ERAS: 4 Lessons Learned for Effective Implementation

Publish Date: April 19, 2017

Implementing Enhanced Recovery After Surgery (ERAS) pathways is the future of evidence-based care, according to Elizabeth Fahlgren, RN, MS, CNOR, operating room manager at the University of California San Francisco Medical Center.

“The ERAS pathway concept is very exciting because it has shown for years to have positive results and I like how we’re using evidence to standardize care,” she says. “We’re all under pressure to give high-quality care with less resources, and so I find it exciting that we can do that with evidence, a team approach, and better communication instead of bringing in a new gadget.”

Fahlgren is part of a multidisciplinary team led by a colorectal surgeon and an anesthesiologist who have worked to establish an ERAS pathway specifically tailored for colorectal surgery patients. Because of its initial success this program has broadened into a perioperative pathways program to encourage adoption across several surgical services.

An ERAS pathway is a series of evidence-based initiatives that stimulate post-operative recovery, while reducing complications. For example, elements of the ERAS pathway implemented for colorectal patients by Fahlgren’s team include:

  • Patient education and possible exercise program prior to surgery
  • Providing alternatives to opioid medication for pain control
  • Epidural
  • Giving the patient a carbohydrate drink four hours before surgery to maintain more normal fluid volume throughout the procedure
  • Avoidance of drains and NG tubes
  • Early ambulation and early diet advancement after surgery

Fahlgren says an important key to the success of implementing this ERAS pathway is expecting that changes will be continually made as the pathway is refined. “It’s these small tweaks in practice for the ERAS pathway that make all the difference,” Fahlgren explains. She says a focus on using existing processes and charting and not implementing new or time intensive steps was a key goal for the pathway coordinators.

As the team continues to refine and expand this ERAS pathway, and broadens this into a perioperative pathways program, here are the four key lessons Fahlgren and her team members have learned for successful implementation:

  1. It Takes a Team

    Representatives from each stage of patient care were involved from the earliest stages of planning for implementation, including clinic, preop, OR, PACU, floor, anesthesia, surgery, as well as IT, pharmacy, and hospital quality. Each of these representatives attended the monthly meetings leading up to and after pathway implementation to share perspectives on efficiency and quality before Go Live and to discuss as a team patient outcomes data and areas for pathway improvement. They continue to meet monthly.

  2. You Learn and Improve as You Go

    The team experienced a long and slow learning curve as they brought providers onboard and continually refined the process. For example, the pathway began with using paper reminders but this was very labor intensive and reliant on individuals to push compliance so the team transitioned to incorporating the ERAS pathway elements into the electronic health record. “This step to an electronic approach for ordering and tracking ERAS steps proved to be a game changer for compliance and effectiveness of the overall pathway,” Fahlgren notes.

    She also says that unexpected benefits for factors such as efficiency were also realized during the ERAS pathway implementation. For example, because each ERAS patient received an epidural, procedure on time start was critical and the important role the perioperative nurse played in coordinating the patient’s preoperative care became evident. “By adjusting his or her schedule slightly to check in with the patient a few minutes earlier to coordinate the epidural in the operating room or in a designated area for nerve block procedures, the perioperative nurse played an important role in reducing the time spent for preoperative coordination.”

  3. Knowledge is Key

    While ERAS steps are evidence-based, they are sometimes counterintuitive to longstanding beliefs of providers. For example, nurses on the floor were sometimes hesitant to get their patients up and walking only six hours after surgery, Fahlgren notes. She says the physician champions for the pathway played an important role in providing inservice education to a large number of providers involved in the pathway to help each provider understand the evidence behind the ERAS step in the pathway.

    “Even within the perioperative nursing profession, we still have much to learn and share about the value of ERAS, particularly in the United States where this approach is much newer than in Europe, for example, where ERAS has become a common approach,” Fahlgren explains.

  4. Measure the Data

    Positive data on improved patient outcomes have made a big impact on winning the hearts and minds of those once unsure about ERAS approaches, according to Fahlgren. For example, data comparing two cohorts of both traditional and ERAS pathway colorectal surgery patients at her facility showed that the patients within the ERAS pathway cohort spent two days less in the hospital and has a 10% lower rate of readmission. Overall pain scores were also lower for ERAS patients. As the study continues, the team is measuring cost savings associated with ERAS pathway procedures.

    From a practice perspective, the anecdotal value of the ERAS pathway has also shown value, Fahlgren adds. “Although more elements of preoperative care were added, efficiency and first case on-time starts were not compromised.” She says the overarching value of implementing this ERAS pathway is how it demonstrates the powerful value of making small evidence-based changes in collaboration to improve a patient’s overall surgical outcome.


Check out this and other posters presented at AORN’s 2017 Global Surgical Conference and Expo.


Explore established pathways for Enhanced Recovery After Surgery from the American Society for Enhanced Recovery.