Implementation of Enhanced Recovery After Surgery: a strategy to transform surgical care across a health system

Abstract

BackgroundEnhanced Recovery After Surgery (ERAS) programs have been shown to have a positive impact on outcome. The ERAS care system includes an evidence-based guideline, an implementation program, and an interactive audit system to support practice change. The purpose of this study is to describe the use of the Theoretic Domains Framework (TDF) in changing surgical care and application of the Quality Enhancement Research Initiative (QUERI) model to analyze end-to-end implementation of ERAS in colorectal surgery across multiple sites within a single health system. The ultimate intent of this work is to allow for the development of a model for spread, scale, and sustainability of ERAS in Alberta Health Services (AHS).MethodsERAS for colorectal surgery was implemented at two sites and then spread to four additional sites. The ERAS Interactive Audit System (EIAS) was used to assess compliance with the guidelines, length of stay, readmissions, and complications. Data sources informing knowledge translation included surveys, focus groups, interviews, and other qualitative data sources such as minutes and status updates. The QUERI model and TDF were used to thematically analyze 189 documents with 2188 quotes meeting the inclusion criteria. Data sources were analyzed for barriers or enablers, organized into a framework that included individual to organization impact, and areas of focus for guideline implementation.ResultsCompliance with the evidence-based guidelines for ERAS in colorectal surgery at baseline was 40%. Post implementation compliance, consistent with adoption of best practice, improved to 65%. Barriers and enablers were categorized as clinical practice (22%), individual provider (26%), organization (19%), external environment (7%), and patients (25%). In the Alberta context, 26% of barriers and enablers to ERAS implementation occurred at the site and unit levels, with a provider focus 26% of the time, a patient focus 26% of the time, and a system focus 22% of the time.ConclusionsUsing the ERAS care system and applying the QUERI model and TDF allow for identification of strategies that can support diffusion and sustainment of innovation of Enhanced Recovery After Surgery across multiple sites within a health care system.

Implementation of an Enhanced Recovery After Surgery Program Can Change Nutrition Care Practice: A Multicenter Experience in Elective Colorectal Surgery

“…The AHS EIP achieved highest compliance in the preoperative period (86%) and lowest in the postoperative period (59%), similar to other colorectal ERAS programs . Possible explanations include development of postoperative complications, which can result in deviations from protocols, and the high degree of patient and multidisciplinary involvement in the postoperative period, which may explain reported differences in the rates of adherence to ERAS care elements and in data recording . Some ERAS elements are more easily tracked and recorded by healthcare professionals, such as ERAS elements found in the medical record or included on order sets; for example, PONV prophylaxes were missed less frequently by the multidisciplinary teams .…”

“…7,8,33 Some ERAS elements are more easily tracked and recorded by healthcare professionals, such as ERAS elements found in the medical record or included on order sets; for example, PONV prophylaxes were missed less frequently by the multidisciplinary teams. 33 Data for elements not found in the medical record and collected using other methodologies, such as patient journals (eg, mobility and nutrition), had lower rates of adherence. 33 Barriers to nutrition care within the AHS EIP have been identified and are related to care processes at individual hospital sites, and information and communication for providers and patients related to eating and drinking after surgery.…”

“…33,34 Strategies to enhance nutrition care include process improvement for ensuring delivery of appropriate snack and ONS, and encouragement and education for patients and healthcare providers. 33 Improved adherence to other ERAS elements that influence oral intake and bowel function (eg, optimal management of pain/nausea, fluid balance, nonopioid analgesia) will contribute to improved postoperative oral intake.…”

Prospective application of an implementation framework to improve postoperative nutrition care processes: Evaluation of a mixed methods implementation study

“…Like other complex interventions, ERAS protocols are challenging to implement and sustain, with multiple barriers to change depending on the local context . Implementation of some individual care practices is easier than others, and adherence is typically lowest for postoperative elements occurring in the complex ward environment . This may reflect greater challenges in changing practice across the multiple disciplines involved …”

“…11,12 Implementation of some individual care practices is easier than others, 13 and adherence is typically lowest for postoperative elements occurring in the complex ward environment. 14 This may reflect greater challenges in changing practice across the multiple disciplines involved. 15 Implementation science has emerged as a scientific approach to translating knowledge into practice, with the goal of improving health services.…”