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REPORT

Enhanced Recovery After Surgery

Surgical Services Taskforce and Anaesthesia Perioperative Care Network

Specialty Specific Example – Colorectal

The following outlines in more detail the components of a colorectal ERAS pathway.

What are the main components of the ERAS Pathway?

Preoperative

  • Education relevant to the specific pathway elements provided by allied health, nursing and medical staff
  • Information is provided in a manner that supports health literacy needs and builds trust
  • Prehabilitation – an opportunity to optimise the patient’s condition prior to surgery
  • Set patient expectations
  • Specialised carbohydrate drinks
  • No / minimal bowel preparation
  • Smoking and alcohol cessation

Intraoperative

  • Pneumatic calf compression
  • Subcutaneous medical thromboprophylaxis
  • Laparoscopic surgery (where possible)
  • Regional blocks and/or local anaesthesia
  • Avoidance of nasogastric tube insertion
  • Minimise drain insertion
  • Multimodal analgesia
  • Avoid excessive amounts of intravenous fluid administration
  • Maintain normothermia
  • Prescribed antiemetics
  • Minimise IV fluid

Postoperative

  • Urinary catheter to be removed on day one
  • Mobilise on day one
  • Commence diet on day one
  • If used, drains to be removed early e.g. on day one
  • Anti-nausea management
  • Patient Controlled Analgesia – transition on day one to oral analgesics
  • Patients invested and motivated to meet set goals to expedite discharge
  • Patients complete a diary to document their diet and how mobile they have been.
  • If appropriate, Criteria Led Discharge may be used to standardise discharge arrangements for ERAS patients.
  • Follow-up phone call post discharge

What are the benefits of using ERASfor the patient and the facility?

  • Lower rates of complication
  • Patients are more actively involved in their care from a holistic approach
  • Patients and their relatives are empowered to become engaged by the process
  • Qualitative data demonstrates that patients appreciate the personalised care and frequent interaction with the ERAS coordinator
  • Reduced readmission rates
  • Decreased length of stay
  • Reduces number of patients on waiting list
  • Increased staff confidence with regard to clinical management
  • Junior doctors have clinical guidelines to simplify postoperative patient care.

What are the challenges to implementation?

In their interviews, clinicians from the three hospitals highlighted some considerations for sites looking to implement an ERAS program.

Achieving consensus amongst key stakeholders such as surgeons, anaesthetists, ICU staff and allied health is challenging but is not a barrier to the introduction of ERAS programs. For example, where they existed, consensus issues on fasting times and bowel preparation were resolved differently at each site.

Introducing a new model of care has the potential to impact on resourcing. For the sites involved, the introduction of the ERAS program had a flow on effect to the physiotherapy service in order to support patients in the pre and post-operative phases. Similarly, the need for additional capacity within the preadmission clinic was also identified.

Ideally, patients participating in the ERAS program should go to postoperative wards where the clinical staff are educated on ERAS principles and local processes. This may require a dedicated ward depending on volume and may involve a change in bed management processes.

It is acknowledged that new graduates, staffing turnover and junior medical officer changeover may impact upon the implementation of ERAS. Therefore, ongoing education of new medical, nursing and allied health staff is required. This is because they may not have been exposed to ERAS before and require education and guidance on local processes. For example, it was identified that junior staff may not follow the pathway unless the next step is clearly documented in the patient notes.

The three sites interviewed had established an ERAS coordinator position in order to implement the program. As this was a newly established role, it had funding implications. However, it was emphasised by all three sites that the reduced length of hospital stay and complication rates have led to overall net financial savings.

What are the enablers of implementation?

Clinical leadership is an essential requirement for implementing a new model of care.

Implementation should be guided by an agreed project plan which is appropriately resourced. Local steering committees and working groups should be established to support the ERAS coordinator/project lead in developing and implementing an ERAS program.

It is essential to identify all relevant stakeholders who may be impacted by the introduction of an ERAS pathway. This includes clinical and non-clinical staff and will require executive leadership. Developing and agreeing on clinical pathways will assist with clinical consensus regarding the management of ERAS patients.

It is important that steps are taken to ensure that Enhanced Recovery After Surgery is delivered in a culturally safe and competent way to allow for Aboriginal and diverse minority groups.

To achieve optimal health outcomes for Aboriginal people it is recommended that implementation of the model include the establishment of clear opportunities for identification of Aboriginality.

Linkages with and referral processes are established with appropriate health and support agencies, with a particular focus on the unique role of local Aboriginal Medical Services.

The ACI provides a number of implementation support tools to assist with project implementation.