Category: Research

Research: Provincial ERAS Implementation – Alberta’s experience

Implementation of Enhanced Recovery After Surgery (ERAS) Across a Provincial Healthcare System: The ERAS Alberta Colorectal Surgery Experience

World J Surg (2016) 40:1092–1103

Gregg Nelson, Lawrence N. Kiyang, Ellen T. Crumley, Anderson Chuck, Thanh Nguyen, Peter Faris, Tracy Wasylak, Carlota Basualdo-Hammond, Susan McKay, Olle Ljungqvist, Leah M. Gramlich


Enhanced recovery after surgery (ERAS) colorectal guideline implementation has occurred primarily in standalone institutions worldwide. We implemented the guideline in a single provincial healthcare system, and our study examined the effect of the guideline on patient outcomes [length of stay (LOS), complications, and 30-day post-discharge readmissions] across a healthcare system.


We compared pre- and post-guideline implementation in consecutive elective colorectal patients, C18 years, from six Alberta hospitals between February 2013 and December 2014. Participants were followed up to 30 days post discharge. We used summary statistics, to assess the LOS and complications, and multivariate regression methods to assess readmissions and to estimate cost impacts.  Read more

Research: Impact of 24-hour post-discharge telephone follow-up

Call to Care: The impact of 24-hour post-discharge telephone follow-up in the treatment of surgical daycare patients

Shay-Anne Daniels, Amanda Kelly, M.Sc., Deborah Bachand, R.N., B.A., Elizabeth Simeoni, R.N., Christine Hall, M.D., M.Sc., F.R.C.P.C., Scott M. Hofer, Ph.D., Allen Hayashi, M.D., M.Sc., F.R.C.S.C. (January 2016)


Patient satisfaction and effective management of post-operative complaints are important factors in determining the success of outpatient surgery programs.


In September 2013 a 24-hour post-discharge telephone follow-up (TFU) call, was initiated by surgical day care nurses at the Royal Jubilee Hospital in Victoria, B.C. The study group was contacted to evaluate the effectiveness of the TFU in identifying and addressing post-operative complaints and determining the level of satisfaction with discharge instructions and care. Read more

References for ERAS Nursing Care

The reference list focuses on nursing care.  Publications are grouped into categories:

  • Nursing Req
  • Convalescence/ Fatigue/ Rehabilitation, Mobilisation
  • Information
  • Patient Satisfaction/ Relatives
  • Implementation
  • Stoma Patients

This document was distributed by the ERAS Nursing Group at the World Congress of Enhanced Recovery After Surgery and Perioperative Medicine, May 2015.

The document can be found under the Tools Tab in the Staff Training folder

Research: Process Evaluation of ERAS Implementation

Successful Implementation of an Enhanced Recovery After Surgery Programme for Elective Colorectal Surgery: a process evaluation of champions’ experiences

Lesley Gotlib Conn, Marg McKenzie, Emily A. Pearsall and Robin S. McLeod (July 2015)


Enhanced recovery after surgery (ERAS) is a multimodal evidence-based approach to patient care that has become the standard in elective colorectal surgery. Implemented globally, ERAS programmes represent a considerable change in practice for many surgical care providers. Our current understanding of specific implementation and sustainability challenges is limited. In January 2013, we began a 2-year ERAS implementation for elective colorectal surgery in 15 academic hospitals in Ontario. The purpose of this study was to understand the process enablers and barriers that influenced the success of ERAS implementation in these centres with a view towards supporting sustainable change.


A qualitative process evaluation was conducted from June to September 2014. Semi-structured interviews with implementation champions were completed, and an iterative inductive thematic analysis was conducted. Following a data-driven analysis, the Normalization Process Theory (NPT) was used as an analytic framework to understand the impact of various implementation processes. The NPT constructs were used as sensitizing concepts, reviewed against existing data categories for alignment and fit.

Read more

ERAS World Congress: Highlights from ERAS Collaborative participants

The Specialist Services Committee sponsored the participation of a multi-disciplinary group from the ERAS Collaborative to attend the ERAS World Congress, May 9-12, 2015, in Washington, DC. Please check out the ERAS Collaborative group’s report, which shares their highlights from the Congress, including ERAS implementation ideas presented by ERAS teams from international sites.

Research: Outcomes of Bowel Preparation in Colon Surgery

Nationwide Analysis of Outcomes of Bowel Preparation in Colon Surgery

Moghadamyeghaneh Z, Hanna M, Carmichael J, et al. (May 2015)


There are limited data comparing the outcomes of preoperative oral antibiotic bowel preparation (OBP) and mechanical bowel preparation (MBP) in colorectal surgery. We sought to identify the relationship between preoperative bowel preparations (BP) and postoperative complications in colon cancer surgery.

Study Design

The NSQIP database was used to examine the clinical data of colon cancer patients undergoing scheduled colon resection during 2012 to 2013. Multivariate regression analysis was performed to identify correlations between BP and postoperative complications.


We evaluated a total of 5,021 patients who underwent elective colon resection. Of these, 44.8% had only MBP, 2.3% had only OBP, 27.6% had both MBP and OBP, and 25.3% of patients did not have any type of BP. In multivariate analysis of data, MBP and OBP were not associated with decreased risk of postoperative complications in right side (adjusted odds ratio [AOR] 0.80, 0.30, p = 0.08, 0.10, respectively) or left side colon resections (AOR 1.02, 0.68, p = 0.81, 0.24, respectively). However, the combination of MBP and OBP before left side colon resections resulted in a significantly decreased risk of overall morbidity (AOR 0.63, p < 0.01), superficial surgical site infection (AOR 0.31, p < 0.01), anastomosis leakage (AOR 0.44, p < 0.01), and intra-abdominal infections (AOR 0.44, p < 0.01).


Our analysis revealed that solitary mechanical bowel preparation and solitary oral bowel preparation had no significant effects on major postoperative complications after colon cancer resection. However, a combination of mechanical and oral antibiotic preparations showed a significant decrease in postoperative morbidity.

Abbreviations and Acronyms:

AOR (adjusted odds ratio), BP (bowel preparation), MBP (mechanical bowel preparation), OBP (oral antibiotic bowel preparation), SSI (surgical site infection)

J Am Coll Surgeons. May 2015;220(5):912–920.



Research: Impact of Protocol Compliance on Post-Op Outcomes

The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection: Results From an International Registry

ERAS Compliance Group: Currie A, Burch J, Jenkins JT, et al. (June 2015)


The ERAS (enhanced recovery after surgery) care has been shown in randomized clinical trials to improve outcome after colorectal surgery compared to traditional care. The impact of different levels of compliance and specific elements, particularly out with a trial setting, is poorly understood.


This study evaluated the individual impact of specific patient factors and perioperative enhanced recovery protocol compliance on postoperative outcome after elective primary colorectal cancer resection.


The international, multicenter ERAS registry data, collected between November 2008 and March 2013, was reviewed. Patient demographics, disease characteristics, and perioperative ERAS protocol compliance were assessed. Linear regression was undertaken for primary admission duration and logistic regression for the development of any postoperative complication.


A total of 1509 colonic and 843 rectal resections were undertaken in 13 centers from 6 countries. Median length of stay for colorectal resections was 6 days, with readmissions in 216 (9.2%), complications in 948 (40%), and reoperation in 167 (7.1%) of 2352 patients. Laparoscopic surgery was associated with reduced complications [odds ratio (OR) = 0.68; P < 0.001] and length of stay (OR = 0.83, P < 0.001). Increasing ERAS compliance was correlated with fewer complications (OR = 0.69, P < 0.001) and shorter primary hospital admission (OR = 0.88, P < 0.001). Shorter hospital stay was associated with preoperative carbohydrate and fluid loading (OR = 0.89, P = 0.001), and totally intravenous anesthesia (OR = 0.86, P < 0.001); longer stay was associated with intraoperative epidural analgesia (OR = 1.07, P = 0.019). Reduced postoperative complications were associated with restrictive perioperative intravenous fluids (OR = 0.35, P < 0.001).


This analysis has demonstrated that in a large, international cohort of patients, increasing compliance with an ERAS program and the use of laparoscopic surgery independently improve outcome.

Annals of Surgery. Volume 261, Number 6, June 2015


Research: School’s in for Surgery Patients

For those of you interested in pre-op optimization for surgical patients, the University of Michigan is training surgical patients on how to improve their chances of healing through the Michigan Surgical Home Optimization Program, or MSHOP. Researchers say better prepared patients will also help surgeons be more successful in treating patients.

“Training leading up to the operation focuses on four areas — move, breathe, eat and relax — and MSHOP addresses these areas through patient support and education. This includes encouraging quitting tobacco and practicing breathing exercises that help improve pulmonary function and decrease post-op pneumonia. The program is also designed to modify patients’ nutrition, exercise and stress levels for faster healing, reduced infections and optimized immune function — among other benefits.”

Read the University of Michigan Health System article here.

Annals of Surgery citation: Ann Surg. 2015 Apr 17. Starting a Surgical Home. Englesbe MJ, Lussiez AD, Friedman JF, Sullivan JA, Wang SC.



Research: ERAS protocols for radical cystectomy

Enhanced Recovery After Surgery protocols for radical cystectomy surgery: review of current evidence and local protocols.

Mir MC, Zargar H, Bolton DM, et al. (March 2015)


Radical cystectomy (RC) remains a morbid procedure. The use of Enhanced Recovery After Surgery (ERAS) pathways has proven to reduce care time and post-operative complications after colorectal surgery. There is a high potential for reducing morbidity associated with RC by utilizing ERAS in this setting. The purpose of this review is to examine the current evidence for ERAS in preoperative, intra-operative and post-operative setting of care for RC patients and to propose ERAS evidence-based protocol for patients undergoing RC in the Australian and New Zealand environment.


Patient’s medical optimization, avoidance of oral mechanical bowel preparation and emphasis on preoperative administration of high-energy carbohydrate drinks from colorectal literature has led to inclusion of these strategies in the preoperative considerations of ERAS in RC.


Epidural analgesia has an integral role in reducing surgical stress response, improving analgesia and expediting functional recovery and should be included in ERAS RC protocols. Of relevance is 72 h maximum length of its duration. With regard to minimally invasive approach to RC, despite encouraging results from high-volume centres, high-level evidence in this field are lacking (ongoing clinical trials). Standardized anaesthetic protocols with particular emphasis on perioperative fluid management are essential components of ERAS protocols.


Avoidance of routine nasogastric tube placement, early mobilization and multifaceted approach to optimization of gut function and elimination of post-operative ileus are the cornerstones of post-operative care in the setting of ERAS in RC patients.

ANZ J Surg. 2015 Mar 17. doi: 10.1111/ans.13043

Research: Chewing gum after surgery to help recovery of the digestive system

Cochrane Review

Short V, Herbert G, Perry R, et al. (2015)


This review identified some evidence for the benefit of postoperative CG in improving recovery of GI function. However, the research to date has primarily focussed on CS and CRS, and largely consisted of small, poor quality trials. Many components of the ERAS programme also target ileus, therefore the benefit of CG alongside ERAS may be reduced, as we observed in this review. Therefore larger, better quality RCTS in an ERAS setting in wider surgical disciplines would be needed to improve the evidence base for use of CG after surgery.

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