Implementing ERAS: how we achieved success within an anesthesia department

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Abstract

Background

The Massachusetts General Hospital is a large, quaternary care institution with 58 operating rooms, 164 anesthesiologists, 76 certified nurse anesthetists (CRNAs), an anesthesiology residency program that admits 25 residents annually, and 35 surgeons who perform laparoscopic, vaginal, and open hysterectomies. In March of 2018, our institution launched an Enhanced Recovery After Surgery (ERAS) pathway for patients undergoing hysterectomy. To implement the anesthesia bundle of this pathway, an intensive 14-month educational endeavor was created and put into effect. There were no subsequent additional educational interventions.

Methods

We retrospectively reviewed records of 2570 patients who underwent hysterectomy between October 2016 and March 2020 to determine adherence to the anesthesia bundle of the ERAS Hysterectomy pathway. RESULTS: Increased adherence to the four elements of the anesthesia bundle ( p < 0.001) was achieved during the intervention period. Compliance with the pathway was sustained in the post-intervention period despite no additional actions.

Conclusions

Implementing the anesthesia bundle of an ERAS pathway in a large anesthesia group with diverse providers successfully occurred using implementation science-based approach of intense interventions, and these results were maintained after the intervention ceased.

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Most cited references 20

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Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

Laura Damschroder, David Aron, Rosalind E Keith … (2009)

Background Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts. Methods We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts. Results The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct. Conclusion The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.

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Evidence-based surgical care and the evolution of fast-track surgery.

Henrik Kehlet, Douglas Wilmore (2008)

Optimization of postoperative outcome requires the application of evidence-based principles of care carefully integrated into a multimodal rehabilitation program. To assess, synthesize, and discuss implementation of "fast-track" recovery programs. Medline MBASE (January 1966-May 2007) and the Cochrane library (January 1966-May 2007) were searched using the following keywords: fast-track, enhanced recovery, accelerated rehabilitation, and multimodal and perioperative care. In addition, the synthesis on the many specific interventions and organizational and implementation issues were based on data published within the past 5 years from major anesthesiological and surgical journals, using systematic reviews where appropriate instead of multiple references of original work. Based on an increasing amount of multinational, multicenter cohort studies, randomized studies, and meta-analyses, the concept of the "fast-track methodology" has uniformly provided a major enhancement in recovery leading to decreased hospital stay and with an apparent reduction in medical morbidity but unaltered "surgery-specific" morbidity in a variety of procedures. However, despite being based on a combination of evidence-based unimodal principles of care, recent surveys have demonstrated slow adaptation and implementation of the fast-track methodology. Multimodal evidence-based care within the fast-track methodology significantly enhances postoperative recovery and reduces morbidity, and should therefore be more widely adopted. Further improvement is expected by future integration of minimal invasive surgery, pharmacological stress-reduction, and effective multimodal, nonopioid analgesia.

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Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials.

Marco Braga, Giovanni Capretti, Luigi Beretta … (2014)

Meta-analyses in the literature show that enhanced recovery after surgery (ERAS) is associated with lower morbidity rate and shorter hospital stay after elective colorectal surgery. However, a recent Cochrane review did not indicate the ERAS pathway as being the new standard of care due to the limited number of published trials, together with their poor quality. We conducted a meta-analysis of randomized controlled trials (RCTs) to assess the impact of the ERAS pathway on overall morbidity, single postoperative complications, length of hospital stay, and readmission rate following colorectal surgery. We searched BioMedCentral, PubMed, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) for RCTs comparing the ERAS pathway to conventional perioperative care. No language restrictions were considered. A quality score was calculated for each trial included. A total of 2,376 patients in 16 RCTs were included in the analysis. The ERAS pathway was associated with a reduction of overall morbidity [relative ratio (RR) = 0.60, (95 % CI 0.46-0.76)], particularly with respect to nonsurgical complications [RR = 0.40, (95 % CI 0.27-0.61)]. The reduction of surgical complications was not significant [RR = 0.76, (95 % CI 0.54-1.08)]. The ERAS pathway shortened hospital stay (WMD = -2.28 days [95 % CI -3.09 to -1.47]), without increasing readmission rate. The ERAS pathway reduced overall morbidity rates and shortened the length of hospital stay, without increasing readmission rates. A significant reduction in nonsurgical complications was evident, while no significant reduction was found for surgical complications.

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Author and article information

Contributors

Dan B. Ellis: dbellis@mgh.harvard.edu

Aalok Agarwala: aalok_agarwala@meei.harvard.edu

Elena Cavallo: ecavallo@partners.org

Pam Linov: plinov@partners.org

Michael K. Hidrue: mhidrue@partners.org

Marcela G. del Carmen: MDELCARMEN@mgh.harvard.edu

Rachel Sisodia: rsisodia@mgh.harvard.edu

Journal

Journal ID (nlm-ta): BMC Anesthesiol

Journal ID (iso-abbrev): BMC Anesthesiol

Title: BMC Anesthesiology

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2253

Publication date (Electronic): 5 February 2021

Publication date PMC-release: 5 February 2021

Publication date Collection: 2021

Volume: 21

Electronic Location Identifier: 36

Affiliations

[1 ]GRID grid.32224.35, ISNI 0000 0004 0386 9924, Department of Anesthesia, Critical Care, and Pain Medicine, , Massachusetts General Hospital, ; 55 Fruit Street, Boston, MA 02114 USA

[2 ]GRID grid.39479.30, ISNI 0000 0000 8800 3003, Department of Anesthesia, , Massachusetts Eye and Ear Infirmary, ; Boston, USA

[3 ]GRID grid.32224.35, ISNI 0000 0004 0386 9924, Department of Anesthesia, Critical Care, and Pain Medicine, , Massachusetts General Hospital, ; 55 Fruit Street, Boston, MA 02114 USA

[4 ]GRID grid.32224.35, ISNI 0000 0004 0386 9924, Massachusetts General Physicians Organization, , Massachusetts General Hospital, ; 55 Fruit Street, Boston, Massachusetts 02114 USA

[5 ]GRID grid.32224.35, ISNI 0000 0004 0386 9924, Department of Gynecology Oncology, , Massachusetts General Hospital, ; 55 Fruit Street, Boston, MA 02114 USA

Article

Publisher ID: 1260

DOI: 10.1186/s12871-021-01260-6

PMC ID: 7863438

PubMed ID: 33546602

SO-VID: 516cc192-e0c8-4185-83c5-4852d211177a

License:

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