56.15 Patients, Tell Us What You Think: Qualitative Evaluation of an Enhanced Recovery Pathway

Posted on January 31, 2019

L. J. Kreutzer1, M. W. Meyers3, M. McGee1,3, S. Ahmad3, K. Gonzalez3, S. Oberoi3, K. Engelhardt1, K. Y. Bilimoria1,2,3, J. K. Johnson1,2  1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA 2Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 3Northwestern Memorial Hospital,Chicago, IL, USA

Introduction: Enhanced Recovery Pathways (ERPs) improve post-surgical recovery and patient outcomes by reducing complications, decreasing length of stay, and improving patient satisfaction; however, hospitals underestimate the complexity of implementing a multifaceted intervention that requires high levels of patient participation pre- and post-operatively. Our goal was to evaluate patient perspectives during early ERP implementation and to address challenges patients face when preparing for, and recovering from, surgery.

Methods: As part of an in-depth, formative evaluation of an ERP for patients recovering from elective colorectal resections at a large urban tertiary care teaching hospital, we conducted semi-structured interviews with patients (n=9) from September 2016 to August 2017. At least two patients for each colorectal surgeon (n=4) participated in the interviews. Patients were asked if they knew they were participating in an ERP and about their pre-operative experience, level of preparedness, and expectations for surgery and post-operative recovery.  Detailed notes were taken during each interview in lieu of audio recording to maintain patient confidentiality. We conducted thematic analysis using the constant comparative method to identify common themes.

Results: All patients approached for an interview agreed to participate.  Patients interviewed were not able to identify specific benefits of ERP related to clinical outcomes but focused their comments on the patient-facing components of ERP. While all patients shared positive feedback regarding their care and post-operative pain control, their comments about ERP were inconsistent. Themes identified included expectations, preparation for surgery, the ERP patient education booklet, and inpatient experience (specifically diet, pain, and education). Patient views about the ERP patient education booklet provided prior to surgery ranged from useful – one patient strongly agreed and said she used the booklet to identify which activities to undertake each postoperative day to enhance her recovery – to inadequate or forgettable with some patients unable to remember receiving the book or not feeling that it fully answered their questions. Another common theme during the interviews involved patient confusion about the early feeding component of the protocol that allowed patients to eat on postoperative day 0.

Conclusion: Conducting patient interviews during the post-operative inpatient stay enabled us to explore patient understanding of an ERP. Patient activation is an important component of a successful ERP and careful attention is needed to engage patients in preoperative expectation setting and postoperative recovery. Multiple modes of education and augmented patient education materials may be more effective than a one-size-fits-all approach to facilitate engagement.
 

16.01 Are you ready? Assessing Readiness to Implement Enhanced Recovery After Surgery

Posted on January 31, 2019

L. J. Kreutzer1, M. F. McGee1,2,3, S. Oberoi3, K. Y. Bilimoria1,2,3, J. K. Johnson1,2  1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA 2Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 3Northwestern Memorial Hospital,Chicago, IL, USA

Introduction: Enhanced Recovery After Surgery (ERAS) is an evidence-based intervention to improve patient outcomes, yet hospitals often underestimate the complexity of implementation. To be most effective, the intervention needs to be context-specific and often requires adaptations so that it is appropriate to the setting and available resources. Organizational and unit-level readiness for change, including the extent to which organizational members are prepared to implement a new intervention, is often overlooked. Our objective was to develop and test a tool to assess hospital readiness to implement ERAS for patients undergoing colorectal procedures.

 

Methods: We developed a Readiness to Implement Core Components of Enhanced Recovery (RECOVER) Tool based on a literature review and our prior experience implementing ERAS. The RECOVER Tool is dual purpose, designed to (1) provide a practical planning tool for the implementation team and (2) collect baseline data of hospital willingness and perceived ability to change practice. The RECOVER Tool includes 4 sections. Section 1 captures information about the hospital’s implementation task force. Section 2 inventories the components of ERAS and identifies implementation willingness. Sections 3 and 4 use a 5-point Likert scale of agreement to assess areas where the task force perceives a need for guidance in implementation and where individual units may need assistance in implementation and in changing behavior. Five hospitals within one health system were asked to complete the RECOVER Tool. Sections 1 and 2 were emailed to representatives from each hospital for completion. Members of the task force from each hospital received sections 3 and 4 through REDCap.

 

Results: The response rate for sections 1 and 2 was 100%. Of the task force members who received a link to complete sections 3 and 4 through REDCap, 60.3% (44 out of 73) completed the survey. The hospital-specific survey response rates ranged from 46.2% to 66.7%.

All hospitals indicated willingness to implement ERAS. Four of the five hospitals struggled with: 1) setting specific goals for implementing ERAS; 2) assigning or clarifying task force roles; 3) gaining buy-in from leadership, 4) engaging IT; and 5) engaging analytics/statistical support.

At the department-level, perceptions of readiness were strong overall across departments; however, one hospital department identified a need to strengthen the ability to adapt quickly when making changes to the way the department works.

 

Conclusion: Assessing readiness to implement a complex intervention, such as ERAS, provides an opportunity to gain insight into perceived barriers to implementation. Furthermore, tools can be tailored to strengthen targeted areas to support hospitals’ implementation process by giving insight into key implementation outcomes: acceptability, feasibility, and appropriateness.