PE R IOPE RAT IVE PRACT ICE
meetings and multidisciplinary meetings. Managing the patients’ pain is an important focus, citing the use of multi-modal analgesia, potentially adding local anaesthetic techniques, distraction therapy and early postoperative review by the pain team. Enhanced recovery includes a particular focus on education and empowerment of the patient including attendance at ‘surgery school’, preoperative nutritional assessment with carbohydrate loading and minimising preoperative starvation and dehydration. In addition, specific attention should be paid to early resumption of eating and drinking after surgery with emphasis on early mobilisation. Drains and tubes which restrict early mobilisation are to be avoided and there should be as much of a reduction of institutionalisation as possible. One of the critical elements of the programme is to reduce variation in treatment, using the best evidence for the best outcomes. It would seem to be an anomaly that ERAS has not just been implemented everywhere, across all specialities as ‘best practice’ in accordance with the evidence. But life was never meant to be simple. Different aspects have led to this: a lack of specific clinical data compounded by a lack of sophisticated data analysis, a certain amount of resistance to external scrutiny, a realisation of the complexity of variables down to each individual patient and their disease, as well as the effectiveness of the teams that treat them.3
Spread of ERAS The Perioperative Quality Improvement Programme provides an annual report and ERAS is a central tenet of their programme. It is reported in their first annual report4
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.
enormous variation among hospitals, with some having all patients enrolled and others having not a single patient enrolled. There is also great variation demonstrated in care across different sites, only two out of ten ERAS components had a greater than 80% compliance within colorectal surgery. The following years’ annual report identified that 124 hospitals in the NHS were contributing to the programme.
Protocols and pathways The guidance for pathways in the different surgical specialities is published by the ERAS society and is easily accessible on-line. The most recent publication, for neonatal intestinal surgery, states that there are few guidelines for neonates and that they suffer considerable numbers of post-operative complications. The guideline, developed and published internationally, is to be welcomed.5
There are many other pathways that
between 40% and 73% of elective patients were on an enhanced recovery pathway with a national average of 61.4% with
for use by all the multidisciplinary teams. However, following the development of integrated care systems (ICSs) and their priorities from the NHS Long Term Plan, there are now many different pathways and protocols – some of which are designed to encompass greater patient empowerment and focus on perioperative medicine. These integrated care pathways will or should replace, or contribute to, discussions about how to improve the integration of services to improve value and outcomes, but they are a ‘management’ activity and, therefore, not necessarily focused on clinical outcomes, but
on creating more integration across primary and secondary care. The Long Term NHS Plan also contains a clear vision that patients should be at the centre of decisions about their own care, which chimes nicely with the principles of ERAS. The Plan focuses on personal responsibility and on prevention guided by the principle of prevention is better than cure. This can be applied to smoking cessation, exercise regimes, obesity and the list goes on. Much emphasis is placed on helping people to lead healthier lives and therefore avoid the need for surgery. However, we know there is a huge pent up demand following COVID-19 and, with a greater percentage of the population older and living with more co-morbidities, when surgery is required, it should be a planned process, if at all possible. The Royal College of Anaesthetists launched a cross-speciality national centre for the advancement and development of perioperative care in May 2019, titled the ‘Centre for Perioperative Care’ (CPOC). They intend to create a variety of work streams, working together with other Royal Colleges and multiple stakeholders, to champion the ‘prehab to rehab’ model which is at the core of perioperative care.
The launch document states that “CPOC will work to inspire professionals and hospitals to better prepare patients for their surgery, increase coordination between specialities and provide a comprehensive aftercare programme to enhance recovery and improve quality of life following surgery.” There is recognition of ERAS within one of the initial documents published by CPOC6 but the movement seems, to this author, to be taking the exact same ground as ERAS. It is difficult to see why CPOC is necessary and wouldn’t the energy devoted to CPOC be better diverted to ERAS effectiveness?
Healthcare staffs views Herbert and colleagues investigated the rather slow implementation of ERAS in 20177
Components of enhanced recovery. 24 l
WWW.CLINICALSERVICESJOURNAL.COM
and focused, in particular, on the facilitating factors and the challenges of implementing the programme. The interviews were held with a range of different professionals who had been involved in ERAS, across a variety of specialities. Key facilitators for successful implementation, such as teamwork and collaborative working, meetings to provide
AUGUST 2020
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