Enhanced Recovery After Surgery (ERAS) Programmes: A Multimodal Approach to Improving Surgical Outcomes and Reducing Hospital Stay (2)

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What are the challenges to the implementation of ERAS pathways?
Each hospital will experience different difficulties. A key step in the establishment of an ERAS pathway is the coordinated review of hospital data and literature by all the different healthcare professionals involved in patients’ care, followed by their collaboration in deciding on an appropriate ERAS pathway. Many hospitals, however, do not know their own data. They also don’t know the literature, which makes things even more difficult, as they cannot put their own data into context.

Introduction and implementation of the pathway is another potential challenge. In my hospital, implementation was not really a problem because the anaesthesiologists, surgeons and nurses – and potentially also social services – worked together to design the pathway. Having input from a variety of healthcare specialists meant that the pathway functioned very well and there was collaboration and commitment from the start. In some cases, it is extremely difficult to enforce ERAS pathways, as the principle is so different from traditional practices. Other hospitals have struggled with implementation for this reason. The collaboration and agreement between healthcare professionals is sometimes very difficult, because in many surgical departments different surgeons practice different care principles. The same is true for the anaesthesiologists and nurses. Furthermore, some professionals can be resistant to any proposed change in their personal practices, despite the availability of clinical evidence to support them doing so. There are so many crucial participants involved with implementing an ERAS pathway, therefore communication and collaboration is key. Unfortunately, in some hospitals it seems very difficult for all healthcare practitioners to work together to outline best practices.

Another problem is that the ERAS pathways involve many components. For example, the ERAS Study Group originally included up to 19 practices in the colonic surgery pathway; if a hospital is asked to implement 19 different care practices, it is very difficult for people to accept and comply with all the steps proposed. The focus should be on the five key components that were initially described [8], which makes the pathway simpler and easier to rationalise.

The challenges experienced also vary, depending on the type of surgery. While implementing an ERAS pathway in colonic surgery in my hospital was relatively straightforward, implementing an ERAS pathway for breast cancer patients was extremely difficult. Breast cancer surgery is a more superficial operation, compared with abdominal surgery or thoracic surgery, and rarely results in serious complications. There is no significant risk of myocardial infarction, pneumonia or thromboembolic complications. Nurses are heavily involved in patient care, and their view was that encouraging rapid patient discharge was a disservice to their patients. The traditional care approach that was supported by nurses for breast cancer patients had been one of encouraging them to ‘take it slow and easy’, with the provision of psychological support. We really had to argue the role of the ERAS pathway, as it was a major change in nursing care practice. While psychological support is still a key component of the ERAS pathway, it is not all-encompassing. Solving somatic problems – such as nausea, vomiting and ileus – is another important component that should be combined with appropriate psychological support to encourage early activity and patient mobilisation. Implementation of ERAS pathways has been a problem in many places around the world, although it has now been well documented thatpatients who follow the pathway have fewer somatic problems, which helps their psychological wellbeing. Patients who follow the pathways experience significant improvements. Minor problems with nausea, vomiting and pain are reduced and, most importantly, patient satisfaction is high.

How do you think compliance with the pathway can be encouraged?
Every surgical department should have a database recording their outcomes, so that they are kept abreast of their own data. They can then compare these data with those of other surgical departments that have been published. Despite this sounding fairly simple, many departments lack such databases.

From an implementation perspective, introduction of an ERAS pathway needs to be led by one, or a few, medical professionals, in order to encourage collaboration between all healthcare professionals involved. However, this is difficult to achieve and an alternative approach
is for government authorities to take on this role. It has been demonstrated in the UK that government involvement helps in the initiation of ERAS pathways [9] Governments can analyse data and identify a problem by referencing the available literature. If the length of hospitalisation for hip and knee arthroplasty is 9 days in one hospital, but only 2 days in many other institutions, then there is clearly a problem.

The ERAS Study Groups are doing an excellent job and are holding annual meetings to educate others on the concept of ERAS pathways and provide an update on outcome results. As already mentioned, the World Congress of Enhanced Recovery After Surgery and Perioperative Medicine has now been established, with a major focus on the US, and the first Chinese ERAS Congress was held in July 2015. Congresses are an excellent method of encouraging compliance and promoting use of the ERAS pathways. A few months ago we had the first Middle East ERAS Congress, which was a major success and had a high level of interest. It is a surprise that it has taken so many years for ERAS pathways to gain popularity, but I am very pleased that they are doing so.

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