What are the impediments to the implementation of enhanced recovery after surgery (ERAS) programs for emergency GI surgical procedures?

Updated: Jan 20, 2021
  • Author: Vikram Kate, FRCS, MS, MBBS, PhD, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS, FFST(Ed); Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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ERAS is a multilayered approach that requires strict adherence to the protocol on the part of a multidisciplinary team, as well as good patient compliance. Although there is enough evidence to prove the superiority of ERAS as compared with conventional methods, implementation of ERAS protocols in day-to-day practice faces several barriers and limitations. These barriers may involve the nature of the intervention, the particular institutional setup, various external factors, individual characteristics, and specific implementations. [42]

Because an ERAS protocol is a multistep process that requires multidisciplinary involvement, its implementation becomes a challenge in emergency situations. A good institutional setup that affords access to the necessary resources (eg, availability of MAS in an emergency, a good multidisciplinary team familiar with ERAS components applicable in emergency settings [with a good team leader to coordinate efforts], and a procedure-specific ERAS design) is required for breaking the barriers to implementing emergency ERAS. [43]

Although full functional recovery is the agreed-upon goal, perceptions about what this means may differ. A healthcare worker's determination of the point of full functional recovery might well be different from that of the patient (eg, a sportsperson who considers full recovery the point at which a former routine sports activity can be resumed), and this potential difference is not addressed by the ERAS protocol. In such a situation, an individualized list of do’s and don’t's at the time of discharge might help minimize subsequent visits of the patient to the hospital.

Prehabilitation—that is, functional optimization before surgery in conjunction with rehabilitation (eg, physiotherapy) after surgery—improves patient outcomes but is subject to institutional cost constraints, leading to patient-reported ineffective outcomes. Preimplementation is a major task that must be accomplished through data collection, analysis of previously published papers, and design of a protocol that is suited to the particular institutional setup. The progression of knowledge on the basis of previous work is vital for updating and educating administrators, residents, staff members, patients, and family members toward the goal of successful implementation of ERAS in emergency settings.

Frontline warriors in this effort include administrators, department heads, surgeons, anesthetists, nurses, residents, postanesthesia care unit (PACU) staff, surgical care unit staff, physiotherapists, and nutritionists, all of whom need to be well informed about the guidelines, along with evidence that could improve the adherence rate. In some institutions, a "local hero" (eg, an influential surgeon, anesthetist, or nurse) can be trained to propagate ERAS principles among the other healthcare workers. [44] Following a multidisciplinary approach with good communication among the healthcare workers can also lead to better implementation.

Another way of improving the success rate is to make use of so-called communities of practice in order to bring together like-minded people wanting to gain knowledge in the field of ERAS. [45] A 2009 review assessed the outcomes of educational meetings in implementation of professional practices and found a 6% increase in the compliance rate. [46] Such meetings also serve the purpose of updating healthcare workers on recent changes and updated protocols.

Providing institutionally designed patient education material preoperatively is helpful in preparing the patient for early recovery in the immediate postoperative period. A systematic review of 11 studies reported that patients who received information preoperatively were well prepared for their surgical procedure and their postoperative recovery. [47] These patients also were active participants in their own recovery.

As stated previously, maintaining a weekly or monthly or annual surgical audit and obtaining useful feedback are of paramount importance for evaluating the pitfalls of any protocol. These practices are also useful for identifying and assessing the various barriers to the implementation of an ERAS protocol, as well as helpful in designing a method for overcoming these barriers.

Undoubtedly, there remain major hindrances to the implementation of ERAS in emergency abdominal surgery, where time is critical and saving lives is more important than following any new protocol. Nevertheless, such implementation is achievable with a set of adapted and updated ERAS components.

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