- Email: [email protected]
The Benefits of Enhanced Recovery Pathways in Perioperative Care
GUEST EDITORIAL
The Benefits of Enhanced Recovery Pathways in Perioperative Care DONNA S. WATSON, RN, MSN, CNOR, FNP
C
olleagues, it is my pleasure to serve as the AORN Journal Guest Editor for this special issue focused on patient management and enhanced recovery pathways (ERPs). Perioperative nurses must deliver quality care that is efficacious and safe for every patient. It is incumbent that we keep abreast of current evidence-based practices that integrate innovative technologies, care pathways, and patient care delivery models intended to enhance patient experiences and outcomes. This issue introduces evidence-based perioperative multimodal ERPs designed to challenge traditional standards of care with an emphasis on a coordinated multidisciplinary care approach for the surgical patient. The article by Brady et al1 describes the process for developing and implementing an ERP for the patient undergoing colorectal surgery. The article by Schatz2 reviews strategies for implementing an ERP in a minimally invasive thoracic surgery program. Last, the article by Sammons and Ritchey3 discusses the use of the transversus abdominis plane block for elderly patients undergoing surgical procedures to relieve pain and reduce the use of narcotics or sedatives during the immediate and extended postoperative recovery period.
THE ORIGIN OF ENHANCED RECOVERY PROGRAMS Henrik Kehlet, MD, PhD, a former professor of perioperative therapy and head of the Section for Surgical Pathophysiology at the Rigshospitalet in Copenhagen, Denmark, introduced concepts for Enhanced Recovery After Surgery (ERAS) programs in the mid-1990s.4 Dr Kehlet stated, “the key
question in our understanding of the pathogenesis of postoperative morbidity is . . . related to the pathophysiological role of the various components of the surgical stress response and whether or not a modification of such responses may improve surgical outcomes.”4(p606) Dr Kehlet challenged traditional standards of care for the patient undergoing colorectal surgery to better understand why a patient could have an unexpected poor outcome when surgery was uneventful and technically proficient. Dr Kehlet shifted patient care management from traditional care (“the way we have always done it”) to assessing and modifying various interventions during the perioperative period with the intent of improving patient outcomes. The initial ERAS protocol introduced for patients undergoing colorectal surgery has been adopted in other surgical specialties and successfully implemented in Europe for more than a decade. Enhanced recovery pathways integrate multimodal evidencebased interventions intended to reduce the surgical stress response, optimize recovery, and improve the experience for a patient undergoing a surgical procedure.5 Enhanced recovery pathways have been successfully and safely adopted globally in a variety of specialties, resulting in decreased lengths of stay and fewer complications in colorectal,6 bariatric,7 thoracic,8 and gynecological surgery.9 In the United States, ERPs have been referred to as surgical home, perioperative surgical home, fast-track, or ERAS.10 Unfortunately, adoption of ERPs in the United States has been slow because of multiple implementation barriers, such as organizational culture that is resistant to change, lack of http://dx.doi.org/10.1016/j.aorn.2015.09.010 ª AORN, Inc, 2015
464 j AORN Journal
www.aornjournal.org
November 2015, Vol. 102, No. 5
Guest Editorial
Enhanced Recovery Pathway (ERP) Resources The following are excellent information on ERPs:
resources
for
more
The Enhanced Recovery After Surgery (ERAS) Society (http://erassociety.org/) has multiple guidelines and resources and a nurse group that serves as an international resource for nurses interested or currently involved in managing an ERP. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Surgical Multimodal Accelerated Recovery Trajectory (SMART) (http://www.sages .org/sages-breaking-news/enhanced-recovery-tool/) combines resources targeted at minimally invasive surgery with ERP recommendations. The American Society for Enhanced Recovery (ASER) (http://aserhq.org/) provides ERP protocols and patient education materials.
support, lack of resources, inability to standardize a protocol,11 and lack of content experts to facilitate development and implementation.
ELEMENTS OF AN ENHANCED RECOVERY PATHWAY An ERP protocol implements different approaches to perioperative patient care based on 20 recommended elements, including but not limited to patient education, optimal fluid management, minimal incision length, decreased use of tubes and drains, opioid-sparing analgesia, early mobilization, and early oral intake.12-15 The following examples are specific to the patient undergoing colorectal surgery.14 In the preoperative phase, the patient receives in-depth education that begins at the time a decision has been made to proceed with surgery.16 The patient is informed of all aspects of care in each of the preoperative, intraoperative, and postoperative phases. Patient education includes expected milestones related to ambulation, nutrition, pain management, and length of stay. Following verbal education, the patient is provided with written material to reinforce instructions.16 The patient is encouraged to be fully engaged in the expected course of care from diagnosis through recovery. Increased patient awareness of expected milestones encourages the patient to advocate on his or her own behalf when care is not delivered as planned. For example, if the patient is expected to be able to sit upright in the bedside chair and to ambulate within three hours
www.aornjournal.org
after surgery and this does not occur, the patient is empowered to ask why. Traditional care promotes preoperative overnight fasting; in an ERP, overnight fasting is avoided to allow for clear liquids until two hours before surgery, solid foods six hours before surgery, and carbohydrate loading.14 Carbohydrate loading is the administration of oral complex carbohydrate drinks with appropriate osmolality intended to decrease surgical stress by decreasing the incidence of postoperative insulin resistance.17 In addition, it is recommended that bowel preparation for the colorectal patient be avoided in most cases, related to the potential for electrolyte balance disturbances that may contribute to dehydration and intestinal edema. However, this is dependent on the surgery type and surgeon preference.18 Fluid and pain management are important throughout the preoperative, intraoperative, and postoperative phases. Fluid management is individualized with the goals of maintaining central euvolemia and avoiding excessive salt and water.19 Salt and water excess resulting in a weight gain of 3 kg following elective colonic resection has been associated with an increased rate of complications, prolonged hospitalization, and delayed gastrointestinal function.20 Pain management includes avoiding preoperative administration of long-acting sedative medications; multimodal pain management includes avoiding long-acting opioids and considering the use of thoracic epidural analgesia, patient-controlled analgesia, and nerve blocks (eg, transversus abdominis plane block, other neural blocks) as appropriate.19,21 When appropriate, laparoscopic surgery is recommended rather than open surgery.14 Research on laparoscopic surgery combined with an ERP has demonstrated decreased lengths of stay, decreased costs, and no difference in 30-day readmission rates.22-24 Nasogastric tubes, drains, and urinary catheters are used only when appropriate,14 and antiemesis medications and thromboprophylaxis are administered.
WHY DEVELOP AND ADOPT ENHANCED RECOVERY PATHWAYS? In 2013, US health care spending increased 3.6% to reach an estimated cost of $2.9 trillion.25 Payers and providers have recognized that alternative approaches intended to improve clinical outcomes while reducing cost are paramount for institutional success and financial viability.26 In addition to providing a clinical solution intended to decrease surgical stress, improve recovery, and improve outcomes, ERPs have an associated cost-effectiveness for the patient, the institution, and society.14,26 Archibald and colleagues24 AORN Journal j 465
Watson
implemented a system-wide integration of a colorectal ERP and reported an average hospital cost decrease of $1,763. Bosio and colleagues27 reported a cost savings with ERP guidelines, including implementation of laparoscopic colorectal resections compared with open colorectal sections, which resulted in a mean direct cost of $4,993 compared to $11,383. Stephen and Berger28 reported an average patient cost savings of $2,240 with use of an ERP. Miller and colleagues stated, “in an era of pay-for-performance programs and economic constraints, a program that improves the quality of health care while reducing costs is obviously very attractive to health care providers, administrators, and patients.”19(p6)
IMPLICATIONS FOR PERIOPERATIVE NURSING The development and coordination of an ERP require a multidisciplinary approach to care that must be supported by administrators and clinicians. A nurse champion is critical to successful ERP development and implementation. A perioperative nurse leader is well suited to deal with the challenges required to facilitate a large multidisciplinary team and is an ideal nurse champion candidate. Essential skills and traits include the ability to interact with all professionals involved in patient care; a willingness to educate and train staff members on ERP protocol; the ability to implement, organize, and participate in multidisciplinary rounds; the ability to assist with data collection for auditing purposes to communicate analytics; and the ability to provide solutions for implementation barriers to promote successful ERP protocol adoption.29 In addition, it is important for perioperative staff members to understand the ERP, implications for patient outcomes, and care expectations implemented by the perioperative nurse and multidisciplinary team throughout the preoperative, intraoperative, and postoperative phases.
CONCLUSION The development and adoption of ERPs promotes standardization of patient care based on evidence-based practices intended to enhance the patient’s experience, reduce postoperative complications, and decrease length of stay.30 This issue is dedicated to describing the key elements of an ERP protocol that challenge traditional practices and promote the adoption of multimodal interventions intended to 466 j AORN Journal
November 2015, Vol. 102, No. 5
decrease surgical stress. Successful ERP adoption involves a culture change that shifts from a conventional care model to an innovative practice model that requires patient participation and multidisciplinary team commitment to provide an enhanced surgical experience with improved patient outcomes.
Editor’s note: Enhanced Recovery After Surgery (ERAS) is a registered trademark of the ERAS Society, Kista, Sweden.
References 1. Brady K, Keller DS, Delaney CP. Successful implementation of an enhanced recovery pathway and nursing role. AORN J. 2015; 102(5):469-481. 2. Schatz C. Enhanced recovery in a minimally invasive thoracic surgery practice. AORN J. 2015;102(5):482-492. 3. Sammons G, Ritchey W. Use of transversus abdominis plane (TAP) blocks for pain management in elderly surgical patients. AORN J. 2015;102(5):493-497. 4. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78(5):606-617. 5. Kehlet H. Fast-track colorectal surgery. Lancet. 2008;371(9615): 791-793. 6. Teeuwen PH, Bleichrodt RP, Strik C, et al. Enhanced recovery after surgery (ERAS) versus conventional postoperative care in colorectal surgery. J Gastrointest Surg. 2010;14(1):88-95. 7. Lemanu DP, Srinivasa S, Singh PP, Johannsen S, MacCormick AD, Hill AG. Optimizing perioperative care in bariatric surgery patients. Obes Surg. 2012;22(6):979-990. 8. Jones NL, Edmonds L, Ghosh S, Klein AA. A review of enhanced recovery for thoracic anaesthesia and surgery. Anaesthesia. 2013; 68(2):179-189. 9. Yoong W, Sivashanmugarajan V, Relph S, et al; Enhanced Recovery After Surgery (ERAS) Team for Gynaecology and Anaesthesia. Can enhanced recovery pathways improve outcomes of vaginal hysterectomy? Cohort control study. J Minim Invasive Gynecol. 2014;21(1):83-89. 10. Kash B, Cline K, Menser T, Zhang Y. The Perioperative Surgical Home: A Comprehensive Literature Review for the American Society of Anesthesiologists. College Station, TX: Center for Health Organization Transformation, Texas A&M University, Health Science Center; 2014. http://ghacall.com/clinical/pshreview.pdf. Accessed September 1, 2015. 11. Pearsall EA, Meghji Z, Pitzul KB, et al. A qualitative study to understand the barriers and enablers in implementing an enhanced recovery after surgery program. Ann Surg. 2015; 261(1):92-96. 12. Fearon KC, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005;24(3):466-477. 13. Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. Clin Nutr. 2012;31(6):783-800.
www.aornjournal.org
November 2015, Vol. 102, No. 5 14. Lassen K, Soop M, Nygren J, et al. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg. 2009; 144(10):961-969. 15. Nygren J, Thacker J, Carli F, et al. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. Clin Nutr. 2012; 31(6):801-816. 16. Patient infomation. ERAS Society. http://erassociety.org/index.php/ patient-information. Accessed July 1, 2015. 17. Awad S, Varadhan KK, Ljungqvist O, Lobo DN. A meta-analysis of randomised controlled trials on preoperative oral carbohydrate treatment in elective surgery. Clin Nutr. 2013;32(1):34-44. 18. Rockall TA, Demartines N. Laparoscopy in the era of enhanced recovery. Best Pract Res Clin Gastroenterol. 2014;28(1):133-142. 19. Miller TE, Gan TJ, Thacker JKM. Enhanced recovery pathways for major abdominal surgery [special report]. Anesthesiol News. http:// www.anesthesiologynews.com/download/SR1422_McMahon_WM .pdf. Accessed July 1, 2015. 20. Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ, Allison SP. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet. 2002;359(9320):1812-1818. 21. Cerantola Y, Valerio M, Persson B, et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS) Society recommendations. Clin Nutr. 2013;32(6):879-887. 22. Vlug MS, Wind J, Hollmann MW, et al. Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg. 2011;254(6):868-875. 23. Geltzeiler CB, Rotramel A, Wilson C, Deng L, Whiteford MH, Frankhouse J. Prospective study of colorectal enhanced recovery after surgery in a community hospital. JAMA Surg. 2014;149(9): 955-961.
www.aornjournal.org
Guest Editorial 24. Archibald LH, Ott MJ, Gale CM, Zhang J, Peters MS, Stroud GK. Enhanced recovery after colon surgery in a community hospital system. Dis Colon Rectum. 2011;54(7):840-845. 25. National health expenditures 2013 highlights. Centers for Medicare & Medicaid Services. http://www.cms.gov/Research-Statistics -Data-and-Systems/Statistics-Trends-and-Reports/NationalHealth ExpendData/Downloads/highlights.pdf. Accessed September 1, 2015. 26. Lee L, Li C, Landry T, et al. A systematic review of economic evaluations of enhanced recovery pathways for colorectal surgery. Ann Surg. 2014;259(4):670-676. 27. Bosio RM, Smith BM, Aybar PS, Senagore AJ. Implementation of laparoscopic colectomy with fast-track care in an academic medical center: benefits of a fully ascended learning curve and specialty expertise. Am J Surg. 2007;193(3):413-415. 28. Stephen AE, Berger DL. Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection. Surgery. 2003;133(3): 277-282. 29. Implementation of an enhanced recovery after surgery (ERAS) program ARTIC project. Council of Academic Hospital of Ontario. http://caho-hospitals.com/wp-content/uploads/2014/02/CAHO-ERAS -ARTIC-Participant-Information-Package-Final.pdf. Accessed September 1, 2015. 30. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630-641.
Donna S. Watson, MSN, RN, CNOR, FNP, is a director with Medtronic Invasive Therapies Group - Health Systems Advantage, Boulder, CO. Ms Watson has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
AORN Journal j 467
The Benefits of Enhanced Recovery Pathways in Perioperative Care DONNA S. WATSON, RN, MSN, CNOR, FNP
C
olleagues, it is my pleasure to serve as the AORN Journal Guest Editor for this special issue focused on patient management and enhanced recovery pathways (ERPs). Perioperative nurses must deliver quality care that is efficacious and safe for every patient. It is incumbent that we keep abreast of current evidence-based practices that integrate innovative technologies, care pathways, and patient care delivery models intended to enhance patient experiences and outcomes. This issue introduces evidence-based perioperative multimodal ERPs designed to challenge traditional standards of care with an emphasis on a coordinated multidisciplinary care approach for the surgical patient. The article by Brady et al1 describes the process for developing and implementing an ERP for the patient undergoing colorectal surgery. The article by Schatz2 reviews strategies for implementing an ERP in a minimally invasive thoracic surgery program. Last, the article by Sammons and Ritchey3 discusses the use of the transversus abdominis plane block for elderly patients undergoing surgical procedures to relieve pain and reduce the use of narcotics or sedatives during the immediate and extended postoperative recovery period.
THE ORIGIN OF ENHANCED RECOVERY PROGRAMS Henrik Kehlet, MD, PhD, a former professor of perioperative therapy and head of the Section for Surgical Pathophysiology at the Rigshospitalet in Copenhagen, Denmark, introduced concepts for Enhanced Recovery After Surgery (ERAS) programs in the mid-1990s.4 Dr Kehlet stated, “the key
question in our understanding of the pathogenesis of postoperative morbidity is . . . related to the pathophysiological role of the various components of the surgical stress response and whether or not a modification of such responses may improve surgical outcomes.”4(p606) Dr Kehlet challenged traditional standards of care for the patient undergoing colorectal surgery to better understand why a patient could have an unexpected poor outcome when surgery was uneventful and technically proficient. Dr Kehlet shifted patient care management from traditional care (“the way we have always done it”) to assessing and modifying various interventions during the perioperative period with the intent of improving patient outcomes. The initial ERAS protocol introduced for patients undergoing colorectal surgery has been adopted in other surgical specialties and successfully implemented in Europe for more than a decade. Enhanced recovery pathways integrate multimodal evidencebased interventions intended to reduce the surgical stress response, optimize recovery, and improve the experience for a patient undergoing a surgical procedure.5 Enhanced recovery pathways have been successfully and safely adopted globally in a variety of specialties, resulting in decreased lengths of stay and fewer complications in colorectal,6 bariatric,7 thoracic,8 and gynecological surgery.9 In the United States, ERPs have been referred to as surgical home, perioperative surgical home, fast-track, or ERAS.10 Unfortunately, adoption of ERPs in the United States has been slow because of multiple implementation barriers, such as organizational culture that is resistant to change, lack of http://dx.doi.org/10.1016/j.aorn.2015.09.010 ª AORN, Inc, 2015
464 j AORN Journal
www.aornjournal.org
November 2015, Vol. 102, No. 5
Guest Editorial
Enhanced Recovery Pathway (ERP) Resources The following are excellent information on ERPs:
resources
for
more
The Enhanced Recovery After Surgery (ERAS) Society (http://erassociety.org/) has multiple guidelines and resources and a nurse group that serves as an international resource for nurses interested or currently involved in managing an ERP. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Surgical Multimodal Accelerated Recovery Trajectory (SMART) (http://www.sages .org/sages-breaking-news/enhanced-recovery-tool/) combines resources targeted at minimally invasive surgery with ERP recommendations. The American Society for Enhanced Recovery (ASER) (http://aserhq.org/) provides ERP protocols and patient education materials.
support, lack of resources, inability to standardize a protocol,11 and lack of content experts to facilitate development and implementation.
ELEMENTS OF AN ENHANCED RECOVERY PATHWAY An ERP protocol implements different approaches to perioperative patient care based on 20 recommended elements, including but not limited to patient education, optimal fluid management, minimal incision length, decreased use of tubes and drains, opioid-sparing analgesia, early mobilization, and early oral intake.12-15 The following examples are specific to the patient undergoing colorectal surgery.14 In the preoperative phase, the patient receives in-depth education that begins at the time a decision has been made to proceed with surgery.16 The patient is informed of all aspects of care in each of the preoperative, intraoperative, and postoperative phases. Patient education includes expected milestones related to ambulation, nutrition, pain management, and length of stay. Following verbal education, the patient is provided with written material to reinforce instructions.16 The patient is encouraged to be fully engaged in the expected course of care from diagnosis through recovery. Increased patient awareness of expected milestones encourages the patient to advocate on his or her own behalf when care is not delivered as planned. For example, if the patient is expected to be able to sit upright in the bedside chair and to ambulate within three hours
www.aornjournal.org
after surgery and this does not occur, the patient is empowered to ask why. Traditional care promotes preoperative overnight fasting; in an ERP, overnight fasting is avoided to allow for clear liquids until two hours before surgery, solid foods six hours before surgery, and carbohydrate loading.14 Carbohydrate loading is the administration of oral complex carbohydrate drinks with appropriate osmolality intended to decrease surgical stress by decreasing the incidence of postoperative insulin resistance.17 In addition, it is recommended that bowel preparation for the colorectal patient be avoided in most cases, related to the potential for electrolyte balance disturbances that may contribute to dehydration and intestinal edema. However, this is dependent on the surgery type and surgeon preference.18 Fluid and pain management are important throughout the preoperative, intraoperative, and postoperative phases. Fluid management is individualized with the goals of maintaining central euvolemia and avoiding excessive salt and water.19 Salt and water excess resulting in a weight gain of 3 kg following elective colonic resection has been associated with an increased rate of complications, prolonged hospitalization, and delayed gastrointestinal function.20 Pain management includes avoiding preoperative administration of long-acting sedative medications; multimodal pain management includes avoiding long-acting opioids and considering the use of thoracic epidural analgesia, patient-controlled analgesia, and nerve blocks (eg, transversus abdominis plane block, other neural blocks) as appropriate.19,21 When appropriate, laparoscopic surgery is recommended rather than open surgery.14 Research on laparoscopic surgery combined with an ERP has demonstrated decreased lengths of stay, decreased costs, and no difference in 30-day readmission rates.22-24 Nasogastric tubes, drains, and urinary catheters are used only when appropriate,14 and antiemesis medications and thromboprophylaxis are administered.
WHY DEVELOP AND ADOPT ENHANCED RECOVERY PATHWAYS? In 2013, US health care spending increased 3.6% to reach an estimated cost of $2.9 trillion.25 Payers and providers have recognized that alternative approaches intended to improve clinical outcomes while reducing cost are paramount for institutional success and financial viability.26 In addition to providing a clinical solution intended to decrease surgical stress, improve recovery, and improve outcomes, ERPs have an associated cost-effectiveness for the patient, the institution, and society.14,26 Archibald and colleagues24 AORN Journal j 465
Watson
implemented a system-wide integration of a colorectal ERP and reported an average hospital cost decrease of $1,763. Bosio and colleagues27 reported a cost savings with ERP guidelines, including implementation of laparoscopic colorectal resections compared with open colorectal sections, which resulted in a mean direct cost of $4,993 compared to $11,383. Stephen and Berger28 reported an average patient cost savings of $2,240 with use of an ERP. Miller and colleagues stated, “in an era of pay-for-performance programs and economic constraints, a program that improves the quality of health care while reducing costs is obviously very attractive to health care providers, administrators, and patients.”19(p6)
IMPLICATIONS FOR PERIOPERATIVE NURSING The development and coordination of an ERP require a multidisciplinary approach to care that must be supported by administrators and clinicians. A nurse champion is critical to successful ERP development and implementation. A perioperative nurse leader is well suited to deal with the challenges required to facilitate a large multidisciplinary team and is an ideal nurse champion candidate. Essential skills and traits include the ability to interact with all professionals involved in patient care; a willingness to educate and train staff members on ERP protocol; the ability to implement, organize, and participate in multidisciplinary rounds; the ability to assist with data collection for auditing purposes to communicate analytics; and the ability to provide solutions for implementation barriers to promote successful ERP protocol adoption.29 In addition, it is important for perioperative staff members to understand the ERP, implications for patient outcomes, and care expectations implemented by the perioperative nurse and multidisciplinary team throughout the preoperative, intraoperative, and postoperative phases.
CONCLUSION The development and adoption of ERPs promotes standardization of patient care based on evidence-based practices intended to enhance the patient’s experience, reduce postoperative complications, and decrease length of stay.30 This issue is dedicated to describing the key elements of an ERP protocol that challenge traditional practices and promote the adoption of multimodal interventions intended to 466 j AORN Journal
November 2015, Vol. 102, No. 5
decrease surgical stress. Successful ERP adoption involves a culture change that shifts from a conventional care model to an innovative practice model that requires patient participation and multidisciplinary team commitment to provide an enhanced surgical experience with improved patient outcomes.
Editor’s note: Enhanced Recovery After Surgery (ERAS) is a registered trademark of the ERAS Society, Kista, Sweden.
References 1. Brady K, Keller DS, Delaney CP. Successful implementation of an enhanced recovery pathway and nursing role. AORN J. 2015; 102(5):469-481. 2. Schatz C. Enhanced recovery in a minimally invasive thoracic surgery practice. AORN J. 2015;102(5):482-492. 3. Sammons G, Ritchey W. Use of transversus abdominis plane (TAP) blocks for pain management in elderly surgical patients. AORN J. 2015;102(5):493-497. 4. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78(5):606-617. 5. Kehlet H. Fast-track colorectal surgery. Lancet. 2008;371(9615): 791-793. 6. Teeuwen PH, Bleichrodt RP, Strik C, et al. Enhanced recovery after surgery (ERAS) versus conventional postoperative care in colorectal surgery. J Gastrointest Surg. 2010;14(1):88-95. 7. Lemanu DP, Srinivasa S, Singh PP, Johannsen S, MacCormick AD, Hill AG. Optimizing perioperative care in bariatric surgery patients. Obes Surg. 2012;22(6):979-990. 8. Jones NL, Edmonds L, Ghosh S, Klein AA. A review of enhanced recovery for thoracic anaesthesia and surgery. Anaesthesia. 2013; 68(2):179-189. 9. Yoong W, Sivashanmugarajan V, Relph S, et al; Enhanced Recovery After Surgery (ERAS) Team for Gynaecology and Anaesthesia. Can enhanced recovery pathways improve outcomes of vaginal hysterectomy? Cohort control study. J Minim Invasive Gynecol. 2014;21(1):83-89. 10. Kash B, Cline K, Menser T, Zhang Y. The Perioperative Surgical Home: A Comprehensive Literature Review for the American Society of Anesthesiologists. College Station, TX: Center for Health Organization Transformation, Texas A&M University, Health Science Center; 2014. http://ghacall.com/clinical/pshreview.pdf. Accessed September 1, 2015. 11. Pearsall EA, Meghji Z, Pitzul KB, et al. A qualitative study to understand the barriers and enablers in implementing an enhanced recovery after surgery program. Ann Surg. 2015; 261(1):92-96. 12. Fearon KC, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005;24(3):466-477. 13. Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. Clin Nutr. 2012;31(6):783-800.
www.aornjournal.org
November 2015, Vol. 102, No. 5 14. Lassen K, Soop M, Nygren J, et al. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg. 2009; 144(10):961-969. 15. Nygren J, Thacker J, Carli F, et al. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. Clin Nutr. 2012; 31(6):801-816. 16. Patient infomation. ERAS Society. http://erassociety.org/index.php/ patient-information. Accessed July 1, 2015. 17. Awad S, Varadhan KK, Ljungqvist O, Lobo DN. A meta-analysis of randomised controlled trials on preoperative oral carbohydrate treatment in elective surgery. Clin Nutr. 2013;32(1):34-44. 18. Rockall TA, Demartines N. Laparoscopy in the era of enhanced recovery. Best Pract Res Clin Gastroenterol. 2014;28(1):133-142. 19. Miller TE, Gan TJ, Thacker JKM. Enhanced recovery pathways for major abdominal surgery [special report]. Anesthesiol News. http:// www.anesthesiologynews.com/download/SR1422_McMahon_WM .pdf. Accessed July 1, 2015. 20. Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ, Allison SP. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet. 2002;359(9320):1812-1818. 21. Cerantola Y, Valerio M, Persson B, et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS) Society recommendations. Clin Nutr. 2013;32(6):879-887. 22. Vlug MS, Wind J, Hollmann MW, et al. Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg. 2011;254(6):868-875. 23. Geltzeiler CB, Rotramel A, Wilson C, Deng L, Whiteford MH, Frankhouse J. Prospective study of colorectal enhanced recovery after surgery in a community hospital. JAMA Surg. 2014;149(9): 955-961.
www.aornjournal.org
Guest Editorial 24. Archibald LH, Ott MJ, Gale CM, Zhang J, Peters MS, Stroud GK. Enhanced recovery after colon surgery in a community hospital system. Dis Colon Rectum. 2011;54(7):840-845. 25. National health expenditures 2013 highlights. Centers for Medicare & Medicaid Services. http://www.cms.gov/Research-Statistics -Data-and-Systems/Statistics-Trends-and-Reports/NationalHealth ExpendData/Downloads/highlights.pdf. Accessed September 1, 2015. 26. Lee L, Li C, Landry T, et al. A systematic review of economic evaluations of enhanced recovery pathways for colorectal surgery. Ann Surg. 2014;259(4):670-676. 27. Bosio RM, Smith BM, Aybar PS, Senagore AJ. Implementation of laparoscopic colectomy with fast-track care in an academic medical center: benefits of a fully ascended learning curve and specialty expertise. Am J Surg. 2007;193(3):413-415. 28. Stephen AE, Berger DL. Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection. Surgery. 2003;133(3): 277-282. 29. Implementation of an enhanced recovery after surgery (ERAS) program ARTIC project. Council of Academic Hospital of Ontario. http://caho-hospitals.com/wp-content/uploads/2014/02/CAHO-ERAS -ARTIC-Participant-Information-Package-Final.pdf. Accessed September 1, 2015. 30. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630-641.
Donna S. Watson, MSN, RN, CNOR, FNP, is a director with Medtronic Invasive Therapies Group - Health Systems Advantage, Boulder, CO. Ms Watson has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
AORN Journal j 467