Overcoming Barriers to the Implementation of an Enhanced Recovery After Surgery Program

Fig. 17.1.

Knowledge to Action Cycle (adapted from Graham ID, Logan J, Harrison MB, et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof 2006;26(1):13–24, with permission).

Common Barriers to Implementation of Enhanced Recovery Programs

Grol and Grimshaw suggest that three common issues affect whether new evidence is introduced into clinical practice: the attributes of the evidence itself, barriers and facilitators to changing practice, and the effectiveness of the implementation strategies [9]. The strength of the evidence supporting the individual elements included in ERPs is discussed throughout this manual and will not be further discussed here. The literature on barriers to adoption of new evidence suggests that it is important to be aware of all potential barriers prior to implementation. Different barriers to change can be identified at the level of the individual professional, the patient, the healthcare team, the organization, or the greater community [9]. As well, studies suggest that different healthcare professionals may perceive different factors as barriers. For physicians, commonly stated barriers include organizational constraints, prevailing practices and social opinions (i.e., current standard of practice, key opinion leaders disagreeing with the proposed change), and personal barriers such as not being aware of or believing the evidence, or not wanting to change practice [9, 10]. For nurses, barriers involve perceptions that they do not have the time, resources, and access to persons who can locate the evidence and translate it for use in practice. Other constraints include lack of support from administration and other healthcare professionals. Unfortunately, there is limited information available about barriers to implementing evidence as a multidisciplinary team.

To address this gap in knowledge, the implementation of enhanced recovery after surgery (iERAS) program at the University of Toronto conducted a qualitative study to better understand the multidisciplinary perioperative teams’ current beliefs regarding enablers and barriers to successful adoption of a local, university-wide ERP. Semi-structured face-to-face audio-recorded interviews were conducted with general surgeons, anesthesiologists, and ward nurses at each of the seven University of Toronto affiliated adult teaching hospitals. The results suggested that overall, interviewees were supportive of the implementation of a standardized ERP.

The most commonly cited barriers to adoption of an ERP related to time and personnel restrictions required to develop the guideline, limited hospital resources (financial, staffing, space restrictions, and education), perceived resistance from other members of the perioperative team, necessity of engagement of the whole perioperative multidisciplinary team, lack of knowledge about the benefits of specific interventions in the program, perceptions about patients’ social and cultural values, and institutional barriers. Institutional barriers such as lack of nursing staff and lack of financial resources from the hospital were seen as barriers by many interviewees. At an individual level, resistance to change by various members of the perioperative team was seen as the primary barrier. As well, many participants felt that poor communication and lack of collaboration among the team members were barriers.

When the data were analyzed at the discipline level, there were a few notable differences and similarities. Surgeons, anesthesiologists, and nurses all felt that their discipline and the others would be resistant to changing their practice and this would be the biggest barrier to adoption of an ERP. Interestingly, each discipline acknowledged their peers as being resistant to change and also suggested that other disciplines were also resistant to change, suggesting that resistance is a systemic issue and not discipline specific.

With respect to enablers, most participants suggested that in order for the program to succeed, they required a standardized guideline based on best evidence, standardized pre- and postoperative order sets, education for the entire perioperative multidisciplinary team, patients and families, and a hospital ERP champion. Surgeons and anesthesiologists placed a high level of importance on having the interventions based on high-quality evidence while the nurses were more concerned with patient education and patient satisfaction. All disciplines suggested that increased communication between disciplines would be required.

Overall, the findings from these interviews suggested that there are many barriers to implementation of an ERP; however the most common barriers related to the multidisciplinary nature of the program. Based on the many known barriers to adoption of new evidence, numerous strategies may be required in order to effectively implement an ERP.

Overcoming the Barriers: Selection of Strategies

There are many known strategies to increase the use of clinical practice guidelines in healthcare. Systematic reviews have evaluated the effectiveness of different strategies with each resulting in small-to-moderate changes in practice. Table 17.1 illustrates the overall effect of each major implementation strategy based on Cochrane reviews of effectiveness [11–16].

Table 17.1.

Summary of Cochrane reviews on the effectiveness of interventions.

Intervention	Author, year	Included studies	Effect
Audit and feedback	Ivers et al. (2012) [11]	140 RCTs	4.3 % (0.5–16 %)
Reminders	Arditi et al. (2012) [12]	32 RCTs	7.0 % (4–16 %)
Continuing educational meetings and workshops	Forsetlund et al. (2009) [13]	81 RCTs	6.0 % (2–15 %)
Educational outreach visits	O’Brien et al. (2007) [14]	65 RCTs	6.0 % (4–16 %)
Opinion leaders	Flodgren et al. (2011) [15]	18 RCTs	12.0 % (6–15 %)
Printed educational meetings	Giguere et al. (2012) [16]	14 RCTs and 31 non-RCTs	2.0 % (0–11 %)

Due to the varied evidence to support implementation strategies and to be consistent with the Knowledge to Action Cycle, the enablers and barriers identified in our study were used to select implementation strategies [5]. As there were multiple barriers and enablers, the iERAS program developed a multipronged implementation strategy that involved all disciplines and that was applicable to all academic hospitals. The implementation strategy included assigning champions, development of standardized materials, development of educational tools, audit and feedback, support from hospital administration, and communication strategies.

Identification of Local Champions at Each Hospital

One of the most important strategies when implementing an ERP is the identification of local champions. It is important that a champion from each discipline be identified including a nurse champion, anesthesia champion and surgeon champion. Identifying a champion in hospital administration can also be a useful strategy to get institutional buy-in and help secure resources for the program. The main role of the champions is to lead implementation. The champions should meet regularly with members of the perioperative team and facilitate education and communication by presenting multidisciplinary educational rounds, in-services, and teaching sessions to increase awareness and acceptance of the guideline recommendations. Having discipline-specific champions is important to address a number of barriers. First, discipline-specific champions are the foundation and leaders of the local ERP team. Having a point person from each discipline allows for open communication between these leaders representing the key stakeholders. Second, discipline-specific champions are key to addressing discipline specific issues, and concerns. For example, nurses may be concerned about the amount of time it will take them to mobilize the patient starting on the day of surgery. The nurse champion would work with the team to discuss these issues specifically and come up with a plan that was agreeable to the rest of the unit. The champion also acts as a liaison between other disciplines. For example, ward nurses may be best able to identify issues with adherence to the guidelines specific to an individual surgeons. The nurse champion would communicate this to the surgeon champion who would then be responsible for following up with these surgeons to understand and address their concerns.

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