Mixed method realist evaluation of the implementation of an Enhanced recovery after surgery (ERAS) programme in Hepato-pancreato-biliary (HPB) surgery
BACKGROUND : The Enhanced Recovery After Surgery (ERAS) programme is an evidence-based, multimodal and patient-centred approach to optimise patient care and experience. Multiple studies have demonstrated that the implementation of ERAS programme in Hepato-Pancreato-Biliary (HPB) surgery improves clinical outcomes such as reduction in length of stay and complications, while reducing hospital costs. However, there is only limited understanding of how the implementation process of ERAS programme and the contextual conditions contribute to success or failure. For many healthcare practitioners, implementation of ERAS protocols represents a significant departure from traditional care. For example, some of the clinical changes applied in ERAS programme are radical in nature and involve abandoning traditional practice such as preoperative fasting in favour of practices such as the consumption of preoperative carbohydrate drinks up to 2 hours prior to surgery. AIM: The aim was to develop an understanding of how particular contextual factors within an ERAS programme trigger mechanisms to produce outcomes in HPB surgery and examine how ERAS works, why, for whom and in what circumstances, from both the healthcare professionals’ and patients’ perspectives. METHODS: This realist evaluation adopted a mixed methods design to provide a detailed explanation of what works, why, how and under what circumstances when an ERAS programme is implemented in HPB surgery. The quantitative element was used to evaluate the impact of the ERAS programme on the clinical outcomes and to confirm whether the programme achieved its aim. This quantitative element was based on clinical outcomes data from a 12-month pre and post ERAS implementation period. A total of 227 adult patients who underwent liver and pancreatic surgery were included in the quantitative data analysis. The qualitative element enabled the study to explore how the contexts within the programme combined with mechanisms to influence the programme outcomes. Semi-structured interviews (25 participants) were used to explore the stakeholders and patients’ experiences and perspectives of the programme and to further probe issues as they emerged. Focus group (4 participants) allowed the study to re-test and refine some of the programme theories tested in the semi-structured interviews. FINDINGS: The outcomes show that the ERAS programme was successfully implemented in HPB surgery. The quantitative data analysis demonstrated that implementation of the ERAS programme resulted in a significantly shorter length of stay following pancreatic surgery and a reduction in major complications. However, implementation of the ERAS programme had no impact on clinical outcomes following liver surgery. Complications, BMI and type of surgery were independently associated with length of stay, whilst complications and high BMI are risk factors for prolonged hospital stay following pancreatic surgery. The analysis also found that longer operation times increased the risk of experiencing major complications following pancreatic surgery. The study identified several contextual factors required for the ERAS programme to be successful; it works when the implementation is supported by adequate resources, staff and patients have knowledge of the programme and patients take ownership of their care and take a collaborative approach. The qualitative data analysis demonstrated that when staff received training prior to involvement in the programme, their knowledge and understanding of the principles of the programme were further improved, which triggered their motivation and determination to empower patients to take responsibility for their care. The evaluation also found that adequately preparing patients for surgery, helps set clear expectations and triggers a sense of ownership in them, which increases their motivation and commitment to the recovery process. The findings of this evaluation also suggest that lack of resources, poor leadership and communication failures during handover hindered the delivery of ERAS programme, which often meant that programme interventions were not implemented. Conclusion This mixed methods study demonstrated that ERAS programmes can produce improved clinical outcomes when implemented in HPB surgery, findings that are consistent with existing literature on this topic. The study identified several contextual conditions that are needed for successful implementation of the ERAS programme in HPB surgery. The refined programme theories have been presented as a useful tool that could support successful future implementation and sustainability of ERAS programmes in HPB surgery.
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