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
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
Call to Care: The impact of 24-hour post-discharge telephone follow-up in the treatment of surgical daycare patients
The reference list focuses on nursing care. Publications are grouped into categories:
- Nursing Req
- Convalescence/ Fatigue/ Rehabilitation, Mobilisation
- Patient Satisfaction/ Relatives
- 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
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.
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.
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.
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)
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.
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
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.