Enhanced recovery, after surgery (ERAS) workshop: effect on attitudes of the perioperative care team.
Abstract: Background Enhanced recovery after surgery (ERAS) or multidisciplinary focused perioperative care model with successful implementation. Several institutions run an on their effect on attitudes and perceptions to perioperative care principles. Methods A ten item survey was designed for perioperative care clinicians attending an annual ERAS workshop. The survey was administered one week before and three weeks after the workshop. Results Seventy seven eligible participants were identified. Forty four(57%) responded to the questionnaire prior to the course. On repeat administration of the survey three weeks after the course there were 28 (36%) responses. The results of the survey indicate that the majority of perioperative care staff were already aware of the evidence behind some of the principles applied in colectomy, with a high pre-course level of understanding shown. However the course significantly changed opinion regarding some other aspects of care to align opinion shown. However the course significantly changed opinion o align opinion with evidence amongst the responders. Conclusion There appears to be high rate of evidence not others amongst perioperative staff. Attending a multidisciplinary ERAS workshop seems to align opinion with evidence.

KEYWORDS Nursing / Perioperative care / Fast track / ERAS / Surgery / Colorectal / Attitudes / Pain
Article Type: Report
Subject: Perioperative care (Research)
Colon (Anatomy) (Surgery)
Colon (Anatomy) (Patient outcomes)
Colon (Anatomy) (Research)
Medical personnel (Training)
Medical personnel (Research)
Authors: Kahokehr, Arman A.
Thompson, Lisa
Thompson, Megan
Soop, Mattias
Hill, Andrew G.
Pub Date: 07/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: July, 2012 Source Volume: 22 Source Issue: 7
Topic: Event Code: 310 Science & research
Accession Number: 300545553
Full Text: Introduction

Evidence based perioperative care is important and is the focus of interventions aimed at enhancing recovery after colorectal surgery. There is abundant literature on individual aspects of care. Accelerated-care or 'Enhanced Recovery After Surgery' (ERAS) programs aim to encompass multiple interventions and to adjust perioperative care principles to bring them in line with existing evidence (Kehlet 2008, Kehlet & Wilmore 2008, Tse & So 2008). However perioperative care is difficult to formalise and is often based upon regional, institutional, and individual clinician preferences. Implementation of ERAS programs is challenging and more than putting a protocol in place is needed to ensure successful outcomes (Maessen et al 2007, Kahokehr et al 2009).

Recent surveys in Europe and North America have demonstrated some of these challenges, documenting the relatively slow change of surgical practice towards evidence-based care ( Kehlet et al 2005, Lassen et al 2005 Hasenberg et al 2009). A perioperative care team plays a crucial part in successful perioperative care and multidisciplinary involvement is required for the implementation and success of ERAS programs. While several ERAS courses are run it is not clear what effect these have on the attitudes and perceptions of members of the perioperative care team.

A survey of attendees at the annual Auckland ERAS (AERAS) course was conducted to help to understand the level of evidence awareness in colonic surgery prior to and after attending a one day multidisciplinary ERAS workshop.

The study

Aim

The aim was to conduct a survey to help understand the level of evidence awareness in colonic surgery prior to and after attending a one day multidisciplinary workshop.

Design

A cross sectional survey study design was used. In April 2010, one week prior to the 'Enhancing Recovery After Surgery-a multidisciplinary course' (see Table 1), an anonymous electronic survey was emailed to all course participants using an online survey tool (www.surveymonkey.com). The same survey was administered three weeks after the course. Collection of data was halted after 60 days.

Morning Introduction and history of ERAS Fluids therapy Physiological and psychological preparation

Break 30 minutes

Theme session: Perioperative fluid therapy Anaesthesia and ERAS

Lunch Break 1hr

Break out sessions

a) Perioperative nursing

Discharge planning Postoperative care principles ERAS nursing practice Discussion

b) Intraoperative interventions Epidural anaesthesia Surgical technique impacts Preventing ileus Discussion

c) Perioperative nutrition focus Prehabilitation Postoperative nutrition Discussion

Break 30 minutes

Afternoon session Implementation The future of ERAS and research Discussions

Table 1 Enhanced recovery after surgery (ERAS) course outline

Data collection

Questions were based around various aspects of perioperative practice regarding elective (arranged) colon resection only (see Figure 1). Opinion was sought regarding individual aspects of care such as preoperative counselling, the admission process, bowel preparation practice, analgesia and 'nil by mouth' status. Space for expansion of answers was provided for each question. Incomplete surveys were excluded from the analysis.

How many years of experience do you have in your current role?

You will now be asked a series of true/false questions. Please answer each question to the best of your knowledge

Q1: All patients presenting for elective surgery benefit from malnutrition screening

Q2: Preoperative oral bowel preparation improves outcomes in colonic surgery

Q3: All patients should be 'starved' (nil by mouth) for six hours or more before elective surgery

Q4: Patients undergoing colorectal surgery are at very low risk for post-operative thrombotic (clotting) events

Q5: Thoracic epidural reduces postoperative ileus risk as compared to systemic opioids after open colorectal surgery

Q6: Thoracic epidural provides better pain relief than systemic opioids after open colorectal surgery

Q7: All patients should have a nasogastric tube (NGT) placed routinely after elective colorectal surgery

Q8: The practice of 'liberal' intravenous fluids after elective colorectal surgery is beneficial

Q9: Early removal of urinary catheter after colonic surgery to assist mobility is safe even with an epidural infusion running

Q10: Patients should be 'nil by mouth' after colon resection until they pass flatus

Q11: Bed rest is an outdated practice and results in muscle wasting and chest complications

Q12: Discharge criteria and planning should be set with patients before the operation.

Data analysis

Results were summarised using SPSS[R] for Windows[R] version 17.0 (SPSS, Chicago, Illinois, USA). No statistical analysis was performed because of the inability, due to the anonymity of the survey, to match responders' answers prior to and after the course.

Ethical consideration

Ethical approval was obtained from the University of Auckland human participants ethics committee.

Results

Seventy seven individuals attended at the course. There were 57 (74%) nurses, 6 (8%) surgeons, 6 anaesthetists, 6 managers and 2 (3%) nutritionists. Forty five (58%) responded to the questionnaire prior to the course (32 nurses, 5 surgeons, 4 anaesthetists, 3 managers and 1 nutritionist). On repeat administration of the survey three weeks after the course 28 (36%) participants responded (20 nurses, 3 managers, 2 anaesthetists, 2 surgeons, 1 nutritionist). The average number of years of clinical experience amongst participants was 12 years (range 1-34). Table 2 shows the pre-course and post-course opinion regarding the 12 aspects of perioperative care for elective colonic surgery.

Discussion

This is the first survey of perioperative care preferences by perioperative staff before and after attending an interactive and multidisciplinary ERAS course that we are aware of. The results of this survey indicate that the majority of responders were already aware of the evidence behind some of the principles applied in colectomy, with a high pre-course level of understanding shown.

However the course significantly changed opinion regarding some other aspects of care to align opinion with evidence.

The latest updated meta-analysis on oral bowel preparation indicates that there is evidence against this practice (Slim et al 2009). However, data for rectal resection are limited (Slim et al 2009). Before the course 50% of responders did not think that preoperative oral bowel preparation would improve outcome in colonic surgery and that increased to 84% after the course.

The use of an epidural has not been shown to significantly affect the length of hospital stay but does produce better post operative pain control, a decrease in paralytic ileus, a decrease in respiratory complications and metabolic benefits when compared to parenteral opioids after colorectal surgery (Nolte and Kehlet 2002, Marret et al 2007, Gendall et al 2007). Before the course, only 66% felt that a thoracic epidural reduced ileus, after the course 92% held that view.Similar results were produced for the analgesic component of thoracic epidural.

Before the course, 42% thought that prolonged 'nil by mouth' status should be routinely practiced prior to elective colonic resection, and after the course only 7% held that view.

After surgery the use of routine nasogastric intubation does not confer any advantages after elective abdominal surgery (Cheatham et al 1995). In fact this practice may delay oral intake and promote nausea and vomiting. Prior to the course a significant proportion of participants (18%) felt that a nasogastric tube (NGT) should be routinely placed after elective colonic resection, and after the course only one responder held that view. Similarly there is no clear advantage to keeping the patient nil-by mouth after bowel surgery (Lewis et al 2001). Early feeding is associated with a reduced overall complication rate.

Attention to fluid therapy has recently been the subject of particular interest with the concept of 'restrictive' or 'goal directed' fluid therapy. These approaches have been shown to be advantageous over more 'traditional' fluid therapy guidelines in that they significantly reduce overall morbidity (Abbas & Hill 2008, Rahbari et al 2009).Prior to the course 64% of responders felt that liberal intravenous fluid was not beneficial and this figure increased to 93% after the course.

The risk of urinary retention has been shown to be 9% in those who have a continuous epidural infusion (Basse et al 2000). The risk of urinary tract infection is lowered to 4% in those who have their catheter removed after 24 hours (Basse et al 2000). Prior to the course only 27% felt that this practice is safe and this figure increased to 93% after the course.

In a recent survey, 37% of specialist colorectal surgeons in Australia and New Zealand reported that they routinely cared for patients in an established ERAS or 'fast track' care practice (Kahokehr & Hill 2010).Less than 10% saw lack of evidence as a barrier. However 39% perceived the lack of institutional support, and 33% a lack of interest from co-specialty personnel, as leading barriers. Interestingly 29% saw no barrier at all and 11% indicated that ERAS was in the process of being instituted in their practice. Based on these data there may be a group of clinicians who continue to achieve satisfying results as reported by patients and as defined by themselves and their institution, without the move towards a more 'formalised' or 'official' ERAS program perse.

These clinicians may be utilising aspects of ERAS on a daily basis. For those who utilise formal ERAS programs, major difficulties can arise when introducing 'one fits all' clinical guidelines into routine practice. In fact, despite the advantages of formalised ERAS programs, their adaptation has been slow (Lassen et al 2005, Kahokehr et al 2009), with change of practice lagging behind evidence in the clinical setting where care tends to be driven by traditional and more conventional attitudes. Even after establishment of such a program, the compliance rate with various aspects of the ERAS protocols can also be a major obstacle (Maessen et al 2007). A protocol alone is not enough to implement multimodal recovery plans in perioperative care (Roig et al 2007). These programs require multidisciplinary group involvement, and a 'transition from the mindset of craftsman to that of an equivalent actor' needs to be taken by clinical staff caring for surgical patients (Amalberti et al 2005).

This study is limited by the lower than expected number of return participants after the course. Conclusions need to take participant loss to follow up into account.

In summary, there appears to be a high rate of evidence agreement with some interventions but not with others in elective colorectal surgical care by perioperative care staff. Attending a focused ERAS workshop seems to align opinion regarding these important areas of perioperative care with evidence. Whether this change in opinion after the course has an impact on patient care now needs to be evaluated.

References

Abbas SM, Hill AG 2008 Systematic review of the literature for the use of oesophageal Doppler monitor for fluid replacement in major abdominal surgery Anaesthesia 63 (1) 44-51

Amalberti R, Auroy, Y, Berwick D, Barach P 2005 Five system barriers to achieving ultrasafe health care Annals of Internal Medicine 142 (9) 756-64

Basse L, Werner M, Kehlet H 2000 Is urinary drainage necessary during continuous epidural analgesia after colonic resection? Regional Anesthesia & Pain Medicine 25 (5) 498-501

Cheatham ML, Chapman WC, Key SP, Sawyers JL 1995 A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy Annals of Surgery 221 (5) 469-76

Gendall KA, Kennedy RR, Watson AJ, Frizelle FA 2007 The effect of epidural analgesia on postoperative outcome after colorectal surgery Colorectal Disease 9 (7) 584-98

Hasenberg T, Keese M, Langle F et at 2009 'Fast-track' colonic surgery in Austria and Germany--results from the survey on patterns in current perioperative practice Colorectal Disease 11 (2) 162-7

Holte K, Kehlet H 2002 Epidural anaesthesia and analgesia-effects on surgical stress responses and implications for postoperative nutrition Clinical Nutrition 21 (3) 199-206

Kahokehr A, Hill AG 2011 Perioperative care in elective colorectal surgery Australia & New Zealand Journal of Surgery 81 (10) 663-664

Kahokehr A, Sammour T, Zargar-Shoshtari K, Thompson L, Hill AG 2009 Implementation of ERAS and how to overcome the barriers International Journal of Surgery 7 (1) 16-9

Kehlet H 2008 Fast-track colorectal surgery Lancet 371 (9615) 791-3

Kehlet H, Williamson R, Buchler MW, Beart RW 2005 A survey of perceptions and attitudes among European surgeons towards the clinical impact and management of postoperative iteus Colorectal Disease 7 (3) 245-50

Kehlet H, Wilmore DW 2008 Evidence-based surgical care and the evolution of fast-track surgery Annals of Surgery 248 (2) 189-98

Lassen K, Hannemann P, Ljungqvist 0 et al 2005 Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries British Medical Journal 330 (7505) 1420-1

Lewis SJ, Egger M, Sylvester PA, Thomas S 2001 Early enteral feeding versus 'nil by mouth' after gastrointestinal surgery: systematic review and meta-analysis of controlled trials British Medical Journal 323 (7316) 773-6

Maessen J, Dejong CH, Hausel J et al 2007 A protocol is not enough to implement an enhanced recovery programme for colorectal resection British Journal of Surgery 94 (2) 224-31

Marret E, Remy C, Bonnet F 2007 Meta-analysis of epidural analgesia versus parenteral opioid analgesia after colorectal surgery British Journal of Surgery 94 (6) 665-73

Rahbari NN, Zimmermann JB, Schmidt T et at 2009 Meta-analysis of standard, restrictive and supplemental fluid administration in colorectal surgery British Journal of Surgery 96 (4) 331-41

Roig JV, Rodriguez-Carrillo R, Garcia-Armengol J et al 2007 Multimodal rehabilitation in colorectal surgery. On resistance to change in surgery and the demands of society Cirugia Espanola 81 (6) 307-15

Slim K, Vicaut E, Launay-Savary MV, Contant C, Chipponi J 2009 Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery Annals of Surgery 249 (2) 203-9

Tse KY, So WK 2008 Nurses' perceptions of preoperative teaching for ambulatory surgical patients Journal of Advanced Nursing 63 (6) 619-25

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Grant support

Arman Kahokehr is recipient of the Ruth Spencer a i j fellowship from the Auckland Medical Research Foundation.

Acknowledgement

I The authors would like to thank Mrs Jan Gardener and Portia Joshi for their administrative help.

by Arman A. Kahokehr, Lisa Thompson, Megan Thompson, Mattias Soop, Andrew G. Hill Correspondence address: Dr Arman Adam Kahokehr, South Auckland Clinical School, PO Box 93311, Auckland, New Zealand. Email: arman.kahokehr@gmail.com

About the authors

Arman A. Kahokehr

BHB, MBChB, PGDip MedSc, PhD

Research Fellow, University of Auckland, New Zealand

Lisa Thompson

Diploma in Nursing Studies

Registered Nurse, Manukau Surgery Centre, New Zealand

Megan Thompson

RCpN, Post Grad Cert STN

Staff Nurse, Colorectal, Manukau Surgery Centre, New Zealand

Mattias Soop

MD, PhD

Senior Lecturer/ Consultant Surgeon, University of Auckland, New Zealand

Andrew G. Hill

MBChB, MD EdD, FRACS, FAGS

Colorectal Surgeon / Professor, Middlemore Hospital, Auckland, New Zealand

No competing interests declared
PRE-COURSE                        POST-COURSE
                   OPINION N=45                       OPINION N=28
                       (%)                                (%)

                       Agree       Disagree    Not        Agree
                                              sure

1 Routine               35 (78)    6 (13)    4 (9)       22 (79)
preoperative
nutritional
screening

2 Routine               13 (29)   22 (49)   10(22)         2 (7)
preoperative oral
bowel
preparation

3 Routine NBM for       19 (42)   21 (47)    5(11)         2 (7)
6 hours or more

4 Risk for                    0   41 (91)    4 (9)         2 (7)
thrombotic event
is low

5 Thoracic              29 (64)     4 (9)   12(27)       25 (90)
epidural reduces
ileus

6 Thoracic              30 (67)     4 (9)  11 (24)       27 (96)
epidural provides
optimal
analgesia

7 NGT should be          8 (18)   35 (78)    2 (4)         1 (4)
placed routinely

8 Liberal                8 (18)   28 (62)   9 (20)         2 (7)
postoperative IVF
is beneficial

9 Early removal         12 (27)   20 (44)   13(29)      *25 (93)
of IDC is safe
even with
epidural
analgesia

10 NBM after            11 (24)   29 (65)   5 (11)         2 (7)
surgery should be
routine

11 Bed rest is          41 (93)     3 (7)    1 (2)       27 (96)
outdated
practice

12 Discharge            39 (87)    5 (11)    1 (2)      28 (100)
planning should
be done
preoperatively

                   Disagree   Not
                             sure

1 Routine            4 (14)  2 (7)
preoperative
nutritional
screening

2 Routine           24 (86)  2 (7)
preoperative oral
bowel
preparation

3 Routine NBM for   26 (93)      0
6 hours or more

4 Risk for          22 (79)  4(14)
thrombotic event
is low

5 Thoracic                0  3(10)
epidural reduces
ileus

6 Thoracic            1 (4)      0
epidural provides
optimal
analgesia

7 NGT should be     27 (96)      0
placed routinely

8 Liberal           26 (93)      0
postoperative IVF
is beneficial

9 Early removal          *0  *2(7)
of IDC is safe
even with
epidural
analgesia

10 NBM after        26 (93)      0
surgery should be
routine

11 Bed rest is        1 (4)      0
outdated
practice

12 Discharge              0      0
planning should
be done
preoperatively

IDC - indwelling urinary catheter, IVF - intravenous fluids,
NBM - nil by mouth, NGT - nasogastric tube.
 * One participant did not respond to this question Table 2
Survey results
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