Implementing ERAS: How We Achieved Success Within an Anesthesia Department

Dan B. Ellis; Aalok Agarwala; Elena Cavallo; Pam Linov; Michael K. Hidrue; Marcela G. del Carmen; Rachel Sisodia


BMC Anesthesiol. 2021;21(36) 

In This Article


Enhanced Recovery After Surgery (ERAS) is one of the most significant innovations in perioperative care.[1] As hospitals streamline care and move increasingly more complex surgeries to outpatient surgical centers, efficiently and safely moving patients through the perioperative environment is of utmost importance.[2–6] Increased adherence to ERAS pathways has repeatedly shown decreased complications and reduced overall perioperative costs.[5,7–10]

Implementing and maintaining strict adherence to ERAS pathways is challenging, and compliance values of approximately 70% are common.[11] Additionally, as greater numbers of providers become involved in ERAS care, achieving high compliance rates with ERAS pathways becomes more complex. This challenge is pronounced in large anesthesia practices, and in academic centers with varying patient acuities and staff of different levels. The national trend of large anesthesia groups covering multiple anesthetizing locations with diverse provider groups also adds to this complexity. To date, the literature describes multidisciplinary approaches to implementing ERAS bundles. However, a step-by-step approach to implementing and maintaining compliance with anesthesia bundles in large anesthesia practices has not been thoroughly described.[12–15]

As part of a quality improvement project, in March of 2018, an Enhanced Recovery After Surgery pathway for laparoscopic, vaginal, and open hysterectomy patients called "ERAS Hysterectomy" was implemented at the Massachusetts General Hospital. This pathway was designed by surgeons and anesthesiologists and utilized the Consolidated Framework For Implementation Research (CFIR) framework to implement evidence-based clinical care.[16,17] The surgical, anesthesia, and nursing champions selected the Consolidated Framework for Implementation Research structure over other approaches as it created a format to design, evaluate, and implement evidence-based practices. In the 2 years following implementation, 35 surgeons, 164 anesthesiologists, 76 certified registered nurse anesthetists (CRNAs), and 130 anesthesia residents participated in caring for patients in the pathway.