Background: In March 2016, an Enhanced Recovery After Surgery (ERAS) initiative was implemented for all elective colorectal resections at an urban hospital in St. John's, Newfoundland and Labrador, Canada. An ERAS coordinator supervised and enforced guideline compliance for 6 months. The aim of this study was to evaluate the sustainability of the ERAS program after supervision of guideline compliance was eliminated. Methods: Patient outcomes and guideline compliance were compared between surgeries performed under standard practice (April 2014 to March 2015) and those performed during and after the implementation of the ERAS initiative (March 2016 to August 2016 was the implementation phase and September 2016 to February 2017 was the sustainability phase). Results: Hospital length of stay decreased from 7.26 days at baseline to 5.44 days during the implementation phase of the ERAS program (p < 0.001). There was no significant difference between length of stay at baseline and during the 6-month sustainability phase of the ERAS program (7.10 d). There were no significant differences in rates of readmission or mortality during and after implementation. Rate of ileus decreased significantly from 13.8% during the implementation phase to 4.6% during the sustainability phase (p = 0.036). Total guideline compliance increased from 52.2% at baseline to 80.7% during the implementation phase (p < 0.001), and decreased to 74.7% during the sustainability phase (p < 0.001). Adherence to postoperative guidelines regressed: 79.2% in the implementation phase and 68.6% in the sustainability phase (p < 0.001). Conclusion: Hospital length of stay decreased when the ERAS program was implemented and the ERAS coordinator was present on the surgical ward. Methods for sustaining guideline implementation are vital to the success of similar programs in the future. Contexte : En mars 2016, une initiative de récupération améliorée après la chirurgie (RAAC) a été mise en place pour toutes les résections colorectales électives effectuées dans un hôpital
Development of a clinical pathway for enhanced recovery in colorectal surgery: a Canadian collaboration C olorectal surgery may be associated with undesirable outcomes, including long length of stay in hospital, high rates of surgical site infection, perioperative nausea and vomiting, high readmission rates, and increased costs. Enhanced Recovery After Surgery (ERAS) has emerged worldwide as the new standard of care for patients undergoing elective colorectal surgery. The goal of ERAS is to reduce the patient's surgical stress response, optimize their physiologic function, and facilitate recovery by incorporating evidence-based interventions into patient management. A metaanalysis published in 2014 including 16 randomized controlled trials comparing the ERAS pathway to conventional perioperative care showed that the ERAS pathway reduced overall morbidity rates and shortened length of stay by 2.28 days, without increasing readmission rates. 1 A significant reduction in nonsurgical complications was noted, while the effect on surgical complications was less pronounced. An economic evaluation of the ERAS multisite implementation program for colorectal surgery in Alberta estimated the net health system savings to be $1768 per patient. 2 In terms of return on investment, for every $1 invested in ERAS, $3.80 could be expected in return. 2 Yet, despite the compelling evidence in support of ERAS, it has not been adopted widely. Results from a Canadian qualitative study suggest that although clinicians see the value in implementing an ERAS program, lack of nursing staff, lack of financial resources, resistance to change, and poor communication and collaboration are perceived as barriers to its adoption. 3 Enhanced Recovery Canada (ERC) is a project-based committee of the Canadian Patient Safety Institute (CPSI) that was formed as part of CPSI's commitment to influence improved surgical safety across the country. In 2017, ERC set out to develop a clinical pathway for elective colorectal surgery based on the key clinical elements of ERAS identified through implementation research, 4 including patient and family engagement, nutrition management, fluid and hydration management, mobility and physical activity, surgical
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