Development of an Enhanced Recovery After Surgery Guideline and Implementation Strategy Based on the Knowledge-to-Action Cycle

Robin S. McLeod, MD; Mary-Anne Aarts, MD; Frances Chung, MD; Cagla Eskicioglu, MD; Shawn S. Forbes, MD; Lesley Gotlib Conn, PhD; Stuart McCluskey, MD; Marg McKenzie, RN; Beverly Morningstar, MD; Ashley Nadler, MD; Allan Okrainec, MD; Emily A. Pearsall, MSc; Jason Sawyer, RN; Naveed Siddique, MD; Trevor Wood, MD


Annals of Surgery. 2015;262(6):1016-1025. 

In This Article

Abstract and Introduction


Background: Enhanced Recovery After Surgery (ERAS) protocols have been shown to increase recovery, decrease complications, and reduce length of stay. However, they are difficult to implement.

Objective: To develop and implement an ERAS clinical practice guideline (CPG) at multiple hospitals.

Methods: A tailored strategy based on the Knowledge-to-action (KTA) cycle was used to develop and implement an ERAS CPG at 15 academic hospitals in Canada. This included an initial audit to identify gaps and interviews to assess barriers and enablers to implementation. Implementation included development of an ERAS guideline by a multidisciplinary group, communities of practice led by multidiscipline champions (surgeons, anesthesiologists, and nurses) both provincially and locally, educational tools, and clinical pathways as well as audit and feedback.

Results: The initial audit revealed there was greater than 75% compliance in only 2 of 18 CPG recommendations. Main themes identified by stakeholders were that the CPG must be based on best evidence, there must be increased communication and collaboration among perioperative team members, and patient education is essential. ERAS and Pain Management CPGs were developed by a multidisciplinary team and have been adopted at all hospitals. Preliminary data from more than 1000 patients show that the uptake of recommended interventions varies but despite this, mean length of stay has decreased with low readmission rates and adverse events.

Conclusions: On the basis of short-term findings, our results suggest that a tailored implementation strategy based on the KTA cycle can be used to successfully implement an ERAS program at multiple sites.


Enhanced Recovery After Surgery (ERAS) pathways have been shown to decrease the amount of stress and gut dysfunction in individuals undergoing elective colorectal surgery, which leads to enhanced recovery and decreased morbidity and length of stay.[1,2] Numerous reports have documented the effectiveness of ERAS guidelines.[1,2] However, the published trials and guidelines often differ in the components included within the ERAS guidelines and the evidence supporting each intervention. Furthermore, in some cases, the components included in the guidelines may be contradictory (eg, inclusion or exclusion of mechanical bowel preparation).[3–7] There is also increasing evidence that ERAS guidelines are difficult to adopt, largely because they require a commitment from all members of the perioperative team.[8–12] The most often sited barriers to adoption are related to time and personnel restrictions required to develop the protocol, limited hospital resources (financial, staffing, space restrictions, and education), active or passive resistance from members of the perioperative team, lack of data and/or education, social and cultural settings, and the organizational environment.[8–12] Because of the relatively high number of interventions that must be adopted simultaneously by a multidisciplinary team, ERAS guidelines require a tailored implementation strategy to increase adherence.

Best Practice in General Surgery (BPIGS) is a University of Toronto quality initiative led by general surgeons. The goal of BPIGS is to optimize patient care at the adult teaching hospitals affiliated with the University of Toronto by developing and implementing guidelines based on best evidence on topics pertinent to general surgery. In 2008, the BPIGS group undertook the development and implementation of a University of Toronto ERAS guideline using the Knowledge-to-action (KTA) framework described by Graham et al.[13]

The KTA process is an iterative process that involves both the creation and application of knowledge (Fig. 1). The creation and synthesis of knowledge in the KTA cycle often occurs simultaneously with the implementation or application of the knowledge. The process of knowledge creation includes locating the knowledge, synthesizing it, and creating knowledge tools or products (eg, guidelines). The action cycle involves multiple stages that may occur sequentially or simultaneously and may also overlap with different stages of the knowledge creation process. These include (1) identification of the problem, (2) adaptation of knowledge to local context, (3) assessment of barriers and enablers to knowledge use, (4) selection, tailoring, and implementation of interventions, (5) monitoring knowledge use, (6) evaluating outcomes, and (7) sustaining knowledge use. The phases in both knowledge creation and the action cycle are dynamic and therefore can influence or be influenced by other phases within or between each of these elements at any time.[13,14]

Figure 1.

Knowledge-to-action cycle.

This report describes the development of an ERAS guideline and an implementation strategy using this multidimensional process consisting of several distinct, yet interconnected phases. The first 4 stages of problem identification, knowledge adaptation, barrier assessment, and intervention implementation are outlined here. It does not include the last 3 phases of monitoring knowledge use, evaluating outcomes, and sustaining knowledge use.