Evaluating the Efficacy of an Educational Intervention about Multimodal and Enhanced Recovery After Surgery (ERAS) Protocols to Improve Certified Registered Nurse Anesthesiologists Perceptions of Implementation and Facilitators� 

Florida Gulf Coast University

Doctorate of Nurse Anesthesia Practice

Jaimee Johnson

Cristhian Patino

Titilope Somade

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Enhanced Recovery After Surgery (ERAS) and Multimodal Pain Management Protocols

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• ERAS Protocols: A multidisciplinary patient-centered program that bundles evidence-based processed measures to both minimize the physiologic stress associated with surgery, and improve rates of post-operative recovery (Stone et al, 2017).

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• Multimodal Pain Management Protocols: Opioid-spairing protocols that utilize adjuncts and regional anesthesia (Anwar et al, 2021).

ERAS and Multimodal Protocols vs Opioid Monotherapy

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• Multimodal pain management and ERAS protocols were created to decrease the use of opioids, decrease perioperative pain levels, reduce the length of hospital stay, and improve overall clinical outcomes in the perioperative setting (Norcross et al., 2019).
• The decrease in opioid prescription creates an opportunity to reduce the risk of opioid dependence and improve patients' pain levels by utilizing non-opioid medications that target different pain receptors, have fewer side effects, and improve the patient's overall clinical course (Chou et al., 2016).
• The use of multimodal pain management and ERAS protocols has gained mounting momentum over the past several years. Existing evidence supports their effectiveness in pain management, decreased side effect profiles when paralleled with opioid monotherapy, shortened hospital stays, and improved clinical outcomes (Kremer & Griffis, 2018).

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Common medications used in ERAS and multimodal protocols

(Graff & Grosh, 2018)

Enhanced Recovery After Surgery (ERAS)

(Pędziwiatr et al., 2018)

ERAS: Further Break Down

• Using multimodal perioperative care pathways, ERAS protocols ensure preoperative organ function and reduce postoperative stress. In addition to preoperative counseling, nutrition optimization, reduced opioid analgesic and anesthetic regimens, and early mobilization, optimized anesthesia care is provided.
• Carbohydrate loading a day before surgery improves perioperative insulin sensitivity, nitrogen and protein losses, and skeletal muscle preservation.
• Reduced insulin resistance, nitrogen losses, and muscle strength loss, enhance metabolic responses, and reduce wound infection and pneumonia.

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(Melnyk et al., 2011)

Facilitators and Barriers to the Implementation of ERAS and Multimodal Pain Management Protocols

• Facilitators:
• Multidisciplinary Team Involvement, Communication, Education, and Structured Training.
• Improved Accessibility to Protocols, Instructions.
• Leadership Involvement, quality audits, and an Anesthesia-led ERAS program.
• Barriers:
• Clinician Reluctance to Protocol Adoption and Time Constraints.
• Logistic Issues and Multidisciplinary Team Disagreement.
• Inadequate Clinician Education and Protocol Complexity

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Improved Protocol Access and Decreased Complexity Facilitate Implementation

• Simplifying and improving the accessibility to detailed instructions to anesthesia professionals in perioperative settings are identified as facilitators of ERAS protocol implementation (Velasco et al., 2019).
• Improved accessibility to the protocol instructions can be achieved by developing easy-to-follow guidelines that cover all aspects of preoperative, intraoperative, and postoperative care related to the protocols (Gustafsson et al., 2018).

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The Essential Role of Structured Clinician Education

• Clinician education and structured training programs are vital facilitators due to their critical impact on clinicians' knowledge and comfort level with implementing the protocols (Edwards et al., 2020).
• Regular education sessions and training should be provided to anesthesia professionals to ensure they are aware of best practice protocols and up-to-date with current evidence on ERAS implementation (Gustafsson et al., 2018).
• Even though “on-the-job” training is necessary, there is an identified need for structured academic training programs that include different learning methods such as computer-based learning modules that offer robust evidence-based education while providing flexibility of completion (Beal et al., 2021).

IMPORTANT: Please copy the link below and paste it on your browser to access the post- educational intervention survey

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https://s.surveyplanet.com/u7gpouvr

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References

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Anwar, S., Herath, B., & O’Brien, B. (2021). Adding Insult to Injury—Are We Fueling the Opioid Crisis During the Perioperative Period? Journal of Cardiothoracic and Vascular Anesthesia, 35(6), 1712–1714. https://doi.org/10.1053/j.jvca.2021.02.059

Chou, R., Gordon, D. B., de Leon-Casasola, O. A., Rosenberg, J. M., Bickler, S., Brennan, T., Carter, T., Cassidy, C. L., Chittenden, E. H., Degenhardt, E., Griffith, S., Manworren, R., McCarberg, B., Montgomery, R., Murphy, J., Perkal, M. F., Suresh, S., Sluka, K., Strassels, S., . . . Wu, C. L. (2016). Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on regional anesthesia, executive committee, and administrative council. The Journal of Pain, 17(2), 131–157. https://doi.org/10.1016/j.jpain.2015.12.008

Graff, V., & Grosh, T. (2018). Multimodal Analgesia and Alternatives to Opioids for Postoperative Analgesia. Anesthesia Patient Safety Foundation, 33(2), 46–47.

Gustafsson, U. O., Scott, M. J., Hubner, M., Nygren, J., Demartines, N., Francis, N., Rockall, T. A., Young-Fadok, T. M., Hill, A. G., Soop, M., de Boer, H. D., Urman, R. D., Chang, G. J., Fichera, A., Kessler, H., Grass, F., Whang, E. E., Fawcett, W. J., Carli, F., . . . Ljungqvist, O. (2018). Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018. World Journal of Surgery, 43(3), 659–695. https://doi.org/10.1007/s00268-018-4844-y

Kremer, M. J., & Griffis, C. A. (2018). Evidence-based use of nonopioid analgesics. AANA Journal, 86(4), 321–327. https://pubmed.ncbi.nlm.nih.gov/31580826/

Melnyk, M., Casey, R. G., Black, P., & Koupparis, A. J. (2011). Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Canadian Urological Association Journal, 342–348. https://doi.org/10.5489/cuaj.11002

Norcross, W., Miller, T. E., Huang, S., Kim, J., Maza, S., Sanders, E., McCarthy, C., & Ransom, E. (2019). Implementation of a successful Enhanced Recovery After Surgery program in a community hospital. Cureus, 2109 Oct (10), Article. https://doi.org/10.7759/cureus.6029

Pędziwiatr, M., Mavrikis, J., Witowski, J. et al. Current status of enhanced recovery after surgery (ERAS) protocol in gastrointestinal surgery. Med Oncol 35, 95 (2018). https://doi.org/10.1007/s12032-018-1153-0

Stone, A. B., Wick, E. C., Wu, C. L., & Grant, M. C. (2017). The US opioid crisis: A role for enhanced recovery after surgery. Anesthesia & Analgesia, 125(5), 1803–1805. https://doi.org/10.1213/ANE.0000000000002236

Velasco, D., Simonovich, S. D., Krawczyk, S., & Roche, B. (2019). Barriers and facilitators to intraoperative alternatives to opioids: Examining CRNA perspectives and practices. AANA Journal, 87(6), 459–467.