Nursing Perspectives on Enhanced Recovery After Surgery

Optimizing nurse staffing in thoracic surgery: the imperative of Enhanced Recovery Programs-a statement of the European Society of Thoracic Surgeons Nursing & Allied Health Professionals Working Group

Enhanced Recovery Programs (ERPs) have revolutionized thoracic surgery by reducing hospital stays and fostering quicker patient recoveries through minimally invasive procedures. However, the perception that patients in ERPs are less complex and require fewer nursing resources is misleading. Despite shorter hospital stays, the complexity of postoperative care remains high, with patients often needing vigilant monitoring and timely interventions. This article challenges the assumption of reduced nursing needs in ERPs, arguing that the fast-paced nature of these programmes intensifies the demand for skilled nursing care. The European Society of Thoracic Surgeons (ESTS) Nurses & Allied Health Professionals Working Group emphasizes that nurse staffing levels must be maintained or even increased to ensure quality care in ERPs. Adequate staffing is crucial for supporting not only the technical aspects of care but also the patient's experience of illness and recovery. Failure to recognize this complexity could compromise patient outcomes, eroding the benefits of ERPs. This paper advocates for a comprehensive approach that balances efficiency with sufficient nursing support to optimize outcomes in thoracic surgery ERPs. It calls for a reassessment of staffing models to meet the evolving demands of these programmes, ensuring that the advantages of shorter recovery times are not undermined by insufficient care.

Ready to Go Home? Nurses' Perspectives of Prolonged Admission for Patients Undergoing Video-Assisted Thoracic Surgery for Non-Small-Cell Lung Cancer in Denmark

Enhanced recovery after surgery programs with median postoperative hospitalization of 2 days improve outcomes after lung cancer surgery. This article explores nursing care practices for patients with lung cancer who remain hospitalized despite having recovered somatically. Qualitative focus group interviews were conducted with 16 nurses. Ricoeur's phenomenological hermeneutics underpins the methodology applied in this study, and we relied on Benner and Wrubel's theory. The nurses emphasized that the thoughts of patients with a recent lung cancer diagnosis revolve around more than the surgery. Nursing comprises not only practicalities but also attending to patients' stress and their coping with being struck with lung cancer and having undergone surgery. A counterculture emerged to counteract the logic of productivity, indicating that caring as a worthy end in itself may be underestimated in protocol-driven care. Prolonging hospitalization largely depends on clinical judgment. The nurses' aim is not to keep patients in the hospital but to avoid any needless suffering, allowing them to reclaim the primacy of caring.

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.

Comparing Analgesia on an As-Needed Basis to Traditional Intravenous Patient-Controlled Analgesia Within Fast-Track Orthopedic Procedures: A Randomized Controlled Trial

BACKGROUND

The aim was to determine if the use of intravenous patient-controlled analgesia (IVPCA) in a fast-track joint replacement program is associated with increased use of perioperative opioid consumption and increased length of hospital stay.

DESIGN

A prospective, double-blind, randomized controlled trial.

SETTINGS

Academic hospital.

PARTICIPANTS/SUBJECTS

A total of 80 patients aged 18-85 years, with body mass index (BMI) 18-40, undergoing elective total knee arthroplasty were recruited.

METHODS

Pre-operatively, patients received gabapentin, celecoxib, and acetaminophen. Peri-operatively, patients received spinal anesthesia with morphine and fentanyl, and periarticular local anesthetic administration by the surgeon. Postoperatively, 80 patients were randomized by a computer-generated sequence into IVPCA group (group A, n = 40) and non-IVPCA group (group B, n = 40).

RESULTS

The primary outcome was 48-hour postoperative opioid consumption and length of hospital stay. Secondary outcomes included side effects of opioids, patient satisfaction, and pain scores. There was no significant difference within 48-hour postoperative opioid consumption (median 61.3 vs. 87.5, p = .181) and length of hospital stay (median 49.8 hours vs. 49.5 hours; p = .89) between the two groups. Also, there was no significant difference in patient satisfaction (median 5 in both groups), pain scores, and opioid-related side effects.

CONCLUSIONS

IVPCA was associated with nonsignificant reduction in opioid exposure in elective total knee arthroplasty surgery within 48 hours. Neither group was superior in terms of length of hospital stay, opioid related side-effects, pain scores, and patient satisfaction.

Knowledge, attitude and application towards fast track surgery among operating room paramedics: a cross-sectional study

BACKGROUND

Fast track surgery has shown its effectiveness to accelerate recovery and gained acceptance in many operations. However, data for paramedics using fast track surgery are limited in China. The aims of our study are to evaluate the knowledge, attitude and application status of fast track surgery in paramedics and to provide suggestions for the better application of fast track surgery.

METHODS

Two Hundred Ninety-one operating room paramedics were investigated by simple random sampling from October 20 to December 20, 2019 time. A self-reported questionnaire was used to collect data with five dimensions: demographic data, cognitive level, knowledge, attitude and application of fast track surgery. Data were analyzed using qualitative and quantitative methods.

RESULTS

19.93% of participants never heard fast track surgery and only 3.32% of participants were very familiar with it. Gender (0.702, 95% CI 0.109-1.294), technical title (0.342, 95% CI 0.126-0.558) and awareness of the concept of fast track surgery (0.471, 95% CI 0.165-0.776) had a correlation with the knowledge level of paramedics towards fast track surgery. In terms of attitude towards fast track surgery, gender (- 1.944, 95% CI -3.830- -0.058), age (0.303, 95% CI 0.021-0.585) and knowledge score of fast track surgery (0.426, 95% CI 0.014-0.838) are related. Half of the paramedics believe the most difficult problem in the application of fast track surgery was the lack of multi-team communication and cooperation.

CONCLUSION

The knowledge of fast track surgery among paramedics in Wuhan is poor, and some paramedics have a negative attitude towards it. As the attitude is positively correlated with the knowledge, it is necessary to improve the knowledge level of fast track surgery among paramedics in Wuhan.

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.

The current and future role of nurses within enhanced recovery after surgery pathways

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways have been proven to expedite recovery after many procedures and reduce lengths of stay in hospital and surgical complications. However, improvements are still needed, especially in postoperative ERAS components delivered by nurses such as early mobilisation and oral feeding. This article summarises the current and possible future role of nurses within ERAS, and recommends areas for future research.

DISCUSSION

Nurses are the professionals who spend the most time with patients throughout the perioperative pathway and are known to play a vital role in delivering many components of an ERAS pathway. They frequently co-ordinate care across disciplines and ensure continuity of care. However, there is a paucity of ERAS research specific to nurses compared to other professional groups. Continual training on ERAS will be required to ensure nurses are highly educated and for the best possible ERAS implementation. In certain types of surgery, nurses may fulfil extended roles in the postoperative period, such as taking over responsibility and leadership for co-ordinating pain management, mobilisation and discharge. However, this requires a well-defined care programme, a clear definition of nursing responsibilities from surgeons, agreed discharge criteria and highly qualified nurses, along with the collection and analysis of data to test safety and efficacy.

CONCLUSION

Increasing nurse involvement in ERAS research is vital to drive improvements in care and to develop nursing roles. Nurses should have a major role in the preoperative clinic, the early postoperative phase and the follow-up post-discharge period, where the benefits of ERAS need to be further documented.

Enhanced recovery protocols in patients undergoing pancreatic surgery: An umbrella review

AIM

To identify, synthesize and appraise the systematic reviews of ERAS for patients undergoing pancreatic surgery and facilitate ERAS implementation.

DESIGN

An umbrella review was used to identify systematic reviews.

METHODS

A systematic search following the PRISMA guidelines was used to search databases including PubMed, Embase, Cochrane Library, CINAHL, CNKI, WanFang and VJIP. AMSTAR 2 was used to appraise the quality of included reviews.

RESULTS

Ten systematic reviews were included. The quality of all included systematic reviews was rated as "critically low." The most frequently reported ERAS elements were epidurals analgesia/PCA (9/10), goal-directed mobilization (9/10) and early removal of drains (9/10). Only one review mentioned audit protocol compliance. None of the included reviews reported discharge standards. Ten reviews reported decreased length of stay, seven reviews reported lower hospital costs, and six reviews reported decreased total complications rate. There were no adverse effects reported.

Level of ERAS understanding affects practitioners' practice and perception of early postoperative resumption of oral intake: a nationwide survey

BACKGROUND

Early postoperative resumption of oral intake is supposed to be safe and beneficial to patients recovery. However, practitioners still have great confusion and disagreement about postoperative resumption of oral intake. This is a nationwide survey to investigate the current status of clinical practice and practitioners' attitude toward postoperative resumption of oral intake along with their level of understanding of the ERAS guidelines.

METHODS

An anonymous web-based survey questionnaire via mobile social platform was carried out in mainland China from December 11-20, 2020. The Wilcoxon signed rank test or chi-square test was used to compare the propensity of the resumption of oral intake.

RESULTS

Totally 5370 responses were received, and 89% of them were from anesthesiology departments. The nature of the responses from clinical practitioners was highly diverse, but each of the three surgery types showed unique patterns of ERAS implementation. The respondents were more conservative regarding the commencement of both fluid and solid diets after gastrointestinal (GI) and hepato-pancreato-biliary (HPB) surgery than after non-abdominal (NA) surgery. Most respondents agreed that early oral intake is beneficial to reduce postoperative complications improve bowel recovery and overall outcome. 55% respondents considered themselves to have a better understanding of ERAS and tended to initiate oral intake early for all three surgery types (P < 0.001).

CONCLUSIONS

The postoperative resumption of oral intake is highly variable among GI, HPB and NA surgeries. A better understanding of ERAS would encourage practitioners to commence oral intake resumption much earlier.

Exploring the Application of a Multi-Targeted Nursing Group for Enhanced Recovery After Surgery Using the LEER ("Less Pain", "Early Movement", "Early Return to a Normal Diet" and "Reassurance") Model

Objective

To explore the effects and value of establishing a multi-target nursing group (MTNG) for facilitating goal-oriented enhanced recovery after surgery (ERAS) using the LEER ("less pain", "early movement", "early return to a normal diet" and "reassurance") model.

Methods

The clinical data of 198 patients with hepatobiliary and pancreatic malignancies were retrospectively analyzed. The patients were divided into two groups: 91 cases were collected in a traditional group, which adopted traditional perioperative care, and 107 cases were collected in an MTNG group, which adopted MTNG measures. The differences in the clinical data including postoperative recovery, unplanned readmission rate, the implementation rate of nursing measures, the degree of a patient's understanding of the disease, and patient compliance and satisfaction with nursing care during hospitalization were compared and analyzed between the two groups.

Results

The MTNG group reflected a lower pain degree and hospitalization expenses (P < 0.05), earlier postoperative flatulence, earlier recommencing of a normal diet, and earlier postoperative ambulation (P < 0.05), together with a shorter postoperative indwelling catheter duration and length of hospital stay (P < 0.05). There were no significant differences in the incidence of postoperative complications and unplanned postoperative readmission rates between the two groups (P > 0.05). The implementation rate of nursing measures and the degree of patients understanding the disease, and patient compliance and satisfaction with nursing care were higher in the MTNG group (P < 0.05).

Conclusion

The MTNG approach, based on ERAS with the LEER model, was conducive to the safe and rapid postoperative recovery of patients, the precise and efficient implementation of ERAS measures, the improvement of medical treatment satisfaction among patients.

A 2-Year Experience With Enhanced Recovery After Surgery: Evaluation of Compliance and Outcomes in Pancreatic Surgery

BACKGROUND

Enhanced Recovery After Surgery (ERAS) programs reduce recovery time, length of stay (LOS), and complications after major surgical procedures.

PURPOSE

We evaluated our 2-year experience with a newly implemented comprehensive ERAS program at a high-volume center after pancreatic surgery.

METHODS

Outcomes, cost, and compliance metrics were assessed in 215 patients who underwent elective pancreatic surgery (pre-ERAS; n = 99; post-ERAS: n = 116). Mann-Whitney U and χ2 tests were used to evaluate continuous and categorical variables.

RESULTS

There were significant decreases in LOS and cost in the post-ERAS cohorts. There were significant increases in compliance with ERAS implementation. Postoperative complication, readmission, and survival rates did not increase.

CONCLUSIONS

Implementation of ERAS at a large-volume hospital may improve compliance and reduce costs and LOS without increasing adverse outcomes.

Opportunities and Challenges for the Next Phase of Enhanced Recovery After Surgery: A Review

Importance

Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement initiative now firmly entrenched within the field of perioperative care. Although ERAS is associated with significant clinical outcome improvements and cost savings in numerous surgical specialties, several opportunities and challenges deserve further discussion.

Observations

Uptake and implementation of ERAS Society guidelines, together with ERAS-related research, have increased exponentially since the inception of the ERAS movement. Opportunities to further improve patient outcomes include addressing frailty, optimizing nutrition, prehabilitation, correcting preoperative anemia, and improving uptake of ERAS worldwide, including in low- and middle-income countries. Challenges facing enhanced recovery today include implementation, carbohydrate loading, reversal of neuromuscular blockade, and bowel preparation. The COVID-19 pandemic poses both a challenge and an opportunity for ERAS.

Conclusions and Relevance

To date, ERAS has achieved significant benefit for patients and health systems; however, improvements are still needed, particularly in the areas of patient optimization and systematic implementation. During this time of global crisis, the ERAS method of delivering care is required to take surgery and anesthesia to the next level and bring improvements in outcomes to both patients and health systems.

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.

Older veterans undergoing inpatient surgery: What is the compliance with best practice guidelines?

BACKGROUND

The United States population is aging, and the number of older adults requiring operative care is increasing at a rapid rate. In order to address this issue, the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society created best practice guidelines surrounding optimal perioperative care for the older adult surgical patient. This study aimed to determine the documented compliance with these guidelines at a single institution.

METHODS

A retrospective chart review was performed on 86 older adults undergoing elective, inpatient coronary artery bypass graft, prostatectomy, or colectomy over a 2-year period (1/2016-12/2017) at a single Veterans Affairs institution. The primary outcome was compliance with the 38 measures from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society Best Practice Guidelines. The secondary outcome was postoperative (including geriatric-specific) complications.

RESULTS

The mean reported compliance across all measures was 41% ± 4%. Of 38 analyzed measures, compliance for 10 measures was achieved for 0 patients, and only 1 patient for 7 measures. There was variance in compliance by phase of care (P < .05) with a high of 56% ± 8% (immediate preoperative phase of care) and a low of 35% ± 4% (intraoperative phase of care).

CONCLUSION

Overall reported compliance with the Best Practice Guidelines of the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society is low (41%) at this institution. This study identifies a need to improve the care provided to the vulnerable population of older adults undergoing an operation. Future work is needed to understand barriers for implementation and how compliance relates to outcomes.

The efficacy of nursing intervention to reduce preoperative anxiety in patients with total knee arthroplasty: A protocol of prospective randomized trial

BACKGROUND

Some patients undergoing the total knee arthroplasty (TKA) have suboptimal postoperative results, and preoperative anxiety may be one of the reasons for these unsatisfactory results. We perform this randomized control study protocol to determine the effectiveness of nursing intervention, on the basis of motivational interview, to decrease the preoperative anxiety in patients receiving TKA.

METHODS

This is a double-blinded, single-center, placebo-controlled and randomized trial, which will be conducted from December 2020 to June 2021. The protocol of this study was approved by the West China Hospital of Sichuan University (W20200803-28). Sixty patients who will undergo TKA are included in our study. Patients are randomly divided into experiential group (with 30 patients) and the control group (with 30 patients). The control group and experimental group receive an informative and separate session via nursing about the operation preparation and operation process. Both the control group and the experimental group are given habitual treatment, but the experimental group need to receive additional motivational interviews. The primary outcomes are the Hospital Anxiety and Depression Scale and the Amsterdam Preoperative Anxiety and Information Scale. Secondary outcome is postoperative pain, which is assessed by visual analogue scale .

RESULTS

Figure 1 will display the comparison of preoperative and postoperative total average anxiety scores in control group and the experimental group.

CONCLUSION

Preoperative psychological distress is familiar in our patients. We hypothesized that nursing intervention may be associated with reduced preoperative anxiety in the patients receiving TKA.

Agreements on perceived use of principles for Enhanced Recovery After Surgery between patients and nursing staff in a gynecological ward

OBJECTIVES

The aim of the study was to evaluate the agreements between patients and nursing staff in perceived use of the principles of Enhanced Recovery After Surgery (ERAS) in a gynecological ward, both prior to and following an educational session on ERAS guidelines for the nursing staff.

STUDY DESIGN

This was a prospective observational study conducted in the in-patient gynecological section of the Department of Obstetrics and Gynecology at the University hospital of Linköping during spring 2017. The study groups comprised women scheduled for elective in-patient gynecological surgery due to benign or malignant diseases and the nursing staff at the gynecological ward. The study was performed in three parts with two structured questionnaire interviews of patients and nursing staff, and an intermediate educational session for the nursing staff regarding ERAS principles, conducted between the parts of the interview. Seventy-two patients were included in Interview part 1 and 68 patients in Interview part 2. The results are shown as the degree of inter-rater agreement and reliability of the responses between patients and nursing staff in numbers and percentages, along with the difference (Δ) in agreement between the interview parts, and its corresponding 95% confidence interval (CI). In addition, Cohen's kappa was used to validate the findings.

RESULTS

Inter-rater agreement in answers to the interview questions was high even before the educational session. The observed agreement was ≥ 70% in 34 out of 42 questions in Interview part 1, and in 38 out of 42 questions in Interview part 2. Thirty of the 42 items (71%) had positive Δ agreement (%) whereas 12 of the 42 (29%) had negative Δ agreement (%).

CONCLUSIONS

This study showed high inter-rater agreement in perceived adherence to ERAS principles between patients and nursing staff in a gynecological ward. This was further improved by an educational session for the staff concerning ERAS guidelines. This might indicate the importance of repeated educational sessions to maintain high compliance with ERAS principles.

Improving the Patient Experience Following Total Knee and Total Hip Arthroplasty: A Practice Development Project

BACKGROUND

The paradigm shift that has occurred for patients with total hip (THA) and knee (TKA) arthroplasty through enhanced recovery programs underscores the need for redesigning care provision.

LOCAL PROBLEM

In this hospital, the patient outcomes and experience anticipated from the implementation of enhanced recovery medical protocols were not fully realized.

METHODS

The Practice Development in Nursing and Healthcare model guided this project.

INTERVENTIONS

A nurse-led team designed a new care delivery model with patient/family-centered interventions based on the best evidence.

RESULTS

Outcomes included an increase in discharges of postoperative day 1 or less of 154% THA and 41.8% TKA and an increase in discharge to home by 24.6% THA and 18.7% TKA. In addition, 90-day readmissions were reduced for both patient groups.

CONCLUSIONS

An interprofessional team of clinicians made sustainable improvements in the experience and outcomes for the surgical patients with THA and TKA.

Enhanced recovery in usual health care improves functional recovery after total knee arthroplasty

BACKGROUND

The success of total knee arthroplasty (TKA) is determined by an effective surgical procedure as well as a well-organized clinical care pathway. Research has shown that day-of-surgery mobilization decreases length of stay (LOS) and complication rates. We developed, implemented, and evaluated a new clinical care pathway for patients undergoing TKA, that included early mobilization, using 'Lean Six Sigma (LSS)', with the aim of accelerating functional recovery and reducing LOS.

METHODS

Data derived from physical therapy reports and LOS were compared between the old (n = 85) and the new (n = 85) clinical care pathways for time to functional recovery (using the modified Iowa Level of Assistance Scale), LOS and joint-related readmission. Group differences were evaluated using Mann-Whitney and Chi-Square tests. The clinical care pathway was redesigned using LSS-methods.

RESULTS

After implementation of the new pathway, median time to functional recovery improved from 4 (2-5) to 2 days (1-8)(P < 0.001) and LOS from 7 (5-11) to 4 days (3-12)(P < 0.001), joint-related readmission declined (3.5-2.4%)(P = 0.65).

CONCLUSION

Implementation of the new clinical care pathway accelerated functional recovery and reduced LOS for patients undergoing TKA. Future research should focus on having multiple discharge moments per day which might encourage patients to achieve functional recovery as soon as possible.