Enhanced recovery after surgery

Enhanced recovery after surgery is abbreviated to ERAS, or can also be termed the enhanced recovery pathway (ERP). ERAS is the use of evidence from research to inform surgical care initially described in colorectal surgery but ERAS has been extended to many other surgical specialities including orthopaedic surgery.

ERAS is essentially evidence-based care, although the evidence quality for each part of the pathway varies. When using the ERAS pathway with its evidence-based research in clinical practice, complications are reduced (Currie et al, 2015). In addition, patients can be safely discharged home after a shorter length of hospital stay.

There are concerns that ERAS will increase the nursing load (Jakobsen et al, 2006); arguably it does not, but it does change the work content (Jeff et al, 2014). ERAS requires more education for patients rather than performing tasks. For example, patients are educated about mobilising each day rather than assisted to

The purpose of ERAS is to improve patient care by following an evidence-based surgical pathway that includes preoperative, perioperative and postoperative elements. Preoperative elements prepare a patient safely for surgery. Perioperative elements of the pathway aim to reduce the surgical stress. Postoperative elements of ERAS aim to improve to baseline conditions faster.

Preoperative enhanced recovery after surgery pathway

The first elements of ERAS include provision of information, education and counselling about the operation and recovery process (Chapman et al, 2020a). How this information is best given is less certain but can be virtual or use multimedia, as well as being face to face. Receiving information is useful to reduce anxiety and ensure informed consent. It is also important to optimise the general health of patients prior to surgery such as smoking cessation.

There is increasing interest in rehabilitation - trying to improve functional capacity through preoperative exercise and additional nutritional care in patients who are malnourished. It is also important to manage any preoperative anaemia. Preoperative sedation is avoided, as is prolonged fasting.

The ERAS pathway plans to ensure no food and milk is taken for 6 hours and no clear fluids for 2 hours prior to surgery, to reduce the risk

Surgery is associated with complications; colorectal surgery has probably the highest number of postoperative complications, about one in three patients will encounter some form of complication. The ERAS pathway is associated with a reduction in the number of complications (Pearce 2018).

ERAS evolves over time as new evidence comes to light. It is important to audit and review results to improve patient care (Francis et al, 2018) and ensure that the pathway meets the patient’s needs (Chapman et al, 2020b).

References

Balfour A. Understanding the benefits and implications of enhanced recovery after surgery. Nursing standard. 2019. https://doi.org/10.7748/ns.2019.e11306  

Chapman SJ, Helliwell JA, Lonsdale DS et al. Patient education about recovery after colorectal surgery: systematic scoping review. Colorectal disease. 2020a;22(12):1842-1849 https://doi.org/10.1111/codi.15337

Chapman SJ, Murray CC, Lonsdale MDS et al. Information needs for recovery after colorectal surgery: a patient focus group study Colorectal Disease. 2020b; 23(4):975-981 https://doi.org/10.1111/codi.15459 

Currie A, Burch J, Jenkins JT et al. The impact of enhanced recovery protocol compliance on elective colorectal cancer resection. Annals of surgery 2015;261(6): 1153-1159. https://doi.org/10.1097/SLA.0000000000001029

Francis NK, Walker T, Carter F et al. Consensus on Training and Implementation of Enhanced Recovery After Surgery: A Delphi Study Nader. World J Surg. 2018. 42(7):1919–1928. https://doi.org/10.1007/s00268-017-4436-2

Jakobsen DH, Sonne e, Kehlet H. Nursing workload and fast track colonic surgery. Journal of advanced perioperative care. 2006;2(4): 177-181.

Jeff A and Taylor C. Ward nurses’ experience of enhanced recovery after