Patterns in Provider Deviation From an Established Colorectal ERAS Pathway

Abstract

Background – Enhanced recovery pathways after surgery (ERAS) improve patient outcomes, reduce health care costs and reduce disparities in surgical care. However, providers deviate from ERAS pathways for various reasons, including clinical judgement, personal preference, and incomplete pathway knowledge. Academic hospitals may face further challenges given trainee involvement in patient care. We aimed to compare preoperative, intraoperative, and early postoperative adherence to an established colorectal ERAS pathway in a tertiary academic hospital to identify patterns in provider-driven pathway deviation and to assess obstacles to maximizing adherence. Study Design – Consecutive patients undergoing elective colorectal resection from January- September 2018 were included (n = 163). Pathway adherence was assessed by reviewing physician, nursing, and pharmacy records through postoperative day 2. Physicians and nursing staff delivering postoperative care during the study period were surveyed on pathway knowledge and perceived obstacles to maximizing adherence. Results – Overall ERAS adherence was higher in the preoperative (80%) and intraoperative (93%) settings, compared the postoperative setting (61%). Only 47% of patients had intravenous fluids terminated upon adequate oral fluid intake. Incomplete delivery of opioid-sparing analgesia and bowel motility agents occurred on up to 2/3 of postoperative hospital days, without clinical rationale in over half of cases. Residents and nurses identified unfamiliarity with ERAS principles and surgeon variability as barriers to adherence, and cited peers (71%) rather than standardized order sets (34%) or attending surgeons (10%) as sources of pathway knowledge. Conclusions – Provider deviation from an ERAS pathway was most frequent in the postoperative period, with incomplete dosing of pathway-dictated medications occurring on approximately 1/3 of hospital days without clinical rationale. Provider-reported lack of knowledge of pathway elements, and variability between surgeons and surgical services, are perceived barriers to adherence. Rationale-driven approaches to pathway deviation should be a target of future education and quality improvement initiatives.