Principles, challenges and current issues in Enhanced Recovery After SurgeryPrinciples, challenges and current issues in Enhanced Recovery After Surgery

The emergence of Enhanced Recovery After Surgery (ERAS) nearly two decades ago has revolutionised perioperative care. The effectiveness of ERAS stems from its pathophysiological basis of perioperative stress reduction and preservation of physiological function in the postoperative patient. ERAS guidelines are designed to reduce the development of insulin resistance, a measure of postoperative stress and a major culprit in the development of postoperative complications. Studies measuring levels of systemic inflammatory markers after surgery showed lower levels of interleukin-6 and C-reactive protein in patients within an ERAS programme compared to those who went through traditional care. This decrease in stress response has been borne out by significant reduction of postoperative complications and length of stay in ERAS programmes across various surgical subspecialties.

Beyond its pathophysiological basis, a key but often overlooked aspect of ERAS is the philosophy of breaking down traditional models of perioperative care. These fragmented, siloed systems are a huge source of waste and unwanted variations in clinical practice, contributing to suboptimal outcomes. The ERAS concept of perioperative care brings all the stakeholders in the surgical journey together, patient included, working towards common goals through better communication, collaboration, shared responsibility and accountability.

Challenges and strategies in ERAS implementation

The success of an ERAS programme is dependent on more than just having a protocol in place. The implementation process itself is just as crucial, or arguably, more important. Common barriers to implementation have been identified as resistance to change, lack of time and staff, and poor communication, collaboration, and coordination between departments.

Having established a successful ERAS programme for various subspecialties in my hospital, and helping others in the region start their programmes, I would propose four fundamental principles that need to be present in establishing an ERAS programme.

The first is the ERAS team. This seems like common sense, but many fail at this stage because of a lack of buy in from the various stakeholders in the programme. It is vital that a team of multidisciplinary clinicians, consisting of at least a surgeon, anaesthesiologist and a nurse lead this team. Members of this team must also believe in the value of ERAS and work well with each other. This transdisciplinary collaboration is not a transient marriage of convenience but a long-term commitment to own and drive the programme from its conception to fruition, and beyond.

Second is getting hospital management support. Many clinical quality improvement projects start as pilot projects, and end as pilot projects. One of the reasons for this is the lack of will and resources to sustain. Ideally, support from hospital management should be present from the beginning, but many programmes start as a ground up approach. In these situations, initial positive results from the programme should help convince hospital management to back the programme and invest required resources, such as manpower, protected time for the staff involved to sustain and scale.

 Third is having a systematic model for implementation. It is often hard enough to institute a single change in clinical practice, but to bring about change to an entire suite of more than 20 practices will take change management strategies that enable existing systems to embrace new changes as seamlessly as possible. This means getting the team of multidisciplinary stakeholders together, going through micro workflows of the perioperative journey, eliminating excesses and unwanted variations and implementing evidenced based practices. This process needs to be constantly reviewed and improved, more regularly at the start, and then less so once a steady state is achieved.

Fourth and final is audit. You cannot change what you don’t know, and often we think we are better than we really are. Audit is the only way to know your outcomes. More than just outcomes, monitoring the compliance to the ERAS protocol has been one of the crucial tenets to the success of an ERAS Programme. Einstein said that “The definition of insanity is doing the same thing over and over again, but expecting different results.” To know how to improve outcomes, you need to know how they were derived. If the outcomes are poor and yet little is known about the process, then the likelihood is that the same mistakes will be repeated. Many centres claim to be practising ERAS, but do not have data to show for it. Only by having data, and using it in meaningful ways, will allow for improvements to be made.

The work doesn’t end with implementation. In fact the real challenge begins after implementation, in sustaining consistent standards of care and results. Even units that have undergone training in implementation have found sustaining a high level of compliance to the protocol difficult. Some of the difficulties in sustainability include staff burnout, high staff turnover, and lack of hospital management support and resources.

Ongoing issues in ERAS

One frequent concern about ERAS is the increasing complexity of the protocols. From the first published ERAS guidelines for colonic surgery in 2005 with 16 elements, ERAS Society has since published 12 surgical subspecialty guidelines comprising up to 25 components. This is a reason some have put forth explaining why ERAS implementation is fraught with difficulties, and uptake has been slower than expected. Furthermore, it is difficult to truly quantify the impact each ERAS element has on the outcomes. Certain elements, for example, minimally invasive surgery, has proven to be an independent factor associated with reduction in complications and better outcomes. Other elements on the other hand, have not been shown to have a significant effect on postoperative outcomes on their own. However, studies have also shown that a high level of compliance to the ERAS protocol has translated to better postoperative outcomes, implying that the ERAS components have a synergistic effect when performed well together.

Rather than perceiving ERAS as a protocol consisting of many individual, independent elements, it is perhaps more important to recognise that many of these elements complement and augment each other. For instance, by allowing oral clear fluids up to two hours before surgery, patients are more likely to be euvolemic when they arrive for surgery. This provides for easier and more optimal intravenous fluid management during surgery, which in turn reduces the adverse effects of dehydration or fluid overload. Similarly, minimally invasive surgery, by virtue of its other proven short term benefits of less postoperative pain, faster return of bowel function, directly enhances other ERAS elements such as opioid sparing analgesia, early enteral nutrition and early mobilisation. These interactions are not coincidental, as they all work to minimise the disruption to homeostasis and the stress of surgery to the patient.

Finally, the issue of value in surgery has to be addressed. Amidst rising healthcare costs worldwide, the value proposition of ERAS lies in its ability to improve outcomes, reduce complications, hospital length of stay, and thereby decreasing healthcare costs. Several health economic studies of ERAS programmes in single or multi-institutional studies have shown cost reductions that comes with successful ERAS programmes. At the same time, medical companies from the perioperative domains have jumped onto the bandwagon, introducing products and technology that seemingly improves care along different parts of the ERAS workflow. Ironically, these usually come with added costs, many significantly. Therefore, it is crucial for clinicians to critically appraise these new products and determine if their addition truly adds value for the patient, based on the risk, benefit and cost equation. It is possible that some of these new developments will indeed improve patient outcomes, but others not so or only in a subset of patients with high surgical risks.

While these issues continue to be debated, what cannot be denied is the unprecedented attention that ERAS has brought onto perioperative care in the last 20 years. This focus needs to be unrelenting. New and emerging evidence in perioperative care needs to constantly and rigorously be reviewed, to distil signal from noise. ERAS protocols have to be continually updated to stay relevant, never losing sight of its original and primary focus of improving patient recovery from surgery. 

References available on request.