Enhanced Recovery After Surgery Implementation: From Planning to Success

Introduction

Clinical benefits from Enhanced Recovery After Surgery (ERAS^®) pathways are now clearly established in various surgical specialties.^1,2 However, ERAS application and implementation remains variable across the world.^3–6 A potential explanation could be the difficulties in setting up and running such enhanced recovery pathway. This article aims to review the key elements for a successful implementation, from the initial set up and business planning to the expectations and challenges expected during this process.

How to Bring ERAS to Clinical Practice

The application of evidence-based medicine into clinical practice, like the elements of an enhanced recovery program, is a real challenge. Simply elaborating and establishing a protocol is not enough ⁷ and much more efforts and changes are needed. The changes should result in improved patient outcomes and should encompass the entire perioperative process of the patient, from the initial consultation through surgery until postoperative recovery. The aim is to offer a sustainable improvement in the overall quality of patient care.

First, a multidisciplinary team must be gathered under the initiative of a dedicated local project leader or “champion.” Each team, consisting of 4–8 persons, should include at least a nurse, an anesthetist, an administrator, and a surgeon. A dedicated and specifically trained ERAS nurse must be designed and should have at least 50% of working time dedicated to this task. The team should then undergo training to implement an enhanced recovery pathway in their own unit or hospital. The ERAS society promotes the implementation process with the ERAS Implementation Program (EIP).

ERAS Implementation process is a systematic training program which assists the team in starting ERAS protocol(s) with high compliance. The training is provided by ERAS academic experts, who are all members of labeled ERAS Centers of Excellence.

The EIP is conducted over an 8- to 10-month structured period (Fig. 1) during four specific workshops. Between the workshops, expert and trainees define “action periods” and each team has some specific « homeworks » and tasks to accomplish. The change management method used is the so-called “Breakthrough method” developed by the Institute for Healthcare Improvement in Boston. ⁸ This well-known and established method is used worldwide in quality improvement projects. Following the definition of measurable goals, actions and plans are put into practice, then observation and measurement are taken, and finally adequate adjustments are made. This system of repeatedly implementing, testing, and adjusting is called the “Plan-Do-Study-Act.” This process is run over and over during the implementation period and even further during the maintenance period.

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FIG. 1.

Overview of the ERAS^® Implementation Program (EIP). Four interactive workshops with active working periods in between are run over an 8–10 months period. (Courtesy of the ERAS Society). EIP, ERAS Implementation Program; ERAS, Enhanced Recovery After Surgery.

With this stepwise approach, and under continuous supervision and support of ERAS experts, a high rate of successful implementation is reached. The ERAS Interactive Audit System, an online interactive software, is used as a specific quality control tool to monitor the compliance and the changes achieved during and following the implementation process. The first experience of broad ERAS implementation program was described in the Netherlands where ERAS was implemented in more than 35 hospitals with a reduction in length of stay (LOS) from 9 to 6 days following colonic resection. ⁹ Long-term follow-up studies acknowledged the sustainability of such improvements. ¹⁰ Implementation programs are now running in several countries worldwide, such as Norway, Portugal, Switzerland, France, Germany, Spain, the Netherlands, the United Kingdom, Sweden, Canada, the United States, Mexico, Brazil, Colombia, Argentina, Singapore, the Philippines, New Zealand, Israel, Uruguay, Chile, and South Africa.

Financial Considerations

While healthcare systems vary widely across the globe, one common factor has been the steady rise in healthcare expenses as a portion of Gross Domestic Product.^11,12 In addition to improvements in quality, this has made cost reduction a critical challenge in most settings. A comprehensive stepwise implementation of ERAS as described above requires significant investments of both financial and human capital. To obtain and sustain institutional support for these efforts, careful attention to their financial impact is warranted.

The key to financially sustaining an ERAS implementation lies in understanding the return on investment (ROI). Demonstrating a grossly positive projected ROI in addition to clinical improvements is critical to engaging organizational leadership. The formula for ROI, (gains − costs)/costs, should guide clinical champions in planning their implementation. Financial gains from ERAS can be both direct and indirect, and there is a growing body of evidence that shows they can be significant.^13–16

Direct savings can be found in decreased resource utilization which, in many instances, is predominantly a result of decreased LOS. Reductions of 2 or more days have been well described. ¹⁷ By multiplying projected LOS reductions by annual case volume, annual inpatient bed-days saved can be approximated; total annual savings can be projected with the help of finance professionals within the implementing institution or appropriate national estimates of inpatient bed-day costs.

Somewhat unique to fee-for-service systems, additional financial gains can be found indirectly in enhancements in revenue allowed by additional capacity and improvements in common pay-for-performance programs. Costs are equally important to project and track; additional training and travel associated with implementation should be carefully accounted for. Dedicated “champion” time should be protected to avoid a loss of focus or deprioritization among shorter-term clinical tasks. Additional clinical supplies should also be accounted for, such as preoperative carbohydrate drinks and intra-op fluid monitoring equipment. Finally, software systems as described above to allow for auditing and feedback are critical to fund.

A chief benefit of ERAS is the intentional collapse of clinical silos through interdisciplinary collaboration. Similarly, budgetary silos can play a key role in obstructing ERAS implementations. In constructing a projected ROI, ERAS champions should be aware that costs and gains often accrue to different parties, often with separate budgets. For example, a clinical department may be reluctant to fund an ERAS nurse if it sees little financial benefit from ensuing LOS reductions. Engaging senior leadership with not only a positive ROI but also a clear sense of where costs and gains accrue can counteract department-level budgetary resistance.

Expectations and Challenges

The principal expectation resulting from ERAS implementation should be reductions in complication rate and enhanced functional recovery. In a survey among Swiss and Swedish experts who implemented ERAS, motivations for ERAS implementation were reduced complications (91%), patient satisfaction (73%), and shorter hospital stay (62%). Then, in descending order, the participants suggested patient quality of life (32%), reducing costs (26%), reducing workload (9%), and for publicity and marketing (6%) (submitted data).

Implementation of an enhanced recovery protocol implies major changes among many professionals involved in the patient care. Making these changes effective and sustained represent the key challenges with a lot of common efforts. For a successful ERAS implementation, it is important to know in advance the potential barriers and then the possible enablers to overcome.

The identified barriers to implementation can be related to the patient, staff, practice, and resources. ¹⁸ Regarding the factors related to the patients, the associated comorbidities or increasing age could be perceived as possible difficulty for enhanced recovery. In fact, it is the opposite and several studies showed that enhanced recovery can safely be applied to all patients, inclusive of elderly.^19,20 Therefore, it is not recommended to perform any patient selection as all can benefit from ERAS program. Another issue could be the patient's perception and personality, which can be overcome by adequate information and education with adequately well written and multimedia documentation. The resistance to change by the working staff is a main barrier and requires again a lot of information with time and investment to get through. Clear and open communication before implementation to all persons involved in the patient perioperative care is essential. ²¹ All the processes need leadership from the main stakeholders, also called the local “champion”. ²² Concerning daily clinical practice, standardized guidelines adapted to local preferences should be available based on the published ERAS guidelines (Fig. 2). The implementation of an ERAS protocol requires not only investment in time but also in resources. The lack of manpower or dedicated time is a main preoccupation. Despite fear of increasing workload with ERAS implementation, recent data showed the opposite with a reduction of nursing workload within ERAS protocol. ²³ The full support from the administration should be solicited and is usually obtained as ERAS is a quality improvement process with the above-mentioned financial benefits.

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FIG. 2.

Mechanism of successful ERAS^® implementation. To apply ERAS into clinical practice, an institutional protocol should be established based on evidence-based and published guidelines. The protocol is further translated into daily practice through a clinical pathway adapted to the institutional requirements.

Conclusion

The implementation of evidence-based protocols such as enhanced recovery into clinical practice represents a major challenge. A multidisciplinary work, as well as a structured implementation program, such as EIP, is required to successfully implement enhanced recovery. In addition, close attention to financial aspects of implementation, including projecting ROI, is necessary in today's cost-conscious healthcare environment. Despite frequently encountered barriers and resistance to change, the common objective of reducing complications should overcome these barriers, so that every patient benefits from the most appropriate perioperative care.