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Sier MAT, Godina E, Tweed TTT, Daher I, Stoot JHMB. Views and experiences of healthcare professionals and patients on the implementation of a 23-hour accelerated enhanced recovery programme: a mixed-method study. BMC Health Serv Res 2024; 24:330. [PMID: 38475839 DOI: 10.1186/s12913-024-10837-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/07/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND An accumulating body of research suggests that an accelerating enhanced recovery after colon surgery protocol is beneficial for patients, however, to obtain these effects, adherence to all elements of the protocol is important. The implementation of complex interventions, such as the Enhanced Recovery After Surgery protocol (ERAS), and their strict adherence have proven to be difficult. The same challenges can be expected in the implementation of the accelerated Enhanced Recovery Pathways (ERPs). This study aimed to understand the perspectives of both healthcare professionals (HCPs) and patients on the locally studied acCelerated enHanced recovery After SurgEry (CHASE) protocol. METHODS For this mixed-method study, HCPs who provided CHASE care and patients who received CHASE care were recruited using purposive sampling. Ethical approval was obtained by the Medical Ethical Committee of the Zuyderland Medical Centre (NL71804.096.19, METCZ20190130, October 2022). Semi-structured, in-depth, one-on-one interviews were conducted with HCPs (n = 13) and patients (n = 11). The interviews consisted of a qualitative and quantitative part, the protocol evaluation and the Measurement Instrument or Determinant of Innovations-structured questionnaire. We explored the perspectives, barriers, and facilitators of the CHASE protocol implementation. The interviews were audiotaped, transcribed verbatim and analysed independently by two researchers using direct content analysis. RESULTS The results showed that overall, HCPs support the implementation of the CHASE protocol. The enablers were easy access to the protocol, the relevance of the intervention, and thorough patient education. Some of the reported barriers included the difficulty of recognizing CHASE patients, the need for regular feedback, and the updates on the implementation progress. Most patients were enthusiastic about early discharge after surgery and expressed satisfaction with the care they received. On the other hand, the patients sometimes received different information from different HCPs, considered the information to be too extensive and few experienced some discomfort with CHASE care. CONCLUSION Bringing CHASE care into practice was challenging and required adaptation from HCPs. The experiences of HCPs showed that the protocol can be improved further, and the mostly positive experiences of patients are a motivation for this improvement. These results yielded practical implications to improve the implementation of accelerated ERPs.
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Affiliation(s)
- Misha A T Sier
- Department of Surgery, Zuyderland Medical Centre, Henri Dunantstraat 5, Heerlen, 6419 PC, The Netherlands.
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Universiteitssingel 40, Maastricht, 6229 ER, The Netherlands.
| | - Eva Godina
- Department of Surgery, Zuyderland Medical Centre, Henri Dunantstraat 5, Heerlen, 6419 PC, The Netherlands
- Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Universiteitssingel 40, Maastricht, 6229 ER, The Netherlands
| | - Thaís T T Tweed
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Universiteitssingel 40, Maastricht, 6229 ER, The Netherlands
- Department of Surgery, Maastricht University Medical Centre+, P. Debyelaan 25, Maastricht, 6229 HX, the Netherlands
| | - Imane Daher
- Department of Gastroenterology, Zuyderland Medical Centre, Henri Dunantstraat 5, Heerlen, 6419 PC, the Netherlands
| | - Jan H M B Stoot
- Department of Surgery, Zuyderland Medical Centre, Henri Dunantstraat 5, Heerlen, 6419 PC, The Netherlands
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Nelson G, Fotopoulou C, Taylor J, Glaser G, Bakkum-Gamez J, Meyer LA, Stone R, Mena G, Elias KM, Altman AD, Bisch SP, Ramirez PT, Dowdy SC. Enhanced recovery after surgery (ERAS®) society guidelines for gynecologic oncology: Addressing implementation challenges - 2023 update. Gynecol Oncol 2023; 173:58-67. [PMID: 37086524 DOI: 10.1016/j.ygyno.2023.04.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Despite evidence supporting its use, many Enhanced Recovery After Surgery (ERAS) recommendations remain poorly adhered to and barriers to ERAS implementation persist. In this second updated ERAS® Society guideline, a consensus for optimal perioperative care in gynecologic oncology surgery is presented, with a specific emphasis on implementation challenges. METHODS Based on the gaps identified by clinician stakeholder groups, nine implementation challenge topics were prioritized for review. A database search of publications using Embase and PubMed was performed (2018-2023). Studies on each topic were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded by an international panel according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS implementation challenge topics are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS The updated evidence base and recommendations for stakeholder derived ERAS implementation challenges in gynecologic oncology are presented by the ERAS® Society in this consensus review.
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Affiliation(s)
- G Nelson
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - C Fotopoulou
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - J Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - J Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - L A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R Stone
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - G Mena
- Department of Anesthesiology, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K M Elias
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - A D Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - S P Bisch
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - P T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, TX, USA
| | - S C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
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Missel M, Beck M, Donsel PO, Petersen RH, Benner P. Do enhanced recovery after lung cancer surgery programs risk putting primacy of caring at stake? A qualitative focus group study on nurses' perspectives. J Clin Nurs 2022. [DOI: 10.1111/jocn.16555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/16/2022] [Accepted: 09/23/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Malene Missel
- Department of Cardiothoracic Surgery Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | - Malene Beck
- Department of Physiotherapy and Occupational Therapy Slagelse Hospital Slagelse Denmark
- Department of Regional Health Research University of Southern Denmark Odense Denmark
| | - Pernille Orloff Donsel
- Department of Cardiothoracic Surgery Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | - René Horsleben Petersen
- Department of Cardiothoracic Surgery Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | - Patricia Benner
- University of Nevada, Las Vegas School of Nursing Las Vegas Nevada USA
- University of California School of Nursing Los Angeles California USA
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Wang D, Liu Z, Zhou J, Yang J, Chen X, Chang C, Liu C, Li K, Hu J. Barriers to implementation of enhanced recovery after surgery (ERAS) by a multidisciplinary team in China: a multicentre qualitative study. BMJ Open 2022; 12:e053687. [PMID: 35288383 PMCID: PMC8921855 DOI: 10.1136/bmjopen-2021-053687] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To explore the attitudes and barriers encountered in the implementation of enhanced recovery after surgery (ERAS) in China from the perspective of multidisciplinary team members. DESIGN Based on Donabedian's structure-process-outcome (SPO) model, a multicentre qualitative study using semistructured interviews was conducted. SETTING From September 2020 to December 2020, the participants of this study were interviewed from six tertiary hospitals in Sichuan province (n=3), Jiangsu province (n=2) and Guangxi province (n=1) in China. PARTICIPANTS A total of 42 members, including surgeons (n=11), anaesthesiologists (n=10), surgical nurses (n=14) and dietitians(n=7) were interviewed. RESULTS Multidisciplinary team (MDT) members still face many barriers during the process of implementing ERAS. Eight main themes are described around the barriers in the implementation of ERAS. Themes in the structure dimension are: (1) shortage of medical resources, (2) lack of policy support and (3) outdated concepts. Themes in the process dimension are: (1) poor doctor-patient collaboration, (2) poor communication and collaboration among MDT members and (3) lack of individualised management. Themes in the outcome dimension are: (1) low compliance and (2) high medical costs. The current implementation of ERAS is still based on ideas more than reality. CONCLUSIONS In general, barriers to ERAS implementation are broad. Identifying key elements of problems in the application and promotion of ERAS from the perspective of the MDT would provide a starting point for future quality improvement of ERAS, enhance the clinical effect of ERAS and increase formalised ERAS utilisation in China.
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Affiliation(s)
- Dan Wang
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhenmi Liu
- West China School of Public Health/West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jing Zhou
- Hepatobiliary and pancreatic surgery, The Second People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Jie Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xinrong Chen
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chengting Chang
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Changqing Liu
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ka Li
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiankun Hu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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5
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An overview of the evidence for enhanced recovery. SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2021.100826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Zorrilla-Vaca A, Stone AB, Ripolles-Melchor J, Abad-Motos A, Ramirez-Rodriguez JM, Galan-Menendez P, Mena GE, Grant MC. Institutional factors associated with adherence to enhanced recovery protocols for colorectal surgery: Secondary analysis of a multicenter study. J Clin Anesth 2021; 74:110378. [PMID: 34144497 DOI: 10.1016/j.jclinane.2021.110378] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/20/2021] [Accepted: 05/10/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Adherence to Enhanced Recovery Protocols (ERPs) is associated with faster functional recovery, better patient satisfaction, lower complication rates and reduced length of hospital stay. Understanding institutional barriers and facilitators is essential for improving adherence to ERPs. The purpose of this study was to identify institutional factors associated with adherence to an ERP for colorectal surgery. METHODS A secondary analysis of a nationwide study was conducted including 686 patients who underwent colorectal surgery across twenty-one institutions in Spain. Adherence to ERPs was calculated based upon the components recommended by the Enhanced Recovery After Surgery (ERAS®) Society. Institutional characteristics (i.e., case volume, ERP duration, anesthesia staff size, multidisciplinary meetings, leadership discipline) were captured from each participating program. Multivariable regression was performed to determine characteristics associated with adherence. RESULTS The median adherence to ERAS was 68.2% (IQR 59.1%-81.8%). Multivariable linear regression revealed that anesthesiologist leadership (+5.49%, 95%CI +2.81% to +8.18%, P < 0.01), duration of ERAS implementation (+0.46% per year, 95%CI +0.06% to +0.86%, P < 0.01) and the use of regular multidisciplinary meetings (+4.66%, 95%CI +0.06 to +7.74%, P < 0.01) were independently associated with greater adherence. Case volume (-2.38% per 4 cases weekly, 95%CI -3.03 to -1.74, P < 0.01) and number of anesthesia providers (-1.19% per 10 providers, 95%CI +2.23 to -8.18%, P < 0.01) were negatively associated with adherence. CONCLUSION Adherence to ERPs is strongly associated with anesthesiology leadership, regular multidisciplinary meetings, and program duration, whereas case volume and the size of the anesthesia staff were potential barriers. These findings highlight the importance of strong leadership, experience and establishing a multidisciplinary team when developing an ERP for colorectal surgery.
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Affiliation(s)
- Andres Zorrilla-Vaca
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Alexander B Stone
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Javier Ripolles-Melchor
- Department of Anesthesia and Critical Care, Infanta Leonor University Hospital, Madrid, Spain
| | - Ane Abad-Motos
- Department of Anesthesia and Critical Care, Infanta Leonor University Hospital, Madrid, Spain
| | | | | | - Gabriel E Mena
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital School of Medicine, Baltimore, MD, USA
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van Noort HHJ, Eskes AM, Vermeulen H, Besselink MG, Moeling M, Ubbink DT, Huisman-de Waal G, Witteman BJM. Fasting habits over a 10-year period: An observational study on adherence to preoperative fasting and postoperative restoration of oral intake in 2 Dutch hospitals. Surgery 2021; 170:532-540. [PMID: 33712307 DOI: 10.1016/j.surg.2021.01.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/29/2020] [Accepted: 01/24/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Since 1999, international guidelines recommend fasting from solid foods up to 6 hours and clear liquids up to 2 hours before surgery. Early recovery after surgery programs recommend restoration of oral intake as soon as possible. This study determines adherence to these guidelines up to 20 years after its introduction. METHODS A 2-center observational study with a 10-year interval was performed in the Netherlands. In period 1 (2009), preoperative fasting time was observed as primary outcome. In period 2 (2019), preoperative fasting and postoperative restoration of oral intake were observed. Fasting times were collected using an interview-assisted questionnaire. RESULTS During both periods, 311 patients were included from vascular, trauma, orthopedic, urological, oncological, gastrointestinal, and ear-nose-throat and maxillary surgical units. Duration of preoperative fasting was prolonged in 290 (90.3%) patients for solid foods and in 208 (67.8%) patients for clear liquids. Median duration of preoperative fasting from solid foods and clear liquids was respectively 2.5 and 3 times the recommended 6 and 2 hours, with no improvements from one period to another. Postoperative food intake was resumed within 4 hours in 30.7% of the patients. Median duration of perioperative fasting was 23:46 hours (interquartile range 20:00-30:30 hours) for solid foods and 11:00 hours (interquartile range 7:53-16:00 hours) for clear liquids. CONCLUSION Old habits die hard. Despite 20 years of fasting guidelines, surgical patients are still exposed erroneously to prolonged fasting in 2 hospitals. Patients should be encouraged to eat and drink until 6 and 2 hours, respectively, before surgery and to restart eating after surgery.
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Affiliation(s)
- Harm H J van Noort
- Department of Nutrition, Physical Activity and Sports, Department of Surgery, Gelderse Vallei Hospital, Ede, The Netherlands; Radboud University Medical Centre, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands; Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Anne M Eskes
- Department of Surgery, Amsterdam UMC, University of Amsterdam, The Netherlands; Menzies Health Institute Queensland and School of Nursing and Midwifery, Griffith University, Gold Coast, Australia. https://twitter.com/Anne_Eskes
| | - Hester Vermeulen
- Radboud University Medical Centre, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands; Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands. https://twitter.com/hvermeulen67
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, The Netherlands. https://twitter.com/MarcBesselink
| | - Miranda Moeling
- Department of Nutrition and Dietetics, Faculty of Health, Nutrition and Sports, The Hague University of Applied Sciences, The Hague, The Netherlands
| | - Dirk T Ubbink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Getty Huisman-de Waal
- Radboud University Medical Centre, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands. https://twitter.com/getty_huisman
| | - Ben J M Witteman
- Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, The Netherlands; Division of Nutrition and Disease, Wageningen University, The Netherlands
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Kluyts HL, Biccard BM. The role of peri-operative registries in improving the quality of care in low-resource environments. Anaesthesia 2021; 76:888-891. [PMID: 33645733 DOI: 10.1111/anae.15445] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2021] [Indexed: 12/20/2022]
Affiliation(s)
- H-L Kluyts
- Department of Anaesthesiology, Dr George Mukhari Academic Hospital, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - B M Biccard
- Department of Anaesthesia and Peri-operative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
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Donadello K, Gottin L. Why are you so tired after surgery? Minerva Anestesiol 2020; 86:1259-1262. [PMID: 33174411 DOI: 10.23736/s0375-9393.20.15247-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Katia Donadello
- Unit of Anesthesiology and Intensive Care B, Department of Surgery, Dentistry, Gynecology and Pediatrics, AOUI-University Hospital Integrated Trust of Verona, University of Verona, Verona, Italy -
| | - Leonardo Gottin
- Unit of Cardio-Thoracic Anesthesiology and Intensive Care, Department of Surgery, Dentistry, Gynecology and Pediatrics, AOUI-University Hospital Integrated Trust of Verona, University of Verona, Verona, Italy
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Spruce L. Enhanced Recovery After Surgery for Patients Undergoing Total Hip or Total Knee Arthroplasty. AORN J 2020; 111:550-557. [PMID: 32343393 DOI: 10.1002/aorn.13034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Enhanced recovery program implementation: an evidence-based review of the art and the science. Surg Endosc 2019; 33:3833-3841. [PMID: 31451916 DOI: 10.1007/s00464-019-07065-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 08/13/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The benefits of enhanced recovery program (ERP) implementation include patient engagement, improved patient outcomes and satisfaction, better team relationships, lower per episode costs of care, lower public consumption of narcotic prescription pills, and the promise of greater access to quality surgical care. Despite these positive attributes, vast numbers of surgical patients are not treated on ERPs, and many of those considered "on pathway" are unlikely to be exposed to a majority of recommended ERP elements. METHODS To explain the gap between ERP knowledge and action, this manuscript reviewed formal implementation strategies, proposed a novel change adoption model and focused on common barriers (and corollary solutions) that are encountered during the journey to a fully implemented and successful ERP. Given the nature of this review, IRB approval was not required/obtained. RESULTS The information reviewed indicates that implementation of best practice is both a science and an art. What many surgeons have learned is that the "soft" skills of emotional intelligence, leadership, team dynamics, culture, buy-in, motivation, and sustainability are central to a successful ERP implementation. CONCLUSIONS To lead teams toward achievement of pervasive and sustained adherence to best practices, surgeons need to learn new strategies, techniques, and skills.
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