Enhanced recovery after surgery

Abstract

From ERAS study group to ERAS® Society The formal concept of enhanced recovery after surgery (ERAS) was developed in 2001when a group of academic surgeons formed the ERAS study group.1 The group had an interest in the stress response to surgery and believed that it would be possible to increase quality of peri-operative care and reduce complications by modifying the metabolic, immune and endocrine responses to tissue damage. This early concept resulted in a protocol based on published evidence and showed that optimising peri-operative care rather than surgery alone predicted the outcomes.1 This initiative evolved globally and, after about 10 years of collaboration and growth of the network involved, it laid the foundation for the formation of the ERAS Society in 2010 (http://www.erassociety.org). The society's mission is to improve peri-operative care worldwide through research and education, employing a multidisciplinary and multiprofessional approach with continuous interactive audit and reporting as a key component in the implementation of evidence-based practice (ERAS Society Guidelines). This is a new way of managing and controlling care and, by using data-driven changes, it creates a readiness of hospital teams to continuously make changes and update as required. The ERAS Society, which celebrates its tenth anniversary, is a Specialist Society of the ESAIC. The ERAS philosophy and ERAS guidelines The concept of the ERAS philosophy is based on a standardised care plan, which covers the entire patient journey from the decision to operate to 30 days postsurgery.1 The care plan includes all evidence-based peri-operative care elements, which impact on recovery, improve outcome and reduce complications and potentially mortality.1,2 These elements of care form the ERAS Society guidelines. These recommendations are developed in a standardised way, based on data that are available in the literature, which is graded according to the GRADE review of evidence.2 Because new knowledge is constantly created, the guidelines are updated on a regular basis. Over the years, an increasing number of ERAS Society guidelines and recommendations (19, including updates) have been published and proven to be successful in many surgical specialties.1 Testing the clinical validity and applicability of these guidelines has been performed by collecting multicentre compliance and audit data for several ERAS Society guidelines.3,4 The ERAS Interactive Audit System (EIAS) not only provides a platform for audit, but also as a base for implementation and international research.5,6 Today, the system encompasses eight different specialties, and data fields are modified as necessary to test specialty-specific guidelines. This approach to implementation and testing of the principles has spread worldwide with hospitals in more than 25 countries, and confirmed with data from over 90 000 patients entered into EIAS.7 ERAS is successful because these pathways have resulted in enhanced patient recovery and reduced complications, and the data suggest that they may improve cancer survival.1 Since the ERAS Society was founded in 2010, the interest in ERAS is growing, as reflected by the increasing number of ERAS-related publications, now exceeding 4000, with almost 6000 citations and more than 700 000 downloads of ERAS Society guidelines. Why so many elements in an ERAS Society Guideline? The ERAS Society's approach to creating the guidelines is to include all elements that are shown to improve outcomes. Repeated studies have shown that the greater the compliance with the recommended elements, the greater the improvement in outcomes.1,8–10 Some authors have expressed concern over the high number of elements, stating that many of these are standard of care.11 Although this may be true in most units, it is equally certain that there will be a huge variation between units when it comes to which elements are viewed as a 'standard of care'. By showing all elements that impact on outcomes and revealing which ones are not being followed training can be directed towards those that may be missing at a local level. It has been the experience of the ERAS Society that this approach works very well. ERAS Society Implementation Programme Systematic implementation of ERAS programmes have shown that as variation and/or improvisation in elements of delivered care increases, the quality of delivered care will be reduced; conversely, an increase in compliance with the use of care elements results in substantially improved outcomes.8,9 An increase in compliance from 50 up to 70% or higher with ERAS Society recommended care elements in colorectal surgery resulted in a reduction in complications by up to 30% and length of stay by several days (up to 40%).6,7 Similar results are demonstrated in other surgical specialties.1 However, it has been the global experience of the ERAS Society that implementation can be challenging. The implementation programme should be a structured process performed by a local multidisciplinary team supported by ERAS experts. It should be focused on change management, training the team to increase guideline compliance and to use interactive auditing as a means of improving clinical outcomes. Implementation of ERAS care varies around the world.1,12 In a recent international survey investigating the status of ERAS protocol implementation in open gynaecological oncology surgery in over 460 units globally, 37% of hospitals in Europe reported that they were delivering ERAS, whilst Asia and Africa had the lowest rates, with ERAS delivery at 30 and 17%, respectively.12 Yet, even within these users, it was reported that many of the key ERAS guideline elements were not practised.1,2 ERAS care challenges traditional care and the move away from conventional practice requires a multimodal approach to integrate ERAS elements within the peri-operative period. Moreover, although many professionals involved in surgical care claim they 'do ERAS', national data on colorectal surgery reveal prolonged hospital stays, contradicting the claimed widespread use of 'ERAS'.1,12 Although some hospitals report they are 'doing ERAS', and even may have had training, consisting of lectures, guidelines and instructions, it does not mean that the guidelines are being followed or that their results are as good as they could be, as shown in a recent Spanish study in 80 hospitals.10 This latter study in colorectal surgery showed that when the rate of adherence to the ERAS protocol was high in ERAS hospitals vs. non-ERAS hospitals (72.7% [IQR, 59.1 to 81.8%] vs. 59.1% [50.0 to 63.6%], respectively; P < 0.001), the patients in hospitals with the highest adherence rates had fewer overall complications (OR, 0.33; 95% CI, 0.26 to 0.43; P < 0.001), and mortality (OR, 0.27; 95% CI, 0.07 to 0.97; P = 0.06).10 The study also showed that simply having a protocol in place is not enough to improve patient outcomes: continuous auditing of outcome is essential.10,13 ERAS saves costs for care It is not surprising that, given the improved clinical outcomes achieved by ERAS protocols in reducing complications and hospital stay, repeated economic analyses have shown high cost savings ranging between US$655 and $16 447 per patient.14–16 In a recent analysis, these cost savings for an entire healthcare system (Alberta Healthcare, Canada) reported a return-on-investment ratio of up to 7.3, meaning that for every dollar invested in ERAS, $7.3 was saved in return.16 On the basis of these data, hospital care decision makers can better understand the value that can be created for the health system, finally gaining better care for lower costs. Future perspectives and Covid-19 ERAS is spreading rapidly across the globe, and many opportunities and challenges for improving outcomes lie ahead. In the near future, many of the challenges and potential improvement for ERAS are related to anaesthesia. These include preparing the patient for major surgery (including prehabilitation, nutrition and anaemia management), carbohydrate loading, fluid management, optimal anaesthesia and pain management; currently, in peri-operative practice, there is too much opioid use and too few multimodal opioid-sparing regimes in use. Many of these aspects of care involve the surgeons as well as nursing and allied health professionals, making collaboration beyond the operating room and PACU even more important. There are also research gaps in ERAS to be addressed, and the most important current issue is how to conduct research to bridge such gaps. In a recent publication, a checklist was suggested to provide a standardised framework for reporting ERAS studies with the goal of increasing the reproducibility of such studies and improving study reporting so that future meta-analyses can be performed more easily. In this light, randomised controlled trials (RCTs) might not be the best way to influence clinical practice at the current time.6 In countries with limited resources where ERAS is particularly important, its implementation will be an even greater challenge. Explanations for the lower uptake of ERAS in low and middle-income countries (LMIC) could be due to financial barriers, insurance status or lack of expertise and education. We believe that ERAS in LMIC can help facilitate the Global Surgery 2030 goals to improve patient outcomes, service efficiency and reduce hospital bed days.17 However, at the moment, the most important challenge for all is the COVID-19 pandemic, which has caused major changes in global health delivery, and is having a marked financial impact.18 Usually, changing clinical care takes 15 years or more but, as a result of COVID-19, many units around the world changed their practice within a few weeks. This presents an opportunity for surgery and anaesthesia to use the momentum of change adopted during the COVID-19 pandemic to modernise peri-operative care by working together in order to break down the outmoded departmental silo mentality with the common goal of improving outcomes for patients by implementing ERAS pathways.18 Apart from reduced length of stay, complications and cost, rapid patient discharge may minimise the risk of in-hospital COVID-19 infections. Moreover, the COVID-19 crisis drives other improvements using modern technology, such as telemedicine, which has been employed to avoid unnecessary in-person visits and to facilitate remote consultation and prehabilitation before surgery. ERAS brings modern monitoring and audit to obtain control of the entire peri-operative process and will lead to much needed improvement in surgical outcomes. In the 10 years since its founding, the ERAS Society has undoubtedly made significant contributions through developing peri-operative pathways, thereby improving peri-operative care worldwide. By research, education and a multidisciplinary, multiprofessional approach, with continuous interactive audit and reporting, the ERAS Society has helped the implementation of evidence-based practice. The strategy of the Society has been to involve teams around the world in a large and growing network, all working together and trained to drive change based on data and audit. For the first 10 years since of the birth of the ERAS Society, this has worked well. Inspired by what has been achieved so far, it remains the goal of the Society to collaborate with all and everyone to build a larger and stronger network that can help improve global peri-operative care.

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