Implementation of Enhanced Recovery After Surgery: a strategy to transform surgical care across a health system

Leah M Gramlich, Caroline E Sheppard, Tracy Wasylak, Loreen E Gilmour, Olle Ljungqvist, Carlota Basualdo-Hammond, Gregg Nelson, Leah M Gramlich, Caroline E Sheppard, Tracy Wasylak, Loreen E Gilmour, Olle Ljungqvist, Carlota Basualdo-Hammond, Gregg Nelson

Abstract

Background: Enhanced Recovery After Surgery (ERAS) programs have been shown to have a positive impact on outcome. The ERAS care system includes an evidence-based guideline, an implementation program, and an interactive audit system to support practice change. The purpose of this study is to describe the use of the Theoretic Domains Framework (TDF) in changing surgical care and application of the Quality Enhancement Research Initiative (QUERI) model to analyze end-to-end implementation of ERAS in colorectal surgery across multiple sites within a single health system. The ultimate intent of this work is to allow for the development of a model for spread, scale, and sustainability of ERAS in Alberta Health Services (AHS).

Methods: ERAS for colorectal surgery was implemented at two sites and then spread to four additional sites. The ERAS Interactive Audit System (EIAS) was used to assess compliance with the guidelines, length of stay, readmissions, and complications. Data sources informing knowledge translation included surveys, focus groups, interviews, and other qualitative data sources such as minutes and status updates. The QUERI model and TDF were used to thematically analyze 189 documents with 2188 quotes meeting the inclusion criteria. Data sources were analyzed for barriers or enablers, organized into a framework that included individual to organization impact, and areas of focus for guideline implementation.

Results: Compliance with the evidence-based guidelines for ERAS in colorectal surgery at baseline was 40%. Post implementation compliance, consistent with adoption of best practice, improved to 65%. Barriers and enablers were categorized as clinical practice (22%), individual provider (26%), organization (19%), external environment (7%), and patients (25%). In the Alberta context, 26% of barriers and enablers to ERAS implementation occurred at the site and unit levels, with a provider focus 26% of the time, a patient focus 26% of the time, and a system focus 22% of the time.

Conclusions: Using the ERAS care system and applying the QUERI model and TDF allow for identification of strategies that can support diffusion and sustainment of innovation of Enhanced Recovery After Surgery across multiple sites within a health care system.

Keywords: Enhanced Recovery After Surgery; Implementation; QUERI; Theoretical Domains Framework.

Figures

Fig. 1
Fig. 1
Compliance change before and after ERAS guideline implementation
Fig. 2
Fig. 2
Number of total quotes based on QUERI [20]. Quotes are separated into barriers and enablers
Fig. 3
Fig. 3
Total number of quotes by level. Quotes are separated into barriers and enablers
Fig. 4
Fig. 4
Total number of quotes stratified by “Spread and Scale” themes, discussed themes, noticeable themes, and other. Quotes are separated into barriers and enablers. MFG & CHO Loading modern fasting guideline and carbohydrate loading. Patterned: sub-theme of above theme
Fig. 5
Fig. 5
Total number of quotes related to sustainability [37]. Themes for “Spread and Scale” were stratified into “Sustainability” categories noted in inclusion. Quotes are separated into barriers and enablers
Fig. 6
Fig. 6
Model for spread, scale, and sustainment of ERAS: supporting system transformation

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