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A Qualitative Study to Understand the Barriers and Enablers in Implementing an Enhanced Recovery After Surgery Program

Pearsall, Emily A. BA*,†,‡; Meghji, Zahida MD; Pitzul, Kristen B. MSc; Aarts, Mary-Anne MD§,**; McKenzie, Marg RN*,†,‡; McLeod, Robin S. MD*,†,‡,**,‡‡; Okrainec, Allan MD¶,**

doi: 10.1097/SLA.0000000000000604
Original Articles

Objective: Explore the barriers and enablers to adoption of an Enhanced Recovery after Surgery (ERAS) program by the multidisciplinary perioperative team responsible for the care of elective colorectal surgical patients.

Background: ERAS programs include perioperative interventions that when used together have led to decreased length of stay while increasing patient recovery and satisfaction. Despite the known benefits of ERAS programs, uptake remains slow.

Methods: Semistructured interviews were conducted with general surgeons, anesthesiologists, and ward nurses at 7 University of Toronto-affiliated hospitals to identify potential barriers and enablers to adoption of 18 ERAS interventions. Grounded theory was used to thematically analyze the transcribed interviews.

Results: Nineteen general surgeons, 18 anesthesiologists, and 18 nurses participated. The mean time of each interview was 18 minutes. Lack of manpower, poor communication and collaboration, resistance to change, and patient factors were cited by most as barriers. Discipline-specific issues were identified although most related to resistance to change. Overall, interviewees were supportive of implementation of a standardized ERAS program and agreed that a standardized guideline based on best evidence; standardized order sets; and education of the staff, patients, and families are essential.

Conclusions: Multidisciplinary perioperative staff supported the implementation of an ERAS program at the University of Toronto–affiliated hospitals. However, major barriers were identified, including the need for patient education, increased communication and collaboration, and better evidence for ERAS interventions. Identifying these barriers and enablers is the first step toward successfully implementing an ERAS program.

Semistructured interviews were conducted with surgeons, anesthesiologists, and nurses from 7 University of Toronto–affiliated hospitals to understand the barriers and enables to implementing an Enhanced Recovery after Surgery (ERAS) program.

*Zane Cohen Clinical Research Centre

Samuel Lunenfeld Research Institute, and

Department of Surgery, Mount Sinai Hospital

§Department of Surgery, Toronto East General Hospital

Division of General Surgery, University Health Network

**Departments of Surgery

††Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.

Reprints: Allan Okrainec, MD, MP 8-3, TWH, Toronto Western Hospital-University Health Network, 399 Bathurst Street, Toronto, Ontario, Canada. E-mail:

Disclosure: Angelo and Alfredo De Gasperis Families Chair in Colorectal and IBD Research. This study was funded by Colon Cancer Canada.

Presented as a Poster at the Canadian Surgery Forum, London, ON, September 2011.

© 2015 by Lippincott Williams & Wilkins.