Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: a process evaluation of champions’ experiences

Implementation Science

Robin S. McLeod¹  Emily A. Pearsall²  Marg McKenzie²  Lesley Gotlib Conn³ 

[1] Department of Surgery, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto M5T 1P5, ON, Canada;Department of Surgery, Mount Sinai Hospital Joseph and Wolf Lebovic Health Complex, 600 University Avenue, Toronto M5G 1X5, ON, Canada;Evaluative Clinical Sciences, Trauma, Emergency and Critical Care Research Program, Sunnybrook Research Institute, 2075 Bayview Ave., Room K3W-28, Toronto M4N 3M5, ON, Canada

关键词: Normalization process theory;    Qualitative research;    Process evaluation;    Implementation;    Enhanced recovery after surgery;   

Others  :  1219594
DOI  :  10.1186/s13012-015-0289-y

 received in 2015-04-29, accepted in 2015-07-02,  发布年份 2015

【 摘 要 】

Background

Enhanced recovery after surgery (ERAS) is a multimodal evidence-based approach to patient care that has become the standard in elective colorectal surgery. Implemented globally, ERAS programmes represent a considerable change in practice for many surgical care providers. Our current understanding of specific implementation and sustainability challenges is limited. In January 2013, we began a 2-year ERAS implementation for elective colorectal surgery in 15 academic hospitals in Ontario. The purpose of this study was to understand the process enablers and barriers that influenced the success of ERAS implementation in these centres with a view towards supporting sustainable change.

Methods

A qualitative process evaluation was conducted from June to September 2014. Semi-structured interviews with implementation champions were completed, and an iterative inductive thematic analysis was conducted. Following a data-driven analysis, the Normalization Process Theory (NPT) was used as an analytic framework to understand the impact of various implementation processes. The NPT constructs were used as sensitizing concepts, reviewed against existing data categories for alignment and fit.

Results

Fifty-eight participants were included: 15 surgeons, 14 anaesthesiologists, 15 nurses, and 14 project coordinators. A number of process-related implementation enablers were identified: champions’ belief in the value of the programme, the fit and cohesion of champions and their teams locally and provincially, a bottom-up approach to stakeholder engagement targeting organizational relationship-building, receptivity and support of division leaders, and the normalization of ERAS as everyday practice. Technical enablers identified included effective integration with existing clinical systems and using audit and feedback to report to hospital stakeholders. There was an overall optimism that ERAS implementation would be sustained, accompanied by concern about long-term organizational support.

Conclusions

Successful ERAS implementation is achieved by a complex series of cognitive and social processes which previously have not been well described. Using the Normalization Process Theory as a framework, this analysis demonstrates the importance of champion coherence, external and internal relationship building, and the strategic management of a project’s organization-level visibility as important to ERAS uptake and sustainability.

【 授权许可】

   
2015 Gotlib Conn et al.

【 参考文献 】

• [1]Dhruva Rao PK, Haray PN. Enhanced recovery after colorectal surgery: principles and current practice. Surgery. 2014; 32(4):185-189.
• [2]Kehlet H. Fast-track colorectal surgery. Lancet. 2008; 371(9615):791-793.
• [3]Wind J, Polle SW, Fung Kon Jin PH et al.. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg. 2006; 93(7):800-809.
• [4]Zhuang CL, Ye XZ, Zhang XD, Chen BC, Yu Z. Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials. Dis Colon Rectum. 2013; 56(5):667-678.
• [5]Keane C, Savage S, McFarlane K, Seigne R, Robertson G, Eglinton T. Enhanced recovery after surgery versus conventional care in colonic and rectal surgery. ANZ J Surg. 2012; 82(10):697-703.
• [6]Khoo CK, Vickery CJ, Forsyth N, Vinall NS, Eyre-Brook IA. A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Ann Surg. 2007; 245(6):867-872.
• [7]Eskicioglu C, Forbes SS, Aarts MA, Okrainec A, Mcleod RS. Enhanced recovery after surgery (ERAS) programs for patients having colorectal surgery: a meta-analysis of randomized trials. J Gastrointest Surg. 2009; 13(12):2321-2329.
• [8]Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJHM. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD007635. doi:. 10. 1002/14651858.CD007635.pub2 webcite
• [9]McLeod RS, Aarts MA, Chung F, et al. Development of an enhanced recovery after surgery guideline and implementation strategy based on the knowledge-to-action cycle. Annals of Surgery. 2015. Epub ahead of print.
• [10]Aarts MA, Okrainec A, Glicksman A, Pearsall E, Victor JC, Mcleod RS. Adoption of enhanced recovery after surgery (ERAS) strategies for colorectal surgery at academic teaching hospitals and impact on total length of hospital stay. Surg Endosc. 2012; 26(2):442-450.
• [11]Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery. 2011; 149(6):830-840.
• [12]Miller TE, Thacker JK, White WD et al.. Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg. 2014; 118(5):1052-1061.
• [13]Gotlib Conn L, Rotstein OD, Greco E et al.. Enhanced recovery after vascular surgery: protocol for a systematic review. Systematic Reviews. 2012; 1:52. BioMed Central Full Text
• [14]Husted H, Troelsen A, Otte KS, Kristensen BB, Holm G, Kehlet H. Fast-track surgery for bilateral total knee replacement. J Bone Joint Surg Br Vol. 2011; 93B(3):351-356.
• [15]Lassen K, Coolsen MM, Slim K. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations. Clinical nutrition (Edinburgh, Scotland). 2012; 31(6):817-830.
• [16]Gillissen F, Hoff C, Maessen JM et al.. Structured synchronous implementation of an enhanced recovery program in elective colonic surgery in 33 hospitals in The Netherlands. World J Surg. 2013; 37(5):1082-1093.
• [17]Ahmed J, Khan S, Lim M, Chandrasekaran TV, MacFie J. Enhanced recovery after surgery protocols—compliance and variations in practice during routine colorectal surgery. Colorectal Dis. 2012; 14(9):1045-1051.
• [18]Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008; 248(2):189-198.
• [19]Pearsall EA, Meghji Z, Pitzul KB et al.. A qualitative study to understand the barriers and enablers in implementing an enhanced recovery after surgery program. Ann Surg. 2015; 261(1):92-96.
• [20]Nadler A, Pearsall EA, Victor JC, Aarts MA, Okrainec A, McLeod RS. Understanding surgical residents’ postoperative practices and barriers and enablers to the implementation of an Enhanced Recovery After Surgery (ERAS) Guideline. J Surg Educ. 2014; 71(4):632-638.
• [21]Lyon A, Solomon MJ, Harrison JD. A qualitative study assessing the barriers to implementation of enhanced recovery after surgery. World J Surg. 2014; 38(6):1374-1380.
• [22]Kahokehr A, Sammour T, Zargar-Shoshtari K, Thompson L, Hill AG. Implementation of ERAS and how to overcome the barriers. Int J Surg. 2009; 7(1):16-19.
• [23]Maessen J, Dejong CH, Hausel J et al.. A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg. 2007; 94(2):224-231.
• [24]Polle SW, Wind J, Fuhring JW, Hofland J, Gouma DJ, Bemelman WA. Implementation of a fast-track perioperative care program: what are the difficulties? Dig Surg. 2007; 24(6):441-449.
• [25]Ljungqvist O. Sustainability after structured implementation of ERAS protocols. World J Surg. 2015; 39(2):534-535.
• [26]Gillissen F, Ament SM, Maessen JM et al.. Sustainability of an enhanced recovery after surgery program (ERAS) in colonic surgery. World J Surg. 2015; 39(2):526-533.
• [27]Ament SM, Gillissen F, Moser A et al.. Identification of promising strategies to sustain improvements in hospital practice: a qualitative case study. BMC Health Serv Res. 2014; 14(1):641. BioMed Central Full Text
• [28]Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost PJ. Reality check for checklists. Lancet. 2009; 374(9688):444-445.
• [29]Wenger EC, Snyder WM. Communities of practice: the organizational frontier. Harv Bus Rev. 2000; 78(1):139-145.
• [30]Ivers N, Jamtvedt G, Flottorp S et al.. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012; 6:Cd000259.
• [31]May CR, Mair F, Finch T et al.. Development of a theory of implementation and integration: Normalization Process Theory. Implement Sci. 2009; 4:29. BioMed Central Full Text
• [32]Strauss A, Corbin J. Basics of qualitative research. Sage, Los Angeles; 2008.
• [33]Creswell JW, Miller DL. Determining validity in qualitative inquiry. Theory into Practice. 2000; 39(3):124-130.
• [34]Murray E, Treweek S, Pope C et al.. Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Med. 2010; 8:63. BioMed Central Full Text
• [35]McEvoy R, Ballini L, Maltoni S, O'Donnell CA, Mair FS, Macfarlane A. A qualitative systematic review of studies using the normalization process theory to research implementation processes. Implement Sci. 2014; 9:2. BioMed Central Full Text
• [36]Flodgren G, Parmelli E, Doumit G, Gattellari M, O'Brien MA, Grimshaw J, Eccles MP. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2011, Issue 8. Art. No.: CD000125. doi. 10. 1002/14651858.CD000125.pub4 webcite
• [37]Locock L, Dopson S, Chambers D, Gabbay J. Understanding the role of opinion leaders in improving clinical effectiveness. Soc Sci Med. 2001; 53(6):745-757.
• [38]Valente TW, Pumpuang P. Identifying opinion leaders to promote behavior change. Health Educ Behav. 2007; 34(6):881-896.
• [39]Dixon-Woods M, Leslie M, Tarrant C, Bion J. Explaining Matching Michigan: an ethnographic study of a patient safety program. Implement Sci. 2013; 8:70. BioMed Central Full Text
• [40]Dixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant literature. BMJ Quality & Safety. 2012; 21(10):876-884.
• [41]Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA, Pronovost PJ. Explaining Michigan: developing an ex post theory of a quality improvement program. Milbank Q. 2011; 89(2):167-205.