PE R IOPE RAT IVE PRACT ICE
Revisiting enhanced recovery pathways
Kate Woodhead RGN DMS discusses the key principles of enhanced recovery, the current progress in adoption and how the principles are now evolving.
Enhanced recovery is a quality improvement programme with a complex number of different elements which are evidence based and have an impact on the patient’s recovery after elective surgery. NHS Improvement describes it as designed to improve the patient experience, improve clinical outcomes and reduce the demand on inpatient beds.1
It
is very much a planned process, involving the whole surgical team and the patient and their family. The main aim is to speed up recovery after surgery and to ensure that patients get the best possible experience. Enhanced recovery programmes are widespread around the country – although they are far from ubiquitous. The most common areas of care, where research has demonstrated the most improvement, are breast care, colorectal, gynaecological, musculoskeletal and urological surgery. There are a few hospitals where thoracic and cardiac surgery utilise enhanced recovery principles. You might ask why this is not practiced as a matter of routine for every speciality and in every hospital. Greenshields and Mythen,2
writing in
January 2020, reviewed the progress of the last ten years in adoption of the enhanced recovery (ERAS) principles and state that while there has been significant progress across multiple surgical specialities, there is difficulty in sustaining a target of more than 80% compliance. However, optimistically they state that, in terms of the current interest in perioperative medicine and prehabilitation, more focus is landing on enhanced recovery.
What is ERAS? Henrik Kehlet, the originator of the programme, was a colorectal surgeon who published a paper in the British Journal of Anaesthesia in 1997. He described a multi- modal approach to control pathophysiology and rehabilitation. He suggested the use of evidence-based interventions which were targeted to the different perioperative periods to improve patient outcomes. The impact was largely down to reducing the surgical stress response which would reduce morbidity and
accelerate recovery. Interventions included:
Preoperative l Optimisation of medical condition l Cessation of alcohol and smoking l Patient education
Stress reduction l Regional anaesthesia and opioid sparing techniques
l Minimally invasive surgical techniques l Normothermia l Pharmacological modifiers
Post-operative l Minimisation of nasogastric tubes and drains
l Early mobilisation l Early oral nutrition l Pain Relief l Prevention and treatment of nausea and vomiting
The ERAS society was formed later that year and has continued to provide a forum for and leadership to those who espouse
22 l
WWW.CLINICALSERVICESJOURNAL.COM
the principles. It produces speciality guidelines for different pathways which help perioperative teams. The society was joined in 2009 by the Enhanced Recovery Partnership Programme to work as clinical champions to engage medical teams and support implementation of ERAS programmes in the NHS. They also provide data on implementation progress and give national improvement targets each year, where the data suggests that aspects of ERAS need new focus. For 2019 / 2020 the targets include
pre-operative assessment – specifying individualised risk assessment, finding anaemia and providing treatment, as well as optimising lifestyles and co-morbidities. There is a series of targets for diabetic management to ensure that Hb1AC is measured, that compliance is identified according to the local protocol and restoring nutrition as soon as possible after surgery. Communication and multidisciplinary team working come in for some particular focus with emphasis on building discussions into clinical routines, with team briefs, staff
AUGUST 2020
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