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


Implementation of ERAS pathways can be challenging, but ultimately rewarding, as patients have fewer complications, spend less time in hospitals, and surgeries may be moved from inpatient arenas to outpatient surgical centers.[19,20] In the US, initial approaches to optimizing perioperative care began with the perioperative surgical home.[21] These preliminary forays into collaborative, team-based approaches to surgical care led to the modern ERAS pathway.

Given that ERAS pathways, particularly in gynecology, are effective at decreasing complications, shortening hospital stays, and cutting costs, successful implementation in the current healthcare environment is of utmost importance.[22] However, pathways are only impactful if providers are compliant with them.[7] Modifying behaviors of a large group of clinicians is challenging and requires a multifaceted, sustained approach with repeated communication and follow-up.

Our team was successful because we followed a deliberate implementation framework. In the 3 months prior to the pathway launch, small-format meetings between the ERAS co-directors and the OB/GYN nursing director, the PACU staff, the post-operative floor nursing managers, and the OR nursing staff occurred. These small-format meetings created space for clinicians to become familiar with and enrolled in the new pathway.

Following the small-format meetings, but prior to the pathway launch, both the surgical and anesthesia bundles were emailed to surgeons and anesthesiologists. The entire pathway was then presented at surgical grand rounds and anesthesiology grand rounds. These large-format meetings allowed a rigorous academic discussion of the evidence behind the pathway and reinforced data that had previously been presented in both small-group discussions and email.

After the pathway was implemented, nightly emails to anesthesia providers who would care for ERAS hysterectomy patients reminded clinicians of the different elements of the pathway. This tactic continued for 14 months following implementation and further reinforced adherence to the pathway.

Finally, by providing anesthesiologists and nurse anesthetists with annual reports detailing individual compliance with different elements of the anesthesia bundle, providers were able to review their performance and compare their individual performance to their peers.

Perhaps the most controversial portion of our pathway centered on the fluid management goal of administering less than 4 mL/kg/hr. Many of the anesthesia clinicians at our institution expressed strong opinions about the quantity and timing of fluids administered, and achieving consensus on this element of the pathway was particularly difficult. However, despite the controversy surround the metric, compliance with fluid administration goals demonstrably increased over time.

There are several limitations of our study worth comment. First, as a retrospective analysis of a quality improvement project, the study is subject to selection bias and confounding bias. Our institution was in the process of developing and implementing multiple other ERAS pathways during our intervention and post-intervention periods. While we demonstrate a significantly increased compliance with our pathway using the CFIR framework, it is possible that this significance was impacted by other endeavors simultaneously occurring at the hospital.

A second limitation of our study is that the metrics related to intraoperative opiate administration were: 1) a "decrease in long-acting narcotic administration" and 2) a "decrease in short-acting narcotic administration." This guidance allowed clinicians to use their best judgment when caring for their patients. However, it did not identify a target quantity of narcotic to administer and could have led to confusion.

A third limitation to our study is that our post-intervention period is 10 months. As anesthesia residency is 3 years, it is possible that we will not capture post-intervention activities in their entirety.

Finally, while our intention had been to ultimately post the ERAS Hysterectomy pathway on a departmental intranet, technical constraints prevented this from happening. Providers relied on their familiarity with the pathway or on previously sent emails that contained the pathway to guide their care. This oversight likely decreased compliance in the post-intervention period.