The current and future role of nurses within enhanced recovery after surgery pathways

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways have been proven to expedite recovery after many procedures and reduce lengths of stay in hospital and surgical complications. However, improvements are still needed, especially in postoperative ERAS components delivered by nurses such as early mobilisation and oral feeding. This article summarises the current and possible future role of nurses within ERAS, and recommends areas for future research.

DISCUSSION

Nurses are the professionals who spend the most time with patients throughout the perioperative pathway and are known to play a vital role in delivering many components of an ERAS pathway. They frequently co-ordinate care across disciplines and ensure continuity of care. However, there is a paucity of ERAS research specific to nurses compared to other professional groups. Continual training on ERAS will be required to ensure nurses are highly educated and for the best possible ERAS implementation. In certain types of surgery, nurses may fulfil extended roles in the postoperative period, such as taking over responsibility and leadership for co-ordinating pain management, mobilisation and discharge. However, this requires a well-defined care programme, a clear definition of nursing responsibilities from surgeons, agreed discharge criteria and highly qualified nurses, along with the collection and analysis of data to test safety and efficacy.

CONCLUSION

Increasing nurse involvement in ERAS research is vital to drive improvements in care and to develop nursing roles. Nurses should have a major role in the preoperative clinic, the early postoperative phase and the follow-up post-discharge period, where the benefits of ERAS need to be further documented.

Postoperative mobilisation as an indicator for the quality of surgical nursing care

BACKGROUND

Postoperative mobilisation is an important part of fundamental care. Increased mobilisation has positive effect on recovery, but immobilisation is still a challenge in postoperative care.

AIMS

To report how the establishment of a national nursing database was used to measure postoperative mobilisation in patients undergoing surgery for ovarian cancer.

METHODS

'Mobilisation' was defined as at least 3 hours out of bed on postoperative day 1, with the goal set at achieving this in 60% of patients. Data entry was performed by clinical nurses on 4400 patients with ovarian cancer.

FINDINGS

46.7% of patients met the goal for mobilisation on the first postoperative day, but variations in duration and type of mobilisation were observed. Of those mobilised, 51.8% had been walking in the hallway.

CONCLUSIONS

A national nursing database creates opportunities to optimise fundamental care. By comparing nursing data with oncological, surgical and pathology data it became possible to study mobilisation in relation to cancer stage, comorbidity, treatment and extent of surgery.

Perioperative nutrition: Recommendations from the ESPEN expert group

BACKGROUND & AIMS

Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14-15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients.

METHODS

This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art.

RESULTS

Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer.

CONCLUSIONS

Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient.

A simple method to secure data-driven improvement of perioperative care

Background:

Enhanced recovery after surgery (ERAS) programmes have been adopted to a varying degree by most surgical departments, not only in Denmark, but worldwide.

Aims:

To report the process from a local ERAS unit in a tertiary university hospital to accelerate implementation of ERAS programmes in all surgical specialties.

Methods:

All surgical departments receive twice-yearly procedure-specific data on length of stay (LOS), readmission rates and death within 30 days, based on surgical codes and the Danish National Patient Register. The ERAS unit and clinical experts review data followed by a clinical audit where appropriate.

Findings:

Setting up data presentation for clinical and nurse leaders has documented progress in implementing ERAS. The combination of outcome data, together with audits have been essential.

Conclusion:

The local ERAS unit has been shown to accelerate implementation of ERAS programmes in all surgical specialties, facilitated by procedure-specific LOS and re-admission data, combined with audit data.

Consensus on Training and Implementation of Enhanced Recovery After Surgery: A Delphi Study

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is widely accepted in current surgical practice due to its positive impact on patient outcomes. The successful implementation of ERAS is challenging and compliance with protocols varies widely. Continual staff education is essential for successful ERAS programmes. Teaching modalities exist, but there remains no agreement regarding the optimal training curriculum or how its effectiveness is assessed. We aimed to draw consensus from an expert panel regarding the successful training and implementation of ERAS.

METHODS

A modified Delphi technique was used; three rounds of questionnaires were sent to 58 selected international experts from 11 countries across multiple ERAS specialities and multidisciplinary teams (MDT) between January 2016 and February 2017. We interrogated opinion regarding four topics: (1) the components of a training curriculum and the structure of training courses; (2) the optimal framework for successful implementation and audit of ERAS including a guide for data collection; (3) a framework to assess the effectiveness of training; (4) criteria to define ERAS training centres of excellence.

RESULTS

An ERAS training course must cover the evidence-based principles of ERAS with team-oriented training. Successful implementation requires strong leadership, an ERAS facilitator and an effective MDT. Effectiveness of training can be measured by improved compliance. A training centre of excellence should show a willingness to teach and demonstrable team working.

CONCLUSIONS

We propose an international expert consensus providing an ERAS training curriculum, a framework for successful implementation, methods for assessing effectiveness of training and a definition of ERAS training centres of excellence.

A nationwide study of the quality of surgical guidelines and written patient information

INTRODUCTION

Clinical practice guidelines (CPGs) support enhanced post-operative recovery and decrease morbidity. In addition, patient information leaflets (PILs) are associated with enhanced overall outcomes and improved patient satisfaction. The aim of this study was to provide an overview of the quality of CPGs and PILs in cancer surgery departments undertaking pulmonary lobectomy, nephrectomy, cystectomy, whipples, colorectal and ovarian surgery.

METHODS

We conducted a cross-sectional descriptive study within 44 surgical departments in six cancer subspecialties: lung (n = 4), kidney (n = 9), bladder (n = 5), pancreas (n = 4), colorectal (n = 18) and ovarian (n = 4). Local CPGs were assessed according to nine key elements, i.e. discharge criteria and plans for mobilisation, pain management, nutrition, fluid, nausea and vomiting, antibiotics, bowel movements and urinary drainage. The PILs were evaluated using the DISCERN tool.

RESULTS

All departments had CPGs and PILs. Overall, 43% of the departments incorporated all nine key elements in the CPGs. Yet, a third of the CPGs lacked well-defined discharge criteria, and half of the PILs were of poor/very poor quality (48%); the remainder were fair (43%) or good (10%).

CONCLUSIONS

CPGs and PILs are highly available in Danish departments that perform cancer surgery. However, this study revealed that local CPGs lacked discharge criteria, and the majority of the PILs were considered of poor quality, suggesting that post-operative management after cancer surgery is of varying quality.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

Standardising fast-track surgical nursing care in Denmark

Considerable variations in procedures, hospital stay and rates of recovery have been recorded within specific surgical procedures at Danish hospitals. The aim of this paper is to report on a national initiative in Denmark to improve the quality of surgical care by implementation of clinical guidelines based on the principles of fast-track surgery-i.e. patient information, surgical stress reduction, effective analgesia, early mobilisation and rapid return to normal eating. Fast-track surgery was introduced systematically in Denmark by the establishment of the Unit of Perioperative Nursing (UPN) in 2004. The unit was responsible for guideline construction and implementation using the 'workshop practice method': establishing a website, creating a knowledge centre, coordinating implementation agents, and arranging national workshops and conferences. The UPN has promoted implementation of fast-track regimes in all surgical departments in Denmark. We recommend the workshop-practice method for implementation of new procedures in other areas of patient care.

[Perioperative care of patients with stage IIIC ovarian cancer]

INTRODUCTION

Besides intraoperative efforts, the perioperative care is essential to improve the postoperative outcome following ovarian cancer surgery. Multimodal evidence-based care within the fast-track methodology significantly enhances postoperative recovery and reduces morbidity. The purpose of this study was to assess and discuss perioperative care principles in patients undergoing ovarian cancer surgery with stage IIIC at the six centres in Denmark performing this surgical procedure.

MATERIAL AND METHODS

The study was a retrospective audit. The study included 90 consecutive patients, 15 from each of the centres at which operations were performed in 2007. Data was obtained from medical and nursing files. The extent of the surgical procedure was recorded.

RESULTS

For patients without extensive surgery effort, the median hospital stay was six days; for patients with extensive surgery, the median hospital stay was 13 days. A total of 48 percent of the patients without maximal surgery effort fulfilled the goals for mobilization on the day of surgery, and 19 percent on the first postoperative day. A total of 35 percent of the patients with maximal surgery effort fulfilled the goals for mobilization on the day of the surgery, and 24 percent on the first postoperative day. Less than half of the patients had regular oral diet and protein enriched drinks on or before the third postoperative day.

CONCLUSION

Mobilization, nutrition, nausea and pain are severe problems for patients undergoing ovarian cancer surgery. Optimized perioperative care is needed including a procedure-specific, evidence-based clinical guideline for patients receiving extensive surgery.

[Convalescence and sick leave after colonic surgery]

The benefits of fast-track surgery are improved recovery and a shorter period of postoperative convalescence. After uncomplicated colonic resection, there is no pathophysiological basis for recommending a postoperative convalescence of more than 2-3 weeks. Advice after discharge - Convalescence: Daily activities and light exercise should be resumed as soon as possible. Physically moderate work should be resumed after two weeks. Physically severe exercise and lifts (> 10 kg) as well as physically strenuous work may be resumed after 3-4 weeks.

[Surgical care guidelines]

INTRODUCTION

Evidence-based guidelines for perioperative care facilitate the recovery process and decrease morbidity and hospital stay. The aim of this study was to evaluate the availability and content of guidelines for perioperative care in all departments performing colonic resection, nephrectomy, ovarian cancer surgery, pulmonary resection and total knee replacement.

MATERIALS AND METHODS

Based upon nationwide workshops and agreement on clinical guidelines for perioperative care a questionnaire was sent to all surgical departments which perform the five procedures. Where available, the guidelines were assessed for presence of written information at admission and discharge, expected hospital stay, plan for mobilisation, nutrition and pain control as well as information on care after discharge.

RESULTS

Between 59% and 88% of the departments within each subspecialty had clinical guidelines for perioperative care. The content in the existing guidelines often lacked accurate information regarding preoperative information, objective pain assessment and well-defined discharge criteria.

CONCLUSION

The number of clinical guidelines is increasing, but there is a need for further implementation of clinical guidelines for perioperative care in order to improve outcome.

Convalescence after colonic surgery with fast-track vs conventional care

OBJECTIVE

To compare convalescence after colonic surgery with a fast-track rehabilitation programme vs conventional care.

BACKGROUND

Introduction of a multimodal rehabilitation programme (fast-track) with focus on epidural anaesthesia, minimal invasive surgical techniques, optimal pain control, and early nutrition and mobilization together with detailed patient information have led to a shorter hospital stay after colonic surgery. There are not much data on convalescence after discharge.

METHODS

A prospective, controlled, non-randomized interview-based assessment in 160 patients undergoing an elective, uncomplicated, open colonic resection or the Hartmann reversal procedure with a fast-track or a conventional care programme in two university hospitals. A structured interview-based assessment was performed preoperatively, and day 14 and 30 postoperatively.

RESULTS

Patients undergoing colonic surgery with a fast-track programme regained functional capabilities earlier with less fatigue and need for sleep compared with patients having conventional care. Despite early discharge of the fast-track patients (mean 3.4 days vs 7.5 days), no differences were found according to the need for home care, social care and visit to general practitioners, although the fast-track group had an increased number of visits at the outpatient clinic for wound care. More patients in the fast-track group were re-admitted, but the overall mean total hospital stay was 4.2 days vs 8.3 days in the conventional group.

CONCLUSION

A fast-track rehabillitation programme led to a shorter hospital stay, less fatigue and earlier resumption of normal activities, without the increased need for support after discharge compared with conventionally treated patients after uncomplicated colonic resection.

[Accelerated course after operation for ovarian cancer]

INTRODUCTION

Introduction of principles for postoperative multimodal rehabilitation (fast track surgery) has decreased hospital stay from about 8-10 days to 2-4 days after colonic resection. The aim of this study was to investigate the effect of a similar fast track regimen in patients operated for ovarian cancer.

METHOD

72 consecutive patients operated with a conventional perioperative treatment regimen (group 1) were compared with the initial 69 consecutive patients (group 2) with a multimodal rehabilitation regimen and the next 50 consecutive patients (group 3) where the fast track regimen was implemented as a routine.

RESULTS

Patients demographics and surgical characteristics were comparable between groups. Median postoperative hospital stay was reduced from six days in group 1, to five days in group 2, and four days in group 3 (p < 0,05). Surgical complications were similar while medical complications were reduced from 12% to 1% (p < 0,05) and readmissions from 10% to 2% (p < 0,05) with the fast track regimen.

CONCLUSION

Principles for postoperative multimodal rehabilitation from colonic surgery lead to faster rehabilitation, decreased risk of medical complications and hospital stay in patients operated for ovarian cancer.

The effect of accelerated rehabilitation on recovery after surgery for ovarian malignancy

BACKGROUND

In patients undergoing colonic surgery the postoperative hospital stay has been reduced from 8-12 days to 2-4 days with multimodal rehabilitation programs. The aim of this study was to evaluate the postoperative outcome after surgery for ovarian malignancy with conventional care compared to fast-track multimodal rehabilitation.

METHODS

Seventy-two consecutive patients receiving conventional care (group 1) were compared with 69 consecutive patients receiving multimodal, fast-track rehabilitation with a planned care program including continuous epidural analgesia, early oral feeding and mobilization (group 2) in the same department. Outcome was postoperative hospital stay and morbidity during the first postoperative month.

RESULTS

Median age was 63 years (group 1) and 62 years (group 2). Median postoperative hospital stay was reduced from 6 days in group 1 (mean 7.3) to 5 days in group 2 (mean 5.4) (p < 0.05). There was no difference in the overall complication rate, although severe medical complications were reduced in group 2 (14% versus 2%; p < 0.01). Readmission rate was 10% in group 1 and 3% in group 2 (p > 0.05).

CONCLUSIONS

The concept of fast-track multimodal rehabilitation appears to be beneficial in patients operated for ovarian malignancy, as hospital stay and medical morbidity are reduced.

Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study

BACKGROUND

Laparoscopic colonic surgery has been claimed to hasten recovery and reduce hospital stay compared with open operation. Recently, enforced multimodal rehabilitation (fast-track surgery) has improved recovery and reduced hospital stay in both laparoscopic and open colonic surgery. Since no comparative data between laparoscopic and open colonic resection with multimodal rehabilitation are available, the value of laparoscopy per se is unknown.

METHODS

In a randomized, observer-and-patient, blinded trial, 60 patients (median age 75 years) underwent elective laparoscopic or open colonic resection with fast-track rehabilitation and planned discharge after 48 hours. Functional recovery was assessed in detail during the first postoperative month.

RESULTS

Median postoperative hospital stay was 2 days in both groups, with early and similar recovery to normal activities as assessed by hours of mobilization per day, computerized monitoring of motor activity assessed, pulmonary function, cardiovascular response to treadmill exercise, pain, sleep quality, fatigue, and return to normal gastrointestinal function. There were no significant differences in postoperative morbidity, mortality, or readmissions, although 3 patients died in the open versus nil in the laparoscopic group.

CONCLUSION

Functional recovery after colonic resection is rapid with a multimodal rehabilitation regimen and without differences between open and laparoscopic operation. Further large-scale studies are required on potential differences in serious morbidity and mortality.

[Accelerated rehabilitation after colon resection]

INTRODUCTION

The stay in hospital after colonic resection is usually 7-12 days, with a complication rate of 20%. A multi-modal rehabilitation regimen, comprising epidural analgesia, early mobilisation, and oral nutrition, reduced the hospital stay to 2-3 days after colonic resection.

METHODS

One hundred patients underwent elective colonic resection with a planned postoperative stay of two days in hospital and a regimen with epidural analgesia, oral nutrition, and mobilisation. Anaesthesia, the surgical technique, and nursing care programme were standardised. Postoperative follow-up visits were arranged for day 8 and day 30.

RESULTS

The median age was 73 years. Forty patients were at high risk, ASA III-IV. Gastrointestinal function (defecation) occurred within 48 hours, except for five patients, and the median hospital stay was two days. The readmission rate was 18% with no acute, potentially lethal conditions. The total hospital stay was three days. None of the patients had cardiopulmonary complications, except for one patient, who died from cardiac failure 36 hours after surgery. Three patients had anastomotic dehiscence, two of whom were treated conservatively.

CONCLUSION

The usual postoperative ileus, "medical complications", and hospital stay were reduced in high-risk patients undergoing colonic resection with a multi-modal rehabilitation programme. These results call for further comparative studies with conventional care programmes and laparoscopic colonic resection.