Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: a process evaluation of champions’ experiences

Abstract

BackgroundEnhanced recovery after surgery (ERAS) is a multimodal evidence-based approach to patient care that has become the standard in elective colorectal surgery. Implemented globally, ERAS programmes represent a considerable change in practice for many surgical care providers. Our current understanding of specific implementation and sustainability challenges is limited. In January 2013, we began a 2-year ERAS implementation for elective colorectal surgery in 15 academic hospitals in Ontario. The purpose of this study was to understand the process enablers and barriers that influenced the success of ERAS implementation in these centres with a view towards supporting sustainable change.MethodsA qualitative process evaluation was conducted from June to September 2014. Semi-structured interviews with implementation champions were completed, and an iterative inductive thematic analysis was conducted. Following a data-driven analysis, the Normalization Process Theory (NPT) was used as an analytic framework to understand the impact of various implementation processes. The NPT constructs were used as sensitizing concepts, reviewed against existing data categories for alignment and fit.ResultsFifty-eight participants were included: 15 surgeons, 14 anaesthesiologists, 15 nurses, and 14 project coordinators. A number of process-related implementation enablers were identified: champions’ belief in the value of the programme, the fit and cohesion of champions and their teams locally and provincially, a bottom-up approach to stakeholder engagement targeting organizational relationship-building, receptivity and support of division leaders, and the normalization of ERAS as everyday practice. Technical enablers identified included effective integration with existing clinical systems and using audit and feedback to report to hospital stakeholders. There was an overall optimism that ERAS implementation would be sustained, accompanied by concern about long-term organizational support.ConclusionsSuccessful ERAS implementation is achieved by a complex series of cognitive and social processes which previously have not been well described. Using the Normalization Process Theory as a framework, this analysis demonstrates the importance of champion coherence, external and internal relationship building, and the strategic management of a project’s organization-level visibility as important to ERAS uptake and sustainability.

What should we do when traditional research fails?

“…There are a variety of studies that have successfully used either quality improvement methodology, or implementation science such as normalisation process theory to embed interventions into clinical practice . Both methodologies share similarities with human factors and ergonomics .…”

Multimodal Pain Management for Enhanced Recovery: Reinforcing the Shift From Traditional Pathways Through Nurse‐Led Interventions

“…In ERAS pathways, the goal of improved patient outcomes is achieved through collaboration across a multidisciplinary group including nurses, surgeons, anesthesiologists, pharmacists, physical therapists, and other hospital personnel. This collaboration should also include the patient and family members or caregivers as part of the team 3,7,31,39,45,53,54 …”

“…Enhanced Recovery After Surgery pathways also include nontraditional nurse‐led interventions, such as the elimination of preoperative bowel preparation and initiation of feeding early after surgery, both of which are radical departures from the traditional care model. Reservations about early postsurgical feeding are related to fear that the patient will develop ileus 54 . In addition, the use of tubes, drains, and catheters is common in conventional perioperative care, but is discouraged in ERAS pathways because heavy reliance on these interventions can prolong the length of stay, hinder mobility, and may contribute to hypotension or postsurgical pain 7,16,31,39 .…”

“…In addition, the use of tubes, drains, and catheters is common in conventional perioperative care, but is discouraged in ERAS pathways because heavy reliance on these interventions can prolong the length of stay, hinder mobility, and may contribute to hypotension or postsurgical pain 7,16,31,39 . Some level of clinicians’ resistance to these major changes in practice is to be expected, but acceptance is more likely when there is an alignment with guidelines that are currently in use and there is an institutional commitment to adopt evidence‐based interventions 54 …”

Investigating the nutritional status and care of older (≥65 years) general surgical patients: a multiphase, action research study

“…At the meso-level (i.e. local and organisational context), lack of formal leadership support, unsupportive culture, limited stakeholder buy-in, complex systems and processes, and failure to establish ongoing audit and feedback processes were identified as barriers to implementation (Gotlib Conn et al, 2015;Gramlich et al, 2017;Herbert et al, 2017;Pearsall et al, 2015;Sutton et al, 2018), whereas embedding the change into existing systems and processes was an enabler (Herbert et al, 2017).…”