Barriers to and Facilitators of Implementing Enhanced Recovery Pathways Using an Implementation Framework

Abstract

IMPORTANCE Enhanced recovery pathways (ERPs) have the potential to reduce length of hospital stay, costs, and complications following surgery but can be challenging to implement. OBJECTIVE To examine the body of literature on ERPs to assess how authors describe barriers and facilitators of ERP implementation and identify, in aggregate, the best practices that should be considered utilizing the Consolidated Framework for Implementation Research (CFIR) to extract these elements and summarize common barriers and facilitators according to its 5 major domains: (1) intervention characteristics, (2) inner setting, (3) outer setting, (4) characteristics of the individuals, and (5) the process of implementation.EVIDENCE REVIEW A systematic review was conducted in accordance with the PRISMA statement. An ERP was defined as a bundle of multiple perioperative interventions that involve a multidisciplinary team, had a label different than traditional care, and had a formal way of measuring outcomes. Six databases (PubMed, MEDLINE, Cumulative Index to Nursing and Allied Health Literature Complete, Web of Science, PsychINFO, and Cochrane Central Register of Controlled Trials) of articles published from 1990 to November 30, 2016, were searched. Articles that were included had to address barriers and facilitators of ERP implementation and provide sufficient detail that the CFIR domain could be identified. Data were abstracted by 2 independent researchers using a standardized extraction form.FINDINGS The initial search strategy returned 4563 results; 3883 studies were eliminated by screening titles and abstracts, leaving 680 articles for full-text screening. Of these, 53 studies were included in the review. The key facilitating factors were (1) adapting the program to fit local contexts, (2) achieving and demonstrating early "wins," (3) gaining buy-in from both frontline clinicians and hospital leadership, (4) having a strong ERP team that met regularly, and (5) leveraging supporters and full-time ERP staff. The major barriers identified were (1) meeting with resistance to change from frontline clinicians, (2) not having enough resources for implementation, and (3) external factors, such as patient complexity or rural hospital location. CONCLUSIONS AND RELEVANCEMost ERP literature focuses on the efficacy, safety, or cost-effectiveness of these protocols. To promote the spread of ERP programs, more high-quality studies on the implementation process are needed.

Early oral feeding after colorectal surgery: A mixed methods study of knowledge translation

“…This process of engagement was another important catalyst to instigate practice change, which relayed an initial positive effect onto EOF improvements as illustrated in Audit 3. The role of staff engagement and effective team communication has also been previously described as a necessary enabler for successful implementation of enhanced recovery programs …”

“…This was consistent with previous literature that has emphasised the importance of staffrelated education to facilitate initiation of change and transition of practice prior to implementation of enhanced recovery programs. [11][12][13][14][15][16]20 As such, the present study included education sessions that described EOF guideline recommendations and descriptions of the nature and availability of local hospital diet codes.…”

“…Effective implementation of enhanced recovery programs requires cultural change to ensure improved communication, teamwork and organisational support. Programs should be adapted to the local context and deliver a data‐driven approach highlighting local deficits, perceived barriers to knowledge uptake, and an opportunity to demonstrate effectiveness . Ultimately, engagement of a multidisciplinary team including both front‐line and senior staff is inherent to support structural changes for implementation success and sustainability …”

“…Programs should be adapted to the local context and deliver a datadriven approach highlighting local deficits, perceived barriers to knowledge uptake, and an opportunity to demonstrate effectiveness. 13,14 Ultimately, engagement of a multidisciplinary team including both front-line and senior staff is inherent to support structural changes for implementation success and sustainability. [13][14][15][16] The aims of the present study were to: 1 Understand local postoperative feeding practices after colorectal surgery 2 Identify barriers and enablers to implementation of EOF guideline recommendations 3 Select, tailor and implement stakeholder engagement strategies to facilitate EOF uptake 4 Evaluate changes to EOF practices Methods A longitudinal, mixed methods study, guided by the action cycle of the knowledge-to-action (KTA) framework, 17 was undertaken to evaluate and improve postoperative feeding practices among patients undergoing elective colorectal surgery.…”

Enhanced recovery after surgery review and urology applications in 2020

“…Any barriers to implementation should be identified, so that it can be determined locally what may delay further execution of the protocol. A thorough systematic review on ERAS implementation showed that there are multiple topics common to most institutions, even though the list of facilitators and barriers may vary considerably from one site to another . In general, lack of clear guidance was found to deter adherence, so standardization with some degree of flexibility to adapt the protocol to local factors is of paramount importance.…”