Delivery of ERAS Care in an Academic Hospital

Abstract

Enhanced Recovery after Surgery (ERAS) pathways in colorectal surgery improve outcomes and reduce disparities, but pathway adherence rates are variable. Sustainability of adherence following initial implementation, particularly in academic settings with trainee involvement, is underexplored. This study measures and describes ERAS adherence for 163 consecutive patients undergoing elective colorectal resection in an academic colorectal surgery department with a well-established ERAS pathway. Providers, including residents and nursing staff, were surveyed regarding pathway knowledge and obstacles to adherence. Adherence was higher preoperatively (80%) and intraoperatively (93%) than postoperatively (61%). Opioid-sparing analgesia and bowel motility agents were underdosed on up to 63% of hospital days, without clinical rationale in ≥50% of cases. Providers cited peer teaching (71%) as the primary source of pathway knowledge and identified individual surgeon preferences as an obstacle to adherence. Formalized ERAS pathway education, communication, and coordination among attending physicians are needed to reduce provider-driven deviation in an academic setting.

Sustainability of enhanced recovery after surgery programmes in gastrointestinal surgery: A scoping review

“…Study designs included: Four qualitative studies (sample size range: 26–123 participants; all multisite studies) 33,34,41,46 Sixteen quantitative studies (sample size range: 55–3022 participants; 11 single facility and five multisite studies; multisite study range: 10–67 facilities). One primary mixed methods study (41 care providers at a single facility) 48 ; and One grey literature mixed methods evaluation (health service report; 7176 colorectal surgery patients and 408 pancreatic surgery patients across two facilities) 53 …”

“…Of the 22 included studies, 12 ( n / N = 4/4 qualitative, 8/17 quantitative, 0/1 mixed methods grey literature) reported determinants (i.e., barriers/enablers) of sustainability 33,34,36,37,41,44,46–50,52 . Determinants were inconsistently reported, with the qualitative studies evaluating determinants in depth, and the quantitative studies superficially reporting encountered barriers and/or enablers to sustainability of ERAS programmes.…”

“…Only 2 of 17 quantitative studies specified criteria of programme sustainability a priori, in both instances this was related to maintaining adherence only, 37 or adherence and outcomes, 37 at a level comparable to the early postimplementation period. The remaining quantitative studies reported adherence to pre, intra and postoperative ERAS elements (all or a combination of these) only (n/N = 3/15), 48,50,52 maintenance of outcomes only (n/N = 1/15), 43 or a combination of both adherence and outcomes (n/N = 11/15) 35,36,[38][39][40]42,44,45,47,49,51 as an indicator of sustainability. Similarly, the mixed methods grey literature evidence 53 reported a combination of both adherence and outcomes, without prespecifying what would determine success.…”

“…Of the 22 included studies, 12 (n/N = 4/4 qualitative, 8/17 quantitative, 0/1 mixed methods grey literature) reported determinants (i.e., barriers/ enablers) of sustainability. 33,34,36,37,41,44,[46][47][48][49][50]52 Determinants were reported using the Theoretical Domains Framework 55 to inform initial implementation but it was unclear whether this also guided their evaluation sustainability.…”

“…Resources were the most frequently identified determinant to sustainability of ERAS programmes (n/N = 9/12, 75%), 33,34,41,44,46,47,49,50,52 commonly resources such as investment in dedicated staff and infrastructure such as audit and reporting systems. This was followed equally by People involved 33,34,36,41,[47][48][49]52 and the Organisational setting 33,34,36,41,44,46,49,52 (n/N = 8/12, 67%). Determinants related to the External environment were least often identified (n/N = 3/12, 25%).…”