Requirements for a successful Enhanced Recovery After Surgery (ERAS) program: a multicenter international survey among ERAS nurses

The Enhanced Recovery After Surgery (ERAS) concept has disseminated worldwide, with established positive effects on patients and healthcare due to reduced complications, length of stay and costs [1]. The success of this modus operandi is based on multimodal and multidisciplinary care. Nurses, in particular dedicated ERAS nurses (also called ERAS nurse coordinators), are the linchpin of a successful and sustainable program [2, 3]. While studies have primarily focused on clinical outcomes and hospital economics, the specific needs and point of view of nursing staff remains poorly explored [4, 5].

The aim of the present survey was to study key elements and challenges for ERAS care from a nurse’s perspective.

In total, 123 out of 306 invited nurses completed the survey (40% response rate). Demographics of the responding participants are summarized in the Table 1 with a focus on setting, implementation history and personal experience.

The present survey revealed some heterogeneity in ERAS coordination and management strategies. Nevertheless, overall program success was generally rated as high, with the main motivators related to improved patient outcomes and satisfaction. Time restraints and logistics were identified as the main drawbacks. Staff education both before and after implementation and a dedicated coordinator appear to be key for a successful program.

Considerable heterogeneity in both coordination and organization of ERAS programs among participating institutions was observed. More specifically, ERAS-dedicated percentage/working time, frequency of staff education and meetings, as well as strategies of data acquisition and complication assessment varied between the various centers. These differences may be related to the international setting of this survey with local discrepancies. The findings also emphasize that there are different ways to achieve the common goal of a successful ERAS program.

The success of ERAS was rated as high (6.9/10). Previously published studies have reported that implementation of ERAS reduces nursing workload [2, 6]. However, these studies focused on the initial implementation period, and it has to be mentioned that further studies observed decreased sustainability after the initial enthusiasm from the implementation period had worn off [7‐9]. Based on the present survey, staff education before as well as after implementation appears to be very important. One of the reasons cited was the constant turnover in nursing staff and physicians, which makes it difficult to sustain the appropriate level of training. Likewise, maintaining high-quality ERAS over time was evaluated to be as high as the implementation of ERAS itself (both > 5/10). While there appears to be no consensus on the optimal frequency of ERAS meetings and educational sessions, most responders agreed that continuous monitoring, mentoring and support by expert centers were important for sustainability. Furthermore, trouble-shooting by auditing clinical outcomes, compliance and problems in daily practice appeared to be more important than the mere focus on numbers and research (Fig. 1d). Importantly, external audit by expert centers was rated as important. This is in line with the findings of a recent study evaluating auditing methods in Switzerland [10]. The assessment of complications appears to be a potential point of frustration (Fig. 1e). Potential reasons for this may be incompatibility of EIAS software and local patient medical records (PMR), as well as logistics issues such as time restraints and insufficient staffing.

There was a need to better define the tasks of an ERAS coordinating nurse. This is important when considering that most participants indicated they only had a part-time commitment to ERAS. This need is illustrated by the high acceptance of pre-operative education and follow-up of the patient and teaching tasks, while data management was rated as less important. Nevertheless, improving both patient outcomes and satisfaction were considered main motivators for ERAS implementation. These results suggest that nurses may be keeping the focus on the patient rather than administrative tasks. At the same time, unless data is properly recorded, the possibility of maintaining high standards and correcting mismanagement is lost. Whether ERAS coordinating teams with shared responsibilities (clinical coordinator and administrator), or a data manager dedicated to data entry in order to lessen the burden for a single coordinator would be an alternative strategy needs to be further investigated and applied.

Interestingly, only 20% of participants considered patients as a barrier for implementation. This is less than the barriers felt from both surgeons (34%) and fellow nurses (30%). On the other hand, time restraints, together with the logistics and administrative workload, appeared to be the main barrier for a successful ERAS program. This has previously been described [11]. Investment and insufficient support, both considered as important barriers in the early days of ERAS, were now only considered as minor issues. It seems that, today, ERAS coordinators and stakeholders put the financial burden of initial implementation into perspective of the repeatedly proven economic benefits in the long run [12, 13].

This study has limitations related to the relatively small number of invited participants and responders and potential selection bias of responders. Nevertheless, it revealed several areas with room for improvement from the nurse’s perspective. These need to be considered in order to maintain a sustained and proliferative ERAS work environment.

Despite heterogeneity in coordination and management, ERAS is reported to be a success from the nurse’s perspective. Continuous staff education beyond the implementation period and a dedicated coordinator appeared to be of key importance for an ERAS program of sustained high quality.