Beyond enhanced recovery after surgery
An expert explains the key elements required to develop an effective ERAS program and strategies to facilitate change in the face of resistance
Collateral improvements to practice
Clinical optimization using evidence-based practices such as enhanced recovery pathways can result in immediate patient benefit. Affecting such profound clinical improvements is energizing and creates a unique opportunity to transform the culture of the entire health care team. Irrespective of our provider roles (surgeon, anesthesiologist, nurse) or areas of interest (practice, research, education, leadership), we are united by a common purpose: to improve the human condition.13 Reaffirming this common purpose, through the collective effort involved in establishing a standardized enhanced recovery pathway, has allowed our practice and those of others to move beyond enhanced recovery and improve other areas of practice.
Other positive effects. The long-term collateral impact of this culture change at our institution is arguably more important than enhanced recovery itself. Examples of downstream impact include14,15:
- 80% reduction in surgical site infection
- 50% reduction in anastomotic leaks
- 60% reduction in blood utilization for patients undergoing surgery for ovarian cancer.
Team-based pragmatic strategies. Additionally, our willingness to make decisions as a division rather than as individuals facilitated universal implementation of sentinel lymph node biopsy for patients with endometrial cancer and standardized imaging, testing, and surgical decision making for patients with ovarian and endometrial cancer.
,The interventions associated with these improvements were not tested in a randomized fashion; however, rather than await perfect data, we made informed decisions based on imperfect data together with a commitment to continuous data review. We find this to be an effective strategy if our goal is to ensure that tomorrow’s outcomes will be better than yesterday’s. In this way, pragmatic trials can be extremely effective in rural settings and tertiary centers.
Barriers to innovation
The widely reported benefits of enhanced recovery beg the question, Why has enhanced recovery not been adopted universally as standard of care? The answer is multifaceted and highlights long-standing shortcomings in our health care system.
Most importantly, our health care system lacks a robust interface to link discovery of new techniques, treatments, and workflows to clinical practice. Perhaps the best example of this is the adoption of minimally invasive surgery (MIS) for endometrial cancer. Ten years have passed since randomized trials showed MIS has equivalent oncologic outcomes and superior recovery compared to laparotomy, yet in the United States less than 50% of women with endometrial cancer benefit.16,17
However, even surgeons who are knowledgeable about recent innovations and genuinely wish to promote improvements may face near-insurmountable skepticism. Blind faith in our abilities and outcomes, overprotection of autonomy, close-mindedness, and satisfaction with the status quo are common responses to innovation and are the enemies of change. Resistance often comes from good intentions, but our desire to avoid complications may result in actions that could just as accurately be labeled superstitious as conservative. These observations suggest that developing methods to incorporate evidence-based practice into routine clinical use is the rate-limiting step in improving surgical quality.
The national Improving Surgical Care and Recovery program is available to specifically aid with ERAS implementation. A collaboration between the Agency for Healthcare Research and Quality (AHRQ) and the American College of Surgeons, the program aims to diffuse enhanced recovery to 750 service lines in 4 surgical subspecialties, including gynecologic surgery, over the next 5 years. (Note: The author is the content expert for the gynecology portion of this program.) The program’s larger aim is to measurably improve patient outcomes, reduce health care utilization, and improve patient experience through the use of an adaptation to AHRQ’s Comprehensive Unit-based Safety Program (CUSP). The backbone for this program is the recent systematic review to establish best practices for gynecologic surgery.1 Free to all participants, the program includes resources such as webinars and coaching calls to assist with the inevitable barriers to ERAS implementation. For more information and to enroll, visit https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/enhanced-recovery /index.html. An important aspect of the program is a registry for tracking outcomes and identifying areas for improvement. For members who currently participate in the National Surgical Quality Improvement Program, clinical data are automatically uploaded into the database. Programs such as Improving Surgical Care and Recovery may be the most reliable way to facilitate diffusion of best practices and take collective responsibility for not only “my outcomes” but also for “our outcomes” as a national community of gynecologic surgeons.
Reference
1. Kalogera E, Nelson G, Liu J, et al. Surgical technical evidence review for gynecologic surgery conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Am J Obstet Gynecol. 2018;219:563.e1-563.e19.
Principles essential to change
Various methodologies have been described to manage change and facilitate implementation of new workflows and practices. Irrespective of the method used, including the more formal discipline of implementation science, at least 4 principles must be followed:
1. Teamwork. Mutual trust, mutual respect, and a sense of common purpose are minimum requirements for any successful initiative. Standardization is difficult or impossible without these elements. Thus, establishing a healthy team is the first step in implementing change.
2. Stakeholder analysis. Feedback from surgeons, nurses, residents, fellows, anesthesiologists, pharmacists, nurse anesthetists, and administrators is necessary to obtain diverse perspectives, facilitate engagement, and promote collaborative management. Negativity and resistance are common reactions to change, and it is particularly important to include those who are most skeptical in the stakeholder analysis to mitigate sabotage.
3. Concrete metrics. Success is possible only if defined a priori by specific and achievable goals. Counterbalances also are important to ensure that interventions do not have unintended consequences. Once a goal is met (for example, reduced hospital length of stay or costs), relevant metrics should be monitored after project completion for a minimum of 3 years to avoid regression to the pre-project state.
4. Leadership. The project champion responsible for the initiative must objectively facilitate all of the above and ensure excellent communication between stakeholders to nurture long-term engagement. Despite best efforts, if a minority of the group rejects compromise, this creates an opportunity to compare outcomes between those who do and do not accept the proposed change. Progress realized by early adopters may convince resistors to conform at a later time. Alternatively, the project champion also must have the insight to recognize when a proposed change is impossible at that point in time with that particular group. For example, our own initial attempts to implement enhanced recovery stalled in 2008, but they were successful 3 years later in a different environment.
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