Enhanced recovery after surgery (ERAS) programmes aim to achieve early recovery after surgery. The concept focuses on optimising all the important perioperative components, such as optimised patient information, anaesthesia, pain and fluid therapy and minimally invasive surgery, together with updated care principles, such as the use of drains, catheters, fasting rules, early mobilisation and nutrition (Kehlet and Wilmore, 2008). ERAS is a multidisciplinary concept in which nursing has a major and decisive impact, as the quality of perioperative care is essential to improve the postoperative outcome. Thus, it is crucial that nurses understand their role and the background and impact of ERAS programmes (Balfour et al, 2019).
Enhanced recovery programmes have been described in all surgical specialties based on procedure-specific, evidence-based clinical guidelines, showing benefits such as faster recovery and reduced length of stay, without increased risk of readmission, fewer medical complications (cardiovascular, pulmonary and thromboembolic), less fatigue and faster resumption of normal daily activities after discharge, as well as reduced costs (Kehlet and Jørgensen, 2016; Ljungqvist et al, 2017).
The concept of enhanced recovery programmes has been adopted to varying degrees by most surgical departments all over Denmark, but, despite the well-documented effect, the overall implementation of enhanced recovery programmes has been slow, not only in Denmark, but worldwide (Kehlet 2018; Rønfeldt et al, 2018; Francis et al, 2018). In this context, the literature describes the challenges of transferring research findings into practice—the knowledge-doing gap (Maessen et al, 2007; Kehlet, 2011), as well as several more or less complicated strategies to solve the problem (Francis et al, 2018).
Successful implementation of ERAS programmes depends on key factors such as data availability, knowledge, leadership and multidisciplinary collaboration (Kehlet and Wilmore, 2008; Kehlet, 2018), supported by teaching and clinical guidelines with daily goals to improve the quality of care by standardising care and reducing practice variation (Hakkennes and Dodd, 2008; Hunter and Segrott, 2008). Evidence-based care plans are available in numerous publications and as guidelines at the ERAS Society's website (www.erassociety.org). A multidisciplinary approach is required with the collaboration of surgeons, anaesthesiologists, nurses and physiotherapists, as well as organisational changes to accommodate the components in the ERAS concept.
However, initial implementation is one thing; the next challenge is to ensure persistent adherence to the ERAS principles. One of the most important tools to ensure sustained implementation is to know your own data such as length of stay, readmission rates, mortality, postoperative complications and outcome (Francis et al, 2018; Kehlet, 2018). In the following sections the authors describe their experiences with national and local initiatives to implementing ERAS programmes in Denmark, as well as methods to ensure sustainability and high quality of surgical care, both with important roles for nurses.
National surgical unit
In 1999, Henrik Kehlet initiated the establishment of the ‘Surgical Project’, a national unit for monitoring surgical outcome in collaboration with the National Board of Health. The purpose was to identify areas for quality improvement and optimised organisation. The work involved several surgeons from various specialties with an interest in quality improvement. It was procedure-specific and the published data showed high morbidity and mortality due to suboptimal organisation, thereby forming the basis for subsequent adjustment with increased specialisation and secondary improvement of outcome. Other studies such as Kehlet and Harling (2012) focused on the degree of implementation of ERAS principles and optimised use of minimally invasive surgery. Overall, the national surgery project had a major impact on the quality improvement of surgical outcomes in Denmark, such as a reduction in hospitalisation and medical complications and resulted in more than 30 published articles in several surgical areas (Azawi et al, 2012; Kehlet and Harling, 2012; Petersen et al, 2019). However, the surgical project was closed after 10 years without an explanation from the central authorities, despite the economic benefits (Kehlet, 2018).
National ERAS unit
Based on the success of ERAS, originally developed in Denmark (Kehlet, 1997), another national initiative was the establishment of the National Unit for Perioperative Nursing in 2004, funded by the Ministry of Health. The purpose of the unit was to work with coordination, teaching and knowledge sharing through an innovative multidisciplinary national network. This resulted in the development of 17 ERAS programmes for the major surgical areas, which were available on a website. These programmes helped to standardise and improve the quality of the surgical care in Denmark, thereby reducing the length of stay nationally without increased readmissions. The National Unit for Perioperative Nursing was found to be an effective facilitator in this implementation work (Hjort Jakobsen et al, 2014), but in 2012 the unit was closed due to lack of funding, despite a minimal cost of 1.8 million Danish krone (DKK) a year (around £215 000).
Local ERAS unit at Rigshospitalet
Based on the experiences of the National Surgical Unit and the National Unit for Perioperative Nursing, the management team at Rigshospitalet, a highly specialised tertiary referral centre in Copenhagen established a local ERAS unit in 2012, to improve the quality of perioperative care for all surgical procedures by ensuring updated ERAS procedure-specific, evidence-based programmes. Two full-time clinical nurse specialists and a part-time professor (surgeon) are employed in the unit and work closely with an anaesthesiologist and the staff from the Department of Quality and Data at Rigshospitalet.
The setup is organised so that, twice a year, all surgical departments receive procedure-specific data such as length of stay (LOS), readmission rate and death within 30 days based on data from the National Patient Register (NPR), as the key to maintaining a constantly high level of quality of care is to know the data and act on them (Kehlet, 2018). The NPR secures data completeness since departments will not receive reimbursement from the government unless the procedure is registered. It also secures a complete follow-up wherever in the country a readmission occurs. Initially, the ERAS unit and clinical experts review the data. If data shows an increase in readmissions or LOS, an analysis of readmitted cases or a clinical audit will be done in order to clarify perioperative problems. Audit and feedback are well-documented methods for assessing clinical practice and to evaluate clinical care issues (Ivers et al, 2012). In the authors' experience, a retrospective audit review of 20 consecutive patients undergoing the same surgical procedures provides a relevant picture of the potential postoperative care issues. Examples of used data are assessment of the pain treatment, degree of mobilisation on individual days, gastrointestinal recovery, oral intake, breakthrough pain, removal time for bladder and epidural catheter etc. Subsequently, audit data are evaluated by the ERAS unit, together with relevant surgeons, nurses and anaesthesiologists in relation to the evidence (ERAS programmes) and new actions are decided on, such as optimised pain management and specific principles for nursing care. The ERAS unit works closely with clinicians and assists in the implementation of new initiatives, which are focused to ensure evidence-based care as well as to help with necessary organisational changes. A follow-up audit will be conducted to assess the impact of the new actions.
All surgical wards at the hospital have made a list of the surgical procedures on which they want data. The list is increasing and presently there are data on LOS, readmission and death within 30 days (Figure 1) on about 100 surgical procedures. In addition, there are data from 90 audits (of which several are repetitions of previous audits) and 20 reports reviewing reasons for readmissions. The ERAS unit team discuss data with the hospital management at least once a year, where optimisation potentials are pointed out and future audits are decided. Both the clinical audit data and the data from the NPR have led to increased awareness about clinical care issues that can complicate and prolong hospital stay.
Results
As a result of an intensive effort in all surgical specialties such as abdominal surgery, urology, orthopaedic surgery, gynaecology, neurosurgery and thoracic surgery at Rigshospitalet, we have experienced progress in implementing the ERAS principles. However, it is a continuous process, with constant room for optimisation. In general, major abdominal surgery audits have shown that when postoperative issues such as pain, nausea, fluid therapy, use of invasive equipment and lack of mobilisation are solved, the result is faster fulfilment of discharge criteria and thereby decreased LOS (Figure 1).
We have experienced and revealed different scenarios in data presentation, typically reflecting the degree of ERAS implementation and organisational issues. As illustrated in Figure 1 and Figure 2, data show the mean LOS for the total stay (pre- and postoperative stay) and the mean postoperative stay for one surgical procedure in one unit. The difference between mean total LOS and mean postoperative LOS shows the length of the preoperative admission, an observation used to discuss the organisation of the preoperative preparation of the patient.
Another example is shown in Figure 2, with data from a complex surgical procedure. An optimisation process has been in progress for some years with implementation of an ERAS programme, as seen by the curve, but the process has been complicated by various organisational conditions, especially a shortage of nurses. Recent audits show major clinical issues, including pain and mobilisation, demonstrating the potential for optimisation. Based on these data, an ongoing, multidisciplinary optimisation process is underway. Despite these issues, it is worth noting that this is an example of a surgical procedure with no pre-operative hospitalisation as the patients are admitted on the day of surgery (mean total and mean postoperative are similar).
Finally, the data allow comparison of outcome following different surgical methods on the same procedure, such as open, laparoscopic or robotic nephrectomy, leading to relevant interdisciplinary discussions of the benefits, disadvantages and outcome in relation to costs, and need for specific resources.
Future challenges and conclusion
In order to obtain adequate data, it has been necessary to work closely with the Department of Quality and Data, which, based on the specific codes for the surgical procedures, gets data from the NPR.
The audit process has been an important supplement to data from the National Patient Register (Gillissen et al, 2015), as the data from the audits provide us with the reasons for hospitalisation, which are used to optimise patient care. As the retrospective audit is based on the clinicians' documentation in the patient record, optimal documentation is of great importance. We are experiencing challenges in finding adequate data after the introduction of a new electronic patient record system. Another significant problem is that the previously used written standard care ERAS plans, to guide the best practice and to ensure a consistently high quality of care, cannot be integrated into the electronic patient record system at Rigshospitalet, a challenge we are trying to solve.
The current process at the ERAS unit at Rigshospitalet is documented in several surgical procedures, especially in breast cancer surgery, where the patient treatment course is now an outpatient course in more than 70% of patients, to everyone's satisfaction, in contrast to 5 days of hospitalisation before implementation of the ERAS programme (Duriaud et al, 2018). Organisational changes and multidisciplinary collaboration form the basis of this success, in which the establishment of a nurse-led outpatient clinic helps to ensure good nursing care and patient satisfaction (Mertz et al, 2013). In well-functioning ERAS settings, nurses have gained enhanced skills both in the preoperative preparation of patients, during hospitalisation and after discharge, which helps to maintain good implementation and good quality of care (Mertz et al, 2013; Specht et al, 2015).
These results are of great importance for the patient-experienced quality of care, as described by Bernard and Foss (2014), who focused on patient satisfaction and concluded that patients report positive aspects of their ERAS experience and favour the programme particularly because home is the preferred place for recovery. Also, from an administrative point of view, these results are important because of significant savings (Modesitt et al, 2016) and reorganisation—the shortened hospital stay, for example, can reduce the number of nursing staff needed at the weekends (Mertz et al, 2013). The same is observed in the multidisciplinary collaboration in fast-track hip and knee surgery, with great cost savings due to clear improvements in care and recovery, despite unchanged staff resources (Specht et al, 2015). Similar experiences have been documented in complex microvascular breast reconstruction, with quality improvement and a more than 50% reduction in LOS (Bonde et al, 2016).
Overall, the establishment of an ERAS unit has been proved to accelerate implementation of ERAS programmes in all surgical specialties. The combination of procedure-specific data concerning LOS and readmission, together with audit data, have facilitated implementation of procedure-specific ERAS programmes in all surgical specialties, improved perioperative quality of care and decreased LOS. Data feedback to frontline providers has a great impact on maintaining ERAS principles as demonstrated in a recent national cohort of hospitals in the USA (Hu et al, 2019). In the authors' experience, continuous data feedback motivates the clinicians to optimise the quality of care by clarifying the perioperative issues and allowing for benchmarking.
The ERAS unit at Rigshospitalet is a success with a documented positive effect, primarily on patient care and secondly on the need for hospitalisation. It is evident that knowing and using data is prerequisite for perioperative improvements. The described method is an easy, simple and continuous process where clinicians become aware of their own practice compared to existing evidence. Furthermore, the method is a pragmatic and cheap tool for the hospital management to ensure the sustainability of ERAS programmes, which also allows cross-hospital benchmarking.