Successful Implementation of Enhanced Recovery After Surgery Program in a Safety-Net Hospital: Barriers and Facilitators.

ABSTRACT

PURPOSE: Enhanced recovery after surgery (ERAS) programs comprise bundles of evidence-based recommendations designed to reduce physiological stress and support early return of function after surgery. In this study, we sought to investigate the barriers and facilitators of successful implementation of ERAS in a major safety-net hospital. DESIGN: Our ERAS program has been designed as a quality improvement pilot project in prospective fashion with a real-time feedback loop. The program is designed to address established culture of safety-net hospitals. METHODS: An extensive multidisciplinary team investigated the barriers to success for three different levels of program stakeholders providers, patients, and the facility. After a systematic review of these barriers, solutions were offered and implemented in a multidisciplinary care model with special attention to outcomes and continuous feedback. The findings are summarized in a grid format for better understanding and implementation ease. FINDINGS: Patients (N = 198) were enrolled in an ERAS program in a nonrandomized fashion during the pilot period of October 2017 to August 2018. ERAS cohort of patients' outcomes were then compared with those of 20,328 non-ERAS patients. The ERAS group had less complication with shorter length of stay compared with their non-ERAS counterparts. Furthermore, it has cost less to take care of these patients. Interestingly, this decrease was not achieved by a reciprocal increase in subsequent readmission or reoperation rates. CONCLUSIONS: Unique barriers exist when implementing an ERAS protocol in a safety-net hospital. These barriers can be overcome to improve the quality of care at a decreased cost. We have provided a grid to facilitate the implementation process.