apply and evaluate these strategies in a stepped-wedge, cluster randomized trial to increase the implementation of ERPs at these 18 hospitals.

Knowledge of enhanced recovery after surgery and influencing factors among abdominal surgical nurses: a multi-center cross-sectional study

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are well established. Evidence describing nurses' knowledge of ERAS is limited.

AIM

To assess surgical nurses' knowledge of ERAS and identify factors that correlate with knowledge level.

DESIGN

An anonymous cross-sectional survey via an online social platform was conducted in the abdominal surgical specialty of 40 hospitals in ten cities in China.

METHODS

Nurses of abdominal surgery in hospitals were enrolled in this study. A self-administered questionnaire that was reviewed by an expert panel was used to assess the knowledge of ERAS in nurses. A generalised linear regression analysis was used to assess factors associated with nurses' knowledge regarding ERAS.

RESULTS

Overall survey participation was 91.8% (2230/2430). The mean score of ERAS-related knowledge among abdominal surgical nurses was 12.10 (SD = 3.79). ERAS knowledge differed according to gender, age, education level, professional title, years of working, specialised working years, ERAS training experience, surgical department, and type of hospital (p < 0.05).

CONCLUSIONS

Chinese nurses employed in abdominal surgical services need to improve the knowledge about ERAS protocols. Standardised training is recommended to improve nurses' ERAS-related knowledge, which can help nurses improve the quality of perioperative care and promote the recovery of patients.

A Scientometric Analysis and Visualization Discovery of Enhanced Recovery After Surgery

Background

Enhanced recovery after surgery (ERAS), a new clinical surgical concept, has been applied in many surgical disciplines with good clinical results for the past 20 years. Bibliometric analysis is an effective method to quantitatively evaluate the academic productivity. This report aimed to perform a scientometric analysis of the ERAS research status and research hotspots.

Methods

Comprehensive scientific mapping analysis of a wide range of literature metadata using the scientometric tools, including the Bibliometrix R Package, Biblioshiny, and CiteSpace. Data were retrieved from the Web of Science Core Collection database of original articles from 2001 to 2020. Specific indicators and maps were analyzed to show the co-authorship, co-institute, co-country, co-citation, and international cooperation. Automatic literature screening, unsupervised cluster filtering, and topic cluster identification methods were used to display the conceptual framework and thematic evolution.

Results

A total of 1,403 research projects drafted by 6,966 authors and published in 413 sources were found. There was an exponential growth in the number of publications on ERAS. There were 709 collaborations between authors from different countries, and the US, China, and the UK had the greatest number of publications. The WORLD JOURNAL OF SURGERY, located in Bradford’s Law 1, had the highest number of published articles (n = 1,276; total citations = 3,193). CiteSpace network analysis revealed 15 highly correlated cluster ERAS studies, and the earliest study was on colonic surgery, and ERAS was recently applied in cardiac surgery. The etiology of ERAS is constantly evolving, with surgery and length of hospital as the main topics. Meta-analyses and perioperative care have tended to decline.

Conclusion

This is the first scientometric analysis of ERAS to provide descriptive quantitative indicators. This can provide a better understanding of how the field has evolved over the past 20 years, help identify research trends, and provide insights and research directions for academic researchers, policymakers, and medical practitioners who want to collaborate in these areas in the future.

Health Professionals Perception of Enhanced Recovery After Surgery: A Scoping Review

PURPOSE

The Enhanced Recovery After Surgery (ERAS) program is currently poorly implemented by healthcare workers. Furthermore, several inhibiting and supporting factors for this implementation have been discovered to influence healthcare workers' perception of the program. This study aims to investigate the perception of healthcare workers regarding the ERAS program.

DESIGN

A scoping review in a systematic manner.

METHODS

A systematic search was performed using six databases: PubMed, ScienceDirect, SCOPUS, EBSCO, Proquest, and Sage Journals, from August 2011 to August 2021. The data was extracted using an excel worksheet, and the results obtained were presented descriptively.

FINDINGS

This study selected a total of 10 articles, where both qualitative and quantitative methods were used to discuss the perceptions of healthcare workers about ERAS.

CONCLUSIONS

Based on this study's findings, not all healthcare workers have a good perception of ERAS. The implementation of ERAS is often hindered by several factors, including resistance to change and lack of knowledge about the program. However, good teamwork and support from hospital management can support the program's implementation.

Patient Characteristics Influencing Adherence to Enhanced Recovery Protocols for Colorectal Surgery: a Multicentric Prospective Study

BACKGROUND

High compliance within enhanced recovery protocols is associated with lower complication rates. Understanding which clinical characteristics make patients more prone to fail adequate adherence to enhanced recovery after surgery guidelines are essential to improve quality care. Our aim was to identify patient characteristics that influence adherence to enhanced recovery protocols in colorectal surgery.

METHODS

A total of 1041 patients underwent colorectal surgery under ERPs from September 2017 through December 2017 across 21 institutions in Spain. Demographic, medical, and surgical characteristics of the patients included were extracted to determine their influence on the adherence to enhanced recovery protocols. High adherence was defined as ≥ 73% (median). A univariate analysis was performed initially, followed by multivariable logistic regression analysis.

RESULTS

Over 85% of the patients underwent colorectal surgery for cancer resection, of which 12% had metastatic disease. In multivariable model, the presence of coronary artery disease (aOR 1.79, 95% CI 1.12-2.96, p = 0.045) was significantly associated with high adherence to enhanced recovery protocols, while preoperative hypoalbuminemia (aOR 0.55, 95% CI 0.37-0.82, p = 0.003), indication for ostomy (aOR 0.55, 95% CI 0.4-0.75, p < 0.001), and preoperative transfusion (aOR 0.48, 95% CI 0.26-0.91, p = 0.02) were associated with lower adherence.

CONCLUSION

In this study, patients that had preoperative transfusions, preoperative hypoalbuminemia, and indication for ostomy were more likely to receive care with less adherence to enhanced recovery protocols elements, while patients with coronary artery disease were more likely to receive more enhanced recovery protocols elements during their hospitalization.

Barriers to implementation of enhanced recovery after surgery (ERAS) by a multidisciplinary team in China: a multicentre qualitative study

OBJECTIVE

To explore the attitudes and barriers encountered in the implementation of enhanced recovery after surgery (ERAS) in China from the perspective of multidisciplinary team members.

DESIGN

Based on Donabedian's structure-process-outcome (SPO) model, a multicentre qualitative study using semistructured interviews was conducted.

SETTING

From September 2020 to December 2020, the participants of this study were interviewed from six tertiary hospitals in Sichuan province (n=3), Jiangsu province (n=2) and Guangxi province (n=1) in China.

PARTICIPANTS

A total of 42 members, including surgeons (n=11), anaesthesiologists (n=10), surgical nurses (n=14) and dietitians(n=7) were interviewed.

RESULTS

Multidisciplinary team (MDT) members still face many barriers during the process of implementing ERAS. Eight main themes are described around the barriers in the implementation of ERAS. Themes in the structure dimension are: (1) shortage of medical resources, (2) lack of policy support and (3) outdated concepts. Themes in the process dimension are: (1) poor doctor-patient collaboration, (2) poor communication and collaboration among MDT members and (3) lack of individualised management. Themes in the outcome dimension are: (1) low compliance and (2) high medical costs. The current implementation of ERAS is still based on ideas more than reality.

CONCLUSIONS

In general, barriers to ERAS implementation are broad. Identifying key elements of problems in the application and promotion of ERAS from the perspective of the MDT would provide a starting point for future quality improvement of ERAS, enhance the clinical effect of ERAS and increase formalised ERAS utilisation in China.

Perception and implementation status of enhanced recovery after surgery

Background: The enhanced recovery after surgery (ERAS) program that is being implemented in Korea is difficult to investigate because it is not a standardized protocol with a unified content, and it instead differs according to the details for each hospital. Herein, the author would like to introduce and analyze the results of a recently conducted large-scale survey on the current status and perception of the ERAS program in Korea among large domestic hospitals.Current Concepts: Surveys of domestic general surgeons in 2019 and hepatobiliary-pancreatic surgeons in 2020 both showed lower-than-expected response rates of less than 50% in questions related to perception and clinical implementation of the ERAS program. Thus, implementation of ERAS items related to the limited application of preoperative fasting and surgical drain insertion and active nutritional support before and after surgery remains low.Discussion and Conclusion: For surgeons in Korea, the implementation of ERAS programs and perception levels were low. In this regard, it is necessary to improve awareness through systematic education and promotion of the ERAS program, and supplementation of related multidisciplinary professional manpower and financial resources is essential to facilitate practical implementation of ERAS programs in clinical practice.

Observations from Implementation of the ERAS Protocol after DIEP Flap Breast Reconstruction

BACKGROUND

 The Enhanced Recovery After Surgery (ERAS) protocol is a multivariate intervention requiring the help of several departments, including anesthesia, nursing, and surgery. This study seeks to observe ERAS compliance rates and obstacles for its implementation at a single academic institution.

METHODS

 This is a retrospective study looking at patients who underwent deep inferior epigastric perforator (DIEP) flap breast reconstruction from January 2016 to September 2019. The ERAS protocol was implemented on select patients early 2017, with patients from 2016 acting as a control. Thirteen points from the protocol were identified and gathered from the patient's electronic medical record (EMR) to evaluate compliance.

RESULTS

 Two hundred and six patients were eligible for the study, with 67 on the control group. An average of 6.97 components were met in the pre-ERAS group. This number rose to 8.33 by the end of 2017. Compliance peaked with 10.53 components met at the beginning of 2019. The interventions most responsible for this increase were administration of preoperative medications, goal-oriented intraoperative fluid management, and administration of scheduled gabapentin postoperatively. The least met criterion was intraoperative ketamine goal of >0.2 mg/kg/h, with a maximum compliance rate of 8.69% of the time.

CONCLUSION

 The introduction of new protocols can take over a year for full implementation. This is especially true for protocols as complex as an ERAS pathway. Even after years of consistent use, compliance gaps remain. Staff-, patient-, or resource-related issues are responsible for these discrepancies. It is important to identify these issues to address them and optimize patient outcomes.

Barriers and enablers to physical activity in patients during hospital stay: a scoping review

BACKGROUND

Low levels of physical activity are common during the hospital stay and have been associated with negative health outcomes. Understanding barriers and enablers to physical activity during a hospital stay can improve the development and implementation of tailored interventions aimed at improving physical activity. Previous studies have identified many barriers and enablers, but a comprehensive overview is lacking. This study aimed to identify and categorize all published patient- and healthcare professional-reported barriers and enablers to physical activity during a hospital stay for acute care, using the Theoretical Domains Framework (TDF).

METHODS

We conducted a scoping review of Dutch and English articles using MEDLINE, CINAHL Plus, EMBASE, PsycINFO, and Cochrane Library (inception to September 2020), which included quantitative, qualitative, and mixed-methods studies reporting barriers and enablers to physical activity during a hospital stay for acute care, as perceived by patients or healthcare professionals. Two reviewers systematically extracted, coded, and categorized all barriers and enablers into TDF domains.

RESULTS

Fifty-six articles were included in this review (32 qualitative, 7 quantitative, and 17 mixed-methods). In total, 264 barriers and 228 enablers were reported by patients, and 415 barriers and 409 enablers by healthcare professionals. Patient-reported barriers were most frequently assigned to the TDF domains Environmental Context & Resources (ECR, n = 148), Social Influences (n = 32), and Beliefs about Consequences (n = 25), while most enablers were assigned to ECR (n = 67), Social Influences (n = 54), and Goals (n = 32). Barriers reported by healthcare professionals were most frequently assigned to ECR (n = 210), Memory, Attention and Decision Process (n = 45), and Social/Professional Role & Identity (n = 31), while most healthcare professional-reported enablers were assigned to the TDF domains ECR (n = 143), Social Influences (n = 76), and Behavioural Regulation (n = 54).

CONCLUSIONS

Our scoping review presents a comprehensive overview of all barriers and enablers to physical activity during a hospital stay and highlights the prominent role of the TDF domains ECR and Social Influences in hospitalized patients' physical activity behavior. This TDF-based overview provides a theoretical foundation to guide clinicians and researchers in future intervention development and implementation.

SCOPING REVIEW REGISTRATION

No protocol was registered for this review.

The Clinical Efficacy and Safety of Enhanced Recovery After Surgery for Cesarean Section: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies

Background: Enhanced recovery after surgery (ERAS) has been adopted in some maternity units and studied extensively in cesarean section (CS) in the last years, showing encouraging results in clinic practice. However, the present evidence assessing the effectiveness of ERAS for CS remains weak, and there is a paucity in the published literature, especially in improving maternal outcomes. Our study aimed to systematically evaluate the clinical efficacy and safety of ERAS protocols for CS.

Methods: A systematic literature search using Embase, PubMed, and the Cochrane Library was carried out up to October 2020. The appropriate randomized controlled trials (RCTs) and observational studies applying ERAS for patients undergoing CS were included in this study, comparing the effect of ERAS protocols with conventional care on length of hospital stay (LOS), readmission rate, incidence of postoperative complications, postoperative pain score, postoperative opioid use, and cost of hospitalization. All statistical analyses were conducted with the RevMan 5.3 software.

Results: Ten studies (four RCTs and six observational studies) involving 16,391 patients were included. ERAS was associated with a decreased LOS (WMD −7.47 h, 95% CI: −8.36 to −6.59 h, p < 0.00001) and lower incidence of postoperative complications (RR: 0.50, 95% CI: 0.37 to 0.68, p < 0.00001). Moreover, pooled analysis showed that postoperative pain score (WMD: −1.23, 95% CI: −1.32 to −1.15, p < 0.00001), opioid use (SMD: −0.46, 95% CI: −0.58 to −0.34, p < 0.00001), and hospital cost (SMD:−0.54, 95% CI: −0.63 to −0.45, p < 0.00001) were significantly lower in the ERAS group than in the conventional care group. No significant difference was observed with regard to readmission rate (RR: 0.86, 95% CI: 0.48 to 1.54, p = 0.62).

Conclusions: The available evidence suggested that ERAS applying to CS significantly reduced postoperative complications, lowered the postoperative pain score and opioid use, shortened the hospital stay, and potentially reduced hospital cost without compromising readmission rates. Therefore, protocols implementing ERAS in CS appear to be effective and safe. However, the results should be interpreted with caution owing to the limited number and methodological quality of included studies; hence, future large, well-designed, and better methodological quality studies are needed to enhance the body of evidence.

Clinical and Economic Outcomes of Enhanced Recovery Dissemination in Michigan Hospitals

OBJECTIVE

To evaluate real-world effects of enhanced recovery protocol (ERP) dissemination on clinical and economic outcomes after colectomy.

SUMMARY BACKGROUND DATA

Hospitals aiming to accelerate discharge and reduce spending after surgery are increasingly adopting perioperative ERPs. Despite their efficacy in specialty institutions, most studies have lacked adequate control groups and diverse hospital settings and have considered only in-hospital costs. There remain concerns that accelerated discharge might incur unintended consequences.

METHODS

Retrospective, population-based cohort including patients in 72 hospitals in the Michigan Surgical Quality Collaborative clinical registry (N = 13,611) and/or Michigan Value Collaborative claims registry (N = 14,800) who underwent elective colectomy, 2012 to 2018. Marginal effects of ERP on clinical outcomes and risk-adjusted, price-standardized 90-day episode payments were evaluated using mixed-effects models to account for secular trends and hospital performance unrelated to ERP.

RESULTS

In 24 ERP hospitals, patients Post-ERP had significantly shorter length of stay than those Pre-ERP (5.1 vs 6.5 days, P < 0.001), lower incidence of complications (14.6% vs 16.9%, P < 0.001) and readmissions (10.4% vs 11.3%, P = 0.02), and lower episode payments ($28,550 vs $31,192, P < 0.001) and postacute care ($3,384 vs $3,909, P < 0.001). In mixed-effects adjusted analyses, these effects were significantly attenuated-ERP was associated with a marginal length of stay reduction of 0.4 days (95% confidence interval 0.2-0.6 days, P = 0.001), and no significant difference in complications, readmissions, or overall spending.

CONCLUSIONS

ERPs are associated with small reduction in postoperative length of hospitalization after colectomy, without unwanted increases in readmission or postacute care spending. The real-world effects across a variety of hospitals may be smaller than observed in early-adopting specialty centers.

[Background, Necessity and Methodology of the S3 Guideline "Perioperative Management of Gastrointestinal Tumours (POMGAT)"]

Malignancies are among the most common diseases, especially in old age, and are responsible for 25% of all deaths in Germany. Especially carcinomas of the gastrointestinal tract can be cured in most cases only through extensive surgery with significant morbidity. About 25 years ago, the multimodal, perioperative Fast Track (FT) concept for reducing postoperative complications was introduced and additional elements were added in the following years. Meanwhile, there is growing evidence that adherence to the key elements of more than 70% leads to reduction in postoperative adverse events as well as a shorter hospital stay and could be associated with an improved oncological outcome. Despite the high level of awareness and the proven advantages of the FT concept, the implementation and maintenance of the measures is difficult and results in an adherence of only 20 - 40%. There are many reasons for this: In addition to a lack of interdisciplinary and interprofessional cooperation and the time consuming and extended logistical efforts, limited human resources are often listed as one of the main causes. We took these aspects as an opportunity and started to develop a S3 guideline for perioperative treatment to accelerate the recovery of patients with gastrointestinal malignancies. By creating a consensus- and evidence-based, multidisciplinary guideline, many of the problems listed above could probably be solved by optimising and standardising interdisciplinary care, which is particularly important in a setting with many different disciplines and their competing interests. Furthermore, the standardisation of the perioperative procedures will reduce the time and logistical effort. The presentation of the evidence allows increased transparency and justifies the additional personnel expenditure on hospital medicine and health insurance companies. In addition, the evidence-based quality indicators generated during the development of the guideline make it possible to include perioperative standards in certification systems and thus to measure and check the quality of perioperative care.

The Attitude of Health Care Workers on Enhanced Recovery After Surgery for Cesarean Delivery: A Scoping Review

OBJECTIVE

Previous systematic reviews have found that the enhanced recovery after surgery (ERAS) protocol for cesarean delivery can vary from one study to another, and the attitudes of health care professionals regarding ERAS methods and the implementation of the ERAS for cesarean delivery remain unclear. We aimed to identify the attitudes of health professionals toward ERAS in the context of cesarean delivery.

DATA SOURCES

Systematic searches were conducted in 6 databases: PubMed, ScienceDirect, EBSCO, Scopus, the Cochrane Library, and Sage Journals from September 2010 to September 2020.

STUDY SELECTION

A total of 4 articles were selected for analysis. All articles use survey methods and present health professional attitudes toward ERAS for cesarean delivery.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using Excel spreadsheets. The results obtained are presented descriptively.

CONCLUSION

This review illustrates that there are many ERAS protocols that health care professionals have not yet implemented for cesarean delivery. Policymakers can use this knowledge to inform the promotion of the ERAS protocol for cesarean delivery.

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

Background

Enhanced Recovery After Surgery (ERAS^®) Society guidelines integrate evidence-based practices into multimodal care pathways that have improved outcomes in multiple adult surgical specialties. There are currently no pediatric ERAS^® Society guidelines. We created an ERAS^® guideline designed to enhance quality of care in neonatal intestinal resection surgery.

Methods

A multidisciplinary guideline generation group defined the scope, population, and guideline topics. Systematic reviews were supplemented by targeted searching and expert identification to identify 3514 publications that were screened to develop and support recommendations. Final recommendations were determined through consensus and were assessed for evidence quality and recommendation strength. Parental input was attained throughout the process.

Results

Final recommendations ranged from communication strategies to antibiotic use. Topics with poor-quality and conflicting evidence were eliminated. Several recommendations were combined. The quality of supporting evidence was variable. Seventeen final recommendations are included in the proposed guideline.

Discussion

We have developed a comprehensive, evidence-based ERAS guideline for neonates undergoing intestinal resection surgery. This guideline, and its creation process, provides a foundation for future ERAS guideline development and can ultimately lead to improved perioperative care across a variety of pediatric surgical specialties.

Electronic supplementary material

The online version of this article (10.1007/s00268-020-05530-1) contains supplementary material, which is available to authorized users.

Application of ERAS protocol in esophagectomy: a national survey among Italian centers performing esophageal surgery

The application of enhanced recovery after surgery guidelines for esophageal surgery in different units remains unclear. This survey intended to investigate how such protocol is applied among Italian esophageal surgery units. A survey with 40 questions was mailed to Italian centers that performed at least 10 esophagectomies per year. It included questions about the type of hospital and unit and pre-, intra- and post-operative items. Difficulties encountered were investigated. Thirteen (65%) centers answered the survey, and all met the minimal safety requirements, e.g., the presence of intensive care units and 24-h on-call operative endoscopy and radiology facilities. Fifty percent of esophagectomies with a minimally invasive approach were performed in 84.6% of the centers. Regarding pre-operative items, the highest scores were for the application of nutritional support, dysphagia palliation and presence of a multidisciplinary tumor board, whereas the lowest score was for the use of immunonutrition. Regarding intra-operative items, hypothermia prevention and the use of goal-directed fluid therapy and volatile anesthesia were diffusely adopted, whereas the rate of using abdominal drains was high. Regarding post-operative items, nausea prevention, multimodal analgesia and early mobilization were applied frequently, whereas the use of nasogastric tubes and regular transfer to intensive care units was diffused. The primary barriers in enhanced recovery after surgery protocol application were resistance and a lack of paramedic personnel. This survey's results highlight the efforts undertaken by several centers to apply enhanced recovery after surgery philosophy and in this regard, demonstrate a good standing in Italy.

Day-only elective cholecystectomy: early experience and barriers to implementation in Australia

BACKGROUND

Day-only laparoscopic cholecystectomy (DOLC) has been shown to be safe and feasible yet has not been widely implemented in Australia. This study explores the introduction of routine DOLC to Westmead Hospital, and highlights the barriers to its implementation.

METHODS

Routine day-only cholecystectomy protocol was introduced at Westmead Hospital in 2014. A retrospective review of patients who underwent elective laparoscopic cholecystectomy during a 12-month period in 2014 was compared to a 12-month period in 2018, to examine the changes in practice after implementation of a unit protocol. Data were collected on patient demographics, admission category, outcomes and re-presentations.

RESULTS

A total of 282 patients were included in the study, of these 169 were booked as day procedures, with 124 (73%) successfully discharged on the same day. There was a significant increase in the proportion of patients booked as day-only from 2014 to 2018 (48% versus 73%, P < 0.001). Day-only failure rates (unplanned overnight admissions), readmissions and complication rates were comparable between the two periods. The most common reason for unplanned overnight admissions were due to intraoperative findings (n = 28/45).

CONCLUSION

Routine DOLC can be adopted in Australian hospitals without compromise to patient safety. Unplanned overnight admission is predominantly due to unexpected surgical pathology and can be reduced by protocols for the use of drains and planned outpatient endoscopic retrograde cholangiopancreatography. Unplanned outpatient review can be minimized by optimizing both intra- and post-operative pain management. Individual surgeon and anaesthetist preferences remain an obstacle to a standardized protocol in the Australian setting.

Pain Management and Education for Ambulatory Surgery: A Qualitative Study of Perioperative Nurses

BACKGROUND

Ambulatory surgery presents unique challenges regarding adequate pain management and education. Studies have documented issues with transfer of information and patient comfort. Our objective was to explore perioperative nurses' perspectives of current practices and challenges with pain management and education.

MATERIALS AND METHODS

We used a qualitative descriptive design and conducted four focus group interviews, with 24 total participants from two perioperative areas of an academic medical center, using a standardized script. Using qualitative analysis software, two investigators reviewed the data and coded major themes and subthemes. The consolidated criteria for reporting qualitative studies guidelines were followed for reporting the data.

RESULTS

We identified four major themes impacting current perioperative pain management and education practices: communication among the perioperative care team, sources of nurses' frustrations in the perioperative setting, patient expectations for pain, and nurse-driven pain management and education. Nurses highlighted their work became easier with adequate information transfer and trust from physicians. Frustrations stemmed from surgeon, system, and patient factors. Nurses often use their clinical experience and judgment in managing patients throughout the perioperative period. Furthermore, nurses felt patients have limited pain education and stressed education throughout the surgical care pathway could improve overall care.

CONCLUSIONS

Perioperative pain management, assessment, and education practices are inconsistent, incomplete, and sources of frustrations according to participants. Participant experiences highlight the need for improved and standardized models. Patient pain education should use a multidisciplinary approach, beginning at the point of surgery scheduling and continuing through postoperative follow-up.

Validation of an enhanced recovery after surgery protocol in gynecologic surgery: an Italian randomized study

BACKGROUND

The enhanced recovery after surgery concept, which was introduced 20 years ago, is based on a multimodal approach to improve the functional rehabilitation of patients after surgery.

OBJECTIVE

This study aimed to validate an enhanced recovery after surgery protocol in gynecologic surgery for both benign and malignant diseases (endometrial cancer and advanced ovarian cancer) and to measure the adherence to the enhanced recovery after surgery protocol items in a randomized trial setting.

STUDY DESIGN

In this trial (NCT03347409), we randomly assigned patients to undergo standard perioperative care or enhanced recovery after surgery protocol. The primary outcome is a shorter length of stay in favor of the enhanced recovery after surgery protocol. Secondary outcomes include measurement of adherence to the enhanced recovery after surgery protocol items: comparison of postoperative pain, vomiting, and nausea; anesthesiologic and surgical complications up to 30 days after surgery; rate of readmissions; the time to event in hours for bowel movements, flatus, drinking, hunger, eating, and walking; and the quality of recovery using a validated questionnaire (QoR-15). Finally, we explored the length of stay in the prespecified subgroups at randomization, based on the type of surgical access and gynecologic disease.

RESULTS

A total of 168 women were available for analysis: 85 women (50.6%) were assigned to the standard perioperative care group, and 83 women (49.4%) were assigned to the enhanced recovery after surgery protocol group. The 2 groups were similar for age, body mass index, comorbidities, anesthesiological risk, smoking habits, surgical access, and complexity of surgical procedures. Seventy-two patients (42.9%) underwent surgery for benign disease, 48 (28.6%) for endometrial cancer, and 48 (28.6%) for ovarian cancer. Women in the enhanced recovery after surgery protocol group had a shorter length of stay (median: 2 [interquartile range, 2-3] vs 4 [interquartile range, 4-7] days; P<.001). A decreased rate of postoperative complications was noted for the enhanced recovery after surgery protocol group, as well as an earlier time to occur for all the events. Mean adherence to protocol items was 84.8% (95% confidence interval, 79.7-89.8), and we registered a better satisfaction in the enhanced recovery after surgery protocol group. The shortening of the length of stay was confirmed also in the prespecified subgroup analysis.

CONCLUSION

Application of the enhanced recovery after surgery protocol in gynecologic surgery translated to a shorter length of stay regardless of surgical access and type of gynecologic disease. Adherence to the enhanced recovery after surgery protocol items in the setting of a randomized trial was high.

Impact of nutritional status/risk and post-operative nutritional management on clinical outcomes in patients undergoing gastrointestinal surgery: a prospective observational study

BACKGROUND

Malnutrition is prevalent in patients undergoing gastrointestinal (GI) surgery and has been linked to adverse outcomes. The present study aimed to determine the association between early post-operative nutritional status/risk, post-operative nutritional management and clinical outcomes.

METHODS

A prospective observational study was conducted in GI surgical patients with a minimum 3-day post-operative length of stay (LOS). Data on patient demographics, nutritional status/risk, post-operative nutritional management and clinical outcomes were collected. Four markers of nutritional status and risk were assessed: preoperative weight loss, nutrition risk, malnutrition status and hand grip strength. Clinical outcomes included: post-operative LOS, complication and readmissions rates. Multivariate linear and logistic regression were used to test for associations with clinical outcomes.

RESULTS

One hundred and fifteen patients (55% female) with mean (SD) age of 60.8 (16.2) years were included. Median (IQR) post-operative LOS was 8.0 days (4.5-11.5), 37% of participants developed at least one complication post-operatively and 24% were readmitted within 30-days of discharge. Mean number of nil-by mouth (NBM) days post-operatively was 0.7 (1.2) and the average time to commence feeding was 3.3 (2.2) days after surgery. Poor nutritional status/risk between days 3-5 post-operatively assessed through all four markers was associated with longer post-operative LOS (all P < 0.05). No association was found between number of NBM days, time to feeding and clinical outcomes.

CONCLUSION

Poor early post-operative nutritional status/risk is associated with longer post-operative LOS in patients undergoing GI surgery, which may facilitate simple identification of patients at high priority for nutritional intervention. The present study highlights the heterogeneity in post-operative nutritional management practices.

Implementation of a Prophylactic Anticoagulation Guideline for Patients with Traumatic Brain Injury

BACKGROUND

Patients with traumatic brain injury (TBI) are at an increased risk of developing complications from venous thromboembolisms (VTEs [blood clots]). Benchmarking by the American College of Surgeons Trauma Quality Improvement Program identified suboptimal use of prophylactic anticoagulation in patients with TBI. We hypothesized that institutional implementation of an anticoagulation protocol would improve clinical outcomes in such patients.

METHODS

A new prophylactic anticoagulation protocol that incorporated education, weekly audits, and real-time adherence feedback was implemented in July 2015. The trauma registry identified patients with TBI before (PRE) and after (POST) implementation. Multivariable regression analysis with risk adjustment was used to compare use of prophylactic anticoagulation, VTE events, and mortality.

RESULTS

A total of 681 patients with TBI (368 PRE, 313 POST) were identified. After implementation of the VTE protocol, more patients received anticoagulation (PRE: 39.4%, POST: 80.5%, p < 0.001), time to initiation was shorter (PRE: 140 hours, POST: 59 hours, p < 0.001), and there were fewer VTE events (PRE: 19 [5.2%], POST: 7 [2.2%], p = 0.047). Multivariable analysis showed that POST patients were more likely to receive anticoagulation (odds ratio [OR] = 10.8, 95% confidence interval [CI] = 6.9-16.7, p < 0.001) and less likely to develop VTE (OR = 0.33, 95% CI = 0.1-1.0, p = 0.05).

CONCLUSION

Benchmarking can assist institutions to identity potential clinically relevant areas for quality improvement in real time. Combining education and multifaceted protocol implementation can help organizations to better focus limited quality resources and counteract barriers that have hindered adoption of best practices.

Adherence to Enhanced Recovery Protocols in NSQIP and Association With Colectomy Outcomes

OBJECTIVE

To evaluate the effect of protocol adherence on length of stay (LOS) and recovery-specific outcomes after colectomy.

BACKGROUND

Enhanced recovery protocols (ERPs) may decrease postoperative morbidity and LOS; however, the effect of overall protocol adherence remains unclear.

METHODS

Using American College of Surgeons' National Surgical Quality Improvement Program colectomy data (July 2014-December 2015) and 13 novel ERP variables, propensity scores were constructed for low (0-5), moderate (6-9), and high adherence (10-13 components). Prolonged LOS (>75th percentile, uncomplicated cases) was modeled with multivariable logistic regression with robust standard errors, adjusted for hospital-level clustering and propensity score. Secondary recovery-specific outcomes were modeled with negative binomial regression. Subgroup analysis was conducted on uncomplicated cases.

RESULTS

Among 8139 elective colectomies at 113 hospitals, LOS increased with decreasing adherence (4.3 days [SD 3.3] high adherence vs 7.8 [SD 6.8] low adherence; P < 0.0001). High adherence was associated with fewer complications, including postoperative ileus, compared with moderate (P < 0.0001) and low adherence (P < 0.0001). High-adherence patients achieved recovery milestones earlier (vs low adherence), with return of bowel function at 1.9 (vs 3.7) days, tolerance of diet at 2.4 (vs 5.4) days, and oral pain control at 2.7 (vs 5.0) days (P < 0.0001). Risk-adjusted odds of prolonged LOS were significantly increased for low (odds ratio 2.7, 95% confidence interval 2.0-3.6) and moderate-adherence (odds ratio 1.7, 95% confidence interval 1.4-2.1) groups. In a negative binomial regression, time to recovery was 60% to 95% longer for low versus high adherence (P < 0.0001).

CONCLUSIONS

In this large, multi-institutional North American data registry, high adherence to ERPs was associated with earlier recovery, decreased complications, and shorter LOS. ERPs can improve outcomes; however, benefits correlate with adherence.

Association of an Enhanced Recovery Pilot With Length of Stay in the National Surgical Quality Improvement Program

Importance

Enhanced recovery protocols (ERPs) are standardized care plans of best practices that can decrease morbidity and length of stay (LOS). However, many hospitals need help with implementation. The Enhanced Recovery in National Surgical Quality Improvement Program (ERIN) pilot was designed to support ERP implementation.

Objective

To evaluate the association of the ERIN pilot with LOS after colectomy.

Design, Setting, and Participants

Using a difference-in-differences design, pilot LOS before and after ERP implementation was compared with matched controls in a hierarchical model, adjusting for case mix and random effects of hospitals and matched pairs. The setting was 15 hospitals of varied size and academic status from the National Surgical Quality Improvement Program. Preimplementation and postimplementation colectomy cases (July 1, 2013, to December 31, 2015) were collected using novel ERIN variables. Emergency and septic cases were excluded. A propensity score match identified a 2:1 control cohort of patients undergoing colectomy at non-ERIN hospitals.

Interventions

Pilot hospitals developed and implemented ERPs that included expert guidance, multidisciplinary teams, data audits, and opportunities for collaboration.

Main Outcomes and Measures

The primary outcome was LOS, and the secondary outcome was serious morbidity or mortality composite.

Results

There were 4975 colectomies performed by 15 ERIN pilot hospitals (3437 before implementation and 1538 after implementation) compared with a control cohort of 9950 colectomies (4726 before implementation and 5224 after implementation). The mean LOS decreased by 1.7 days in the pilot (6.9 [interquartile range (IQR), 4-8] days before implementation vs 5.2 [IQR, 3-6] days after implementation, P < .001) compared with 0.4 day in controls (6.4 [IQR, 4-7] days before implementation vs 6.0 [IQR, 3-7] days after implementation, P < .001). Readmission did not differ pre-post for the pilot or controls. Serious morbidity or mortality decreased for pilot participants (485 [14.1%] before implementation vs 162 [10.5%] after implementation, P < .001), with no difference in controls, and remained significant after risk adjustment (adjusted odds ratio, 0.76; 95% CI, 0.60-0.96). After adjusting for differences in case mix and for clustering in hospitals and matched pairs, the adjusted difference-in-differences model demonstrated a decrease in LOS by 1.1 days in the pilot over controls (P < .001).

Conclusions and Relevance

Participating ERIN pilot hospitals achieved shorter LOS and decreased complications after elective colectomy, without increasing readmissions. The ability to implement ERPs across hospitals of varied size and resources is essential. Lessons from the ERIN pilot may inform efforts to scale this effective and evidence-based intervention.

Remote Surveillance Technologies: Realizing the Aim of Right Patient, Right Data, Right Time

The convergence of multiple recent developments in health care information technology and monitoring devices has made possible the creation of remote patient surveillance systems that increase the timeliness and quality of patient care. More convenient, less invasive monitoring devices, including patches, wearables, and biosensors, now allow for continuous physiological data to be gleaned from patients in a variety of care settings across the perioperative experience. These data can be bound into a single data repository, creating so-called data lakes. The high volume and diversity of data in these repositories must be processed into standard formats that can be queried in real time. These data can then be used by sophisticated prediction algorithms currently under development, enabling the early recognition of patterns of clinical deterioration otherwise undetectable to humans. Improved predictions can reduce alarm fatigue. In addition, data are now automatically queriable on a real-time basis such that they can be fed back to clinicians in a time frame that allows for meaningful intervention. These advancements are key components of successful remote surveillance systems. Anesthesiologists have the opportunity to be at the forefront of remote surveillance in the care they provide in the operating room, postanesthesia care unit, and intensive care unit, while also expanding their scope to include high-risk preoperative and postoperative patients on the general care wards. These systems hold the promise of enabling anesthesiologists to detect and intervene upon changes in the clinical status of the patient before adverse events have occurred. Importantly, however, significant barriers still exist to the effective deployment of these technologies and their study in impacting patient outcomes. Studies demonstrating the impact of remote surveillance on patient outcomes are limited. Critical to the impact of the technology are strategies of implementation, including who should receive and respond to alerts and how they should respond. Moreover, the lack of cost-effectiveness data and the uncertainty of whether clinical activities surrounding these technologies will be financially reimbursed remain significant challenges to future scale and sustainability. This narrative review will discuss the evolving technical components of remote surveillance systems, the clinical use cases relevant to the anesthesiologist's practice, the existing evidence for their impact on patients, the barriers that exist to their effective implementation and study, and important considerations regarding sustainability and cost-effectiveness.

Understanding the benefits and implications of Enhanced Recovery After Surgery

Enhanced Recovery After Surgery (ERAS) programmes are an innovative approach to optimising patient outcomes in the perioperative period and have been implemented in various surgical departments across a range of specialties, with varying degrees of success. ERAS is an evidence-based, multimodal programme that has repeatedly demonstrated a reduction in post-operative complications and reduced the length of hospital stays following elective surgery. However, despite extensive evidence to support these benefits, several barriers to ERAS implementation have been identified. This article outlines the components of ERAS, focusing on the barriers to its implementation and how these could be overcome. It also discusses the implications of ERAS for patients, nurses and healthcare organisations.

Hospital Staffs' Perceptions of Postoperative Nutrition Among Colorectal Patients: A Qualitative Study

BACKGROUND

After lower gastrointestinal surgery, few patients start eating within timeframes outlined by evidence-based guidelines or meet their nutrition requirements in hospital. The present study explored hospital staffs' perceptions of factors influencing timely and adequate feeding after colorectal surgery to inform future interventions for improving postoperative nutrition practices and intakes.

METHODS

This qualitative exploratory study was conducted at an Australian hospital where Enhanced Recovery After Surgery guidelines had not been formally implemented. One-on-one semistructured interviews were conducted with hospital staff who provided care to patients undergoing colorectal surgery. Interviews lasted from 21 to 47 minutes and were audio recorded and transcribed verbatim. Data were analyzed using inductive thematic analysis. Emergent themes and subthemes were discussed by all investigators to ensure consensus of interpretation.

RESULTS

Eighteen staff participated in interviews, including 9 doctors, 5 nurses, 2 dietitians, and 2 foodservice staff. Staffs' responses formed 3 themes: (1) variability in perceived acceptability of postoperative feeding; (2) improving dynamics and communication within the treating team; and (3) optimizing dietary intakes with available resources.

CONCLUSION

Staff and organizational factors need to be considered when attempting to improve postoperative nutrition among patients who undergo colorectal surgery. Introducing a feeding protocol, enhancing intraprofessional and interdisciplinary communication, and ensuring the availability of appropriate, nutrient-dense foods are pivotal to improve nutrition practices and intakes.

A qualitative exploration of factors influencing medical staffs' decision-making around nutrition prescription after colorectal surgery

BACKGROUND

Enhanced Recovery After Surgery (ERAS) guidelines recommend early oral feeding with nutritionally adequate diets after surgery. However, studies have demonstrated variations in practice and poor adherence to these recommendations among patients who have undergone colorectal surgery. Given doctors are responsible for prescribing patients' diets after surgery, this study explored factors which influenced medical staffs' decision-making regarding postoperative nutrition prescription to identify potential behaviour change interventions.

METHODS

This qualitative study involved one-on-one, semi-structured interviews with medical staff involved in prescribing nutrition for patients following colorectal surgery across two tertiary teaching hospitals. Purposive sampling was used to recruit participants with varying years of clinical experience. The Theoretical Domains Framework (TDF) underpinned the development of a semi-structured interview guide. Interviews were audio recorded, with data transcribed verbatim before being thematically analysed. Emergent themes and sub-themes were discussed by all investigators to ensure consensus of interpretation.

RESULTS

Twenty-one medical staff were interviewed, including nine consultants, three fellows, four surgical trainees and five junior medical doctors. Three overarching themes emerged from the data: (i) Prescription preferences are influenced by perceptions, experience and training; (ii) Modifying prescription practices to align with patient-related factors; and (iii) Peers influence prescription behaviours and attitudes towards nutrition.

CONCLUSIONS

Individual beliefs, patient-related factors and the social influence of peers (particularly seniors) appeared to strongly influence medical staffs' decision-making regarding postoperative nutrition prescription. As such, a multi-faceted approach to behaviour change is required to target individual and organisational barriers to enacting evidence-based feeding recommendations.

Enhanced Recovery After Surgery implementation in practice: an ethnographic study of services for hip and knee replacement

OBJECTIVES

Enhanced Recovery After Surgery (ERAS) programmes aim to improve care quality by optimising components of the care pathway and programmes for hip and knee replacement exist across the UK. However, there is variation in delivery and outcomes. This study aims to understand processes that influence implementation using the Consolidated Framework for Implementation Research (CFIR) to inform the design and delivery of services.

DESIGN

An ethnographic study using observations and interviews with staff involved in service delivery. Data were analysed using a thematic analysis, followed by an abductive approach whereby themes were mapped onto the 31 constructs and 5 domains of the CFIR.

SETTING

Four hospital sites in the UK delivering ERAS services for hip and knee replacement.

PARTICIPANTS

38 staff participated including orthopaedic surgeons, nurses and physiotherapists.

RESULTS

Results showed 17 CFIR constructs influenced implementation in all five domains. Within 'intervention characteristics', participants thought ERAS afforded advantages over alternative solutions and guidance was adaptable. In the 'outer setting', it was felt ERAS should be tailored to patients and education used to empower them in their recovery. However, there were concerns about postdischarge support and tensions with primary care. Within the 'inner setting', effective multidisciplinary collaboration was achieved by transferring knowledge about patients along the care pathway and multidisciplinary working practices. ERAS was viewed as a 'message' that had to be communicated consistently. There were concerns about resources and high volumes of patients. Staff access to information varied. At the domain 'characteristics of individuals', knowledge and beliefs impacted on implementation. Within 'process', involving opinion leaders in development and 'champions' who acted as a central point of contact, helped to engage staff. Formal and informal feedback helped to develop services.

CONCLUSIONS

Findings demonstrate successful implementation involves empowering patients to work towards recovery, providing postdischarge support and promoting successful multidisciplinary team working.