Best Practice Guidelines
Delivering enhanced recovery: helping patients to get better sooner after surgery
Department of Health, 31 March 2010
www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasse
t/dh_115156.pdf
Quality and Service Improvement Tools: Enhanced Recovery Programme
NHS Institute for Innovation and Improvement, 2008
www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement
_tools/enhanced_recovery_programme.html
Journal Articles
Laparoscopic gastric surgery in an enhanced recovery programme.
Citation: British Journal of Surgery, October 2010, vol./is. 97/10(p1547-51)
Author(s): Grantcharov TP, Kehlet H
Abstract: BACKGROUND: Laparoscopy is associated with less pain and organ dysfunction than open
surgery. Improved perioperative care (enhanced recovery programmes, fast-track methodology)
has also led to reduced morbidity and a shorter hospital stay. The effects of a combination of
laparoscopic resection and accelerated recovery have not been examined previously in the context
of gastric surgery. METHODS: This was a prospective study of 32 consecutive patients undergoing
laparoscopic gastric resection combined with an enhanced recovery protocol (early oral intake, no
drains or nasogastric tubes, no epidural analgesia, use of a urinary catheter for less than 24 h and
planned discharge 72 h after surgery). Outcomes included length of hospital stay, intraoperative
and postoperative complications, readmission rate and 30-day mortality. RESULTS: Operative
procedures were elective distal or subtotal gastrectomy (22 patients) and total gastrectomy (10).
Median length of hospital stay was 4 (range 2-30) days. There were two major complications:
postoperative bleeding requiring reoperation and pulmonary embolism. Two patients required
readmission, one for a wound abscess and one for treatment of a urinary tract infection. There
were no deaths within 30 days. CONCLUSION: Minimally invasive gastrectomy with enhanced
postoperative recovery results in a short hospital stay and low morbidity rate.
Source: MEDLINE
Available in print at Health Sciences Library, Frimley Park Hospital
Impact of an enhanced recovery programme in colorectal surgery.
Citation: British Journal of Nursing (BJN), 23 September 2010, vol./is. 19/17(p1091-1099)
Author(s): Slater R
Abstract: Surgery is undergoing revolutionary change as a result of newer approaches to pain
control, the introduction of techniques that reduce the post-operative stress response, and the use
1
of minimally invasive operations, such as laparoscopic surgery. As demand for hospital beds
continues to escalate, it is paramount that patients recover from surgery quickly and safely; the use
of evidence-based interventions to hasten recovery within an enhanced recovery programme (ERP)
can play a vital role in achieving this, as well as reducing costs by shortening hospital stay. This
article outlines the principles and key elements of an ERP, and discusses how it can help to achieve
an improved and safe recovery and shorter hospital stay for patients, thereby reducing the cost to
the NHS of inpatient treatment and recovery. The literature surrounding the development of
'enhanced recovery' (also called 'fast-track') surgery is reviewed to determine whether it is
appropriate for patients undergoing elective colorectal surgery.
Source: CINAHL
Available in fulltext at EBSCO Host
Available in print at Health Sciences Library, Frimley Park Hospital
Randomized clinical trial of laxatives and oral nutritional supplements within an
enhanced recovery after surgery protocol following liver resection.
Citation: British Journal of Surgery, August 2010, vol./is. 97/8(p1198-206)
Author(s): Hendry PO, van Dam RM, Bukkems SF, McKeown DW, Parks RW, Preston T, Dejong CH,
Garden OJ, Fearon KC, Enhanced Recovery After Surgery (ERAS) Group
Abstract: BACKGROUND: Routine laxatives may expedite gastrointestinal recovery and early
tolerance of food within an enhanced recovery after surgery (ERAS) programme. Combined with
carbohydrate loading and oral nutritional supplements (ONS), it may further enhance recovery of
gastrointestinal function and promote earlier overall recovery. METHODS: Seventy-four patients
undergoing liver resection were randomized in a two-by-two factorial design to receive either
postoperative magnesium hydroxide as a laxative, preoperative carbohydrate loading and
postoperative ONS, their combination or a control group. Patients were managed within an ERAS
programme of care. The primary outcome measure was time to first passage of stool. Secondary
outcome measures were gastric emptying, postoperative oral calorie intake, time to functional
recovery and length of hospital stay. RESULTS: Sixty-eight patients completed the trial. The laxative
group had a significantly reduced time to passage of stool: median (interquartile range) 4 (3-5)
versus 5 (4-6) days (P = 0.034). The ONS group showed a trend towards a shorter time to passage of
stool (P = 0.076) but there was no evidence of interaction in patients randomized to the
combination regimen. Median length of hospital stay was 6 (4-7) days. There were no differences in
secondary outcomes between groups. CONCLUSION: Within an ERAS protocol for patients
undergoing liver resection, routine postoperative laxatives result in an earlier first passage of stool
but the overall rate of recovery is unaltered. Copyright (c) 2010 British Journal of Surgery Society
Ltd. Published by John Wiley & Sons, Ltd.
Publication Type: Journal Article, Multicenter Study, Randomized Controlled Trial
Source: MEDLINE
Available in print at Health Sciences Library, Frimley Park Hospital
The Enhanced Recovery Programme for stoma patients: an audit.
2
Citation: British Journal of Nursing (BJN), 08 July 2010, vol./is. 19/13(p831-834)
Author(s): Bryan S, Dukes S
Abstract: An enhanced recovery programme was implemented at Salisbury NHS Foundation Trust
for elective patients undergoing colonic surgery with a stoma in October 2007. The programme is a
multimodal approach first described by Professor H. Kehlet in 2000. In order for ERP to be
successful in reducing length of stay and promoting earlier stoma independence, there was a need
to educate, inform and prepare patients comprehensively in the pre-operative phase to enhance
their understanding. A change of practice was necessary as, traditionally, the majority of practical
and psychological care was promoted in the postoperative phase. A retrospective audit was carried
out on 20 patients before undertaking the enhanced recovery programme, and 20 patients
afterwards, which demonstrated a reduction in the patients' mean length of stay from 20 to 7 days,
with 60% being discharged at 5 days or less after the programme. The mean number of days until
stoma-independent decreased from 12 to 5 days as a result of the enhanced recovery programme.
A further 40 patients have been audited.
Publication Type: journal article
Source: CINAHL
Available in fulltext at EBSCO Host
Available in print at Health Sciences Library, Frimley Park Hospital
Effectiveness of a written clinical pathway for enhanced recovery after
transthoracic (Ivor Lewis) oesophagectomy.
Citation: British Journal of Surgery, May 2010, vol./is. 97/5(p714-8))
Author(s): Munitiz V, Martinez-de-Haro LF, Ortiz A, Ruiz-de-Angulo D, Pastor P, Parrilla P
Abstract: BACKGROUND: This study assessed the feasibility of a protocol-driven written clinical
pathway for multidisciplinary postoperative management after oesophagectomy for oesophageal
neoplasia, and examined whether the application of such a protocol could shorten hospital stay and
reduce postoperative morbidity and mortality. METHODS: Consecutive patients undergoing
transthoracic oesophagectomy for oesophageal neoplasia were divided into those treated between
2003 and 2008 to whom a clinical pathway was applied for postoperative management (group 1),
and a control group treated between 1998 and 2002 when no clinical pathway was applied (group
2). RESULTS: There were 74 patients in each group. Morbidity rates were similar in the two groups:
31 per cent in group 1 and 38 per cent in group 2. There were more pulmonary complications in
group 2 (23 versus 14 per cent; P = 0.025). One patient (1 per cent) in group 1 and four (5 per cent)
in group 2 died after surgery (P = 0.010). The median (range) length of hospital stay was 9 (5-98)
days for group 1 and 13 (8-106) days in group 2 (P = 0.012). CONCLUSION: Use of a written clinical
pathway in patients undergoing oesophageal resection significantly reduced pulmonary
complications, postoperative mortality and hospital stay. Copyright 2010 British Journal of Surgery
Society Ltd.
Publication Type: Evaluation Studies, Journal Article, Research Support, Non-U.S. Gov't
Source: MEDLINE
Available in print at Health Sciences Library, Frimley Park Hospital
3
Fast-track vs standard care in colorectal surgery: a meta-analysis update.
Citation: International Journal of Colorectal Disease, October 2009, vol./is. 24/10(p1119-31)
Author(s): Gouvas N, Tan E, Windsor A, Xynos E, Tekkis PP
Abstract: BACKGROUND: Fast-track (FT) protocols accelerate patient's recovery and shorten
hospital stay as a result of the optimization of the perioperative care they offer. The aim of this
review is to examine the latest evidence for fast-track protocols when compared with standard care
in elective colorectal surgery involving segmental colonic and/or rectal resection. MATERIALS AND
METHODS: All randomized controlled trials and controlled clinical trials on FT colorectal surgery
were reviewed systematically. The main end points were short-term morbidity, length of primary
postoperative hospital stay, length of total postoperative stay, readmission rate, and mortality.
Quality assessment and data extraction were performed independently by two observers. RESULTS:
Eleven studies were eligible for analysis (four randomized controlled trials (RCTs) and seven
controlled clinical trials (CCT)), including 1,021 patients. Primary hospital stay (weighted mean
difference -2.35 days, 95% confidence interval (CI) -3.24 to -1.46 days, P < 0.00001) and total
hospital stay (weighted mean difference -2.46 days, 95% CI -3.43 to -1.48 days, P < 0.00001) were
significantly lower for FT programs. Morbidity was also lower in the FT group. Readmission rates
were not significantly different. No increase in mortality was found. CONCLUSIONS: FT protocols
show high-level evidence on reducing primary and total hospital stay without compromising
patients' safety offering lower morbidity and the same readmission rates. Enhanced recovery
programs should become a mainstay of elective colorectal surgery.
Publication Type: Comparative Study, Journal Article, Meta-Analysis
Source: MEDLINE
Available in fulltext at ProQuest
Enhanced recovery pathway in colorectal surgery 1: background and principles.
Citation: Nursing Times, 21 July 2009, vol./is. 105/28(p23-25)
Author(s): Burch J
Abstract: This first in a two-part unit outlines background on the enhanced recovery pathway in
colorectal surgery. Enhanced recovery is used in colorectal surgery to optimise care for patients
before, during and after their operations. It can be used in other specialties. The pathway includes a
number of activities that nurses should explain to patients so they understand these principles.
There are some major changes from traditional post-operative care after colorectal surgery. The
most obvious one is that fluids and food are allowed and, in fact, encouraged after surgery on the
same day as the operation. In addition, early mobilisation by sitting in a chair on the evening after
surgery and walking the following day are recommended if a patient's condition allows.
Publication Type: journal article
Source: CINAHL
Available in print at Health Sciences Library, Frimley Park Hospital
4
Improving quality by introducing enhanced recovery after surgery in a
gynaecological department: consequences for ward nursing practice.
Citation: Quality &amp; Safety in Health Care, 01 June 2009, vol./is. 18/3(p236-240)
Author(s): Sjetne IS, Krogstad U, ødegård S, Engh ME
Abstract: INTRODUCTION: Enhanced Recovery After Surgery (ERAS) is a perioperative treatment
protocol that can improve individual recovery. This allows patients to leave hospital earlier,
implying a cost reduction. The programme seems to spread slowly. ERAS was introduced at the
Department of Obstetrics and Gynaecology at Akershus University Hospital in 2005. The objective
of this study was to monitor changes in the workload and work environment of the ward nursing
staff when ERAS was introduced at the department. METHODS: A pre-postintervention prospective
design was used. Triangulated data were collected immediately before introduction (Phase 1), soon
after (Phase 2), and 1 year after introduction (Phase 3). Data sources in all phases were
registrations of time spent caring for individual patients during their stay, personnel survey
responses and verbal interviews with informants from different staff groups. Patients were
included consecutively, the aim being to include a minimum of 40 per phase. RESULTS: Time
registration showed that during the observation period, there was a 28% reduction in mean length
of stay (-1.3 days, 95% CI -1.63 to -0.97, p<0.001) and 39% reduction in total time used in nursing
activities per stay (-162 min, 95% CI -239.3 to -84.4, p<0.001). The personnel survey had a 100%
response rate and presented few changes other than decreasing workload. The interview data from
four informants described a successful change. CONCLUSION: The findings confirmed the successful
introduction of ERAS in the gynaecological department of a large university hospital. The
experiences we made indicate that the expected gains of implementing ERAS are achieved without
compromising the workload or work environment of ward nursing staff.
Publication Type: journal article
Source: CINAHL
Available in fulltext at Highwire Press
Available in print at Health Sciences Library, Frimley Park Hospital
An enhanced-recovery protocol improves outcome after colorectal resection
already during the first year: a single-center experience in 168 consecutive patients.
Citation: Diseases of the Colon & Rectum, May 2009, vol./is. 52/5(p978-85)
Author(s): Nygren J, Soop M, Thorell A, Hausel J, Ljungqvist O, ERAS Group
Abstract: PURPOSE: This study was designed to investigate the clinical outcome and recovery
before and immediately after implementation of the enhanced recovery after surgery enhanced
recovery after surgery protocol in colonic and rectal resection. METHODS: One hundred and sixtyeight consecutive patients in a single center underwent colorectal surgery before (traditional, n =
69) and immediately after implementing enhanced recovery after surgery (n = 99). Rectal surgery
was performed in 77 patients. Postoperative food and fluid intake, mobilization, physiologic
function, and clinical outcome were measured prospectively. RESULTS: Resumption of oral diet was
achieved on postoperative day postoperative day 1 in the enhanced recovery after surgery group.
In the enhanced recovery after surgery group, mobilization more than 6 hours daily was achieved
on postoperative day 2 to 3 and passage of stool occurred on postoperative day 2 vs. postoperative
5
day 5 in the traditional group (P < 0.0001). Muscle strength and lung function were less reduced in
the enhanced recovery after surgery group (P < 0.05). Median hospital stay was reduced by 2 days
(P < 0.01). Readmission rates increased (4 percent vs. 15 percent, P < 0.01) but total hospital stay
was still lower in the enhanced recovery after surgery group (P < 0.01). After colonic resection,
postoperative complications decreased in enhanced recovery after surgery (37 percent vs. 18
percent, P < 0.05), whereas no change was found after rectal resection. CONCLUSION: Immediately
after implementing enhanced recovery after surgery, recovery was improved and length of hospital
stay was reduced. Notably, postoperative morbidity decreased only in patients undergoing colonic
resection.
Publication Type: Comparative Study, Journal Article, Research Support, Non-U.S. Gov't
Source: MEDLINE
Available in fulltext at ProQuest
News
Patient care. To reduce ICU stays, get patients moving.
Citation: Hospitals & Health Networks, August 2010, vol./is. 84/8(p14)
Author(s): Charet GP
Publication Type: News
Source: MEDLINE
Available in fulltext at EBSCO Host
Available in fulltext at ProQuest
Patient recovery scheme cuts hospital stay in half.
Citation: Nursing Times, April 2010, vol./is. 106/15(p1)
Author(s): Santry C
Publication Type: News
Source: MEDLINE
Available in print at Health Sciences Library, Frimley Park Hospital
This list features only papers available online* or in print at the Health Sciences Library. If you
would like to receive a more comprehensive listing that includes references to articles that could be
ordered from other health libraries, please contact the Library Team library@fph-tr.nhs.uk
*An NHS Athens password may be required. These are available to all NHS staff and students on
placement. Register online at www.library.nhs.uk.
Health Sciences Library
1st Floor (above Post Grad)
01276 604168
library@fph-tr.nhs.uk
6