What makes a nurse a good ERAS nurse?

The emergence of enhanced recovery after surgery (ERAS) has created advances in perioperative care. The effectiveness of ERAS is based on pathophysiological perioperative stress reduction and preservation of physiological function in the postoperative patient. ERAS guidelines are designed to reduce the development of insulin resistance, a measure of postoperative stress and a major culprit in the development of postoperative complications. The key elements of ERAS include patient/family education, patient optimization prior to admission, minimal fasting that includes a carbohydrate beverage 2 ​h before anesthesia, multimodal analgesia with appropriate use of opioids when indicated, return to normal diet and activities the day of surgery, and return to usual activities of daily living.

Studies measuring levels of systemic inflammatory markers after surgery showed lower levels of interleukin-6 and C-reactive protein in patients within an ERAS program compared to those who went through traditional care. This decrease in stress response has been borne out by significant reduction of postoperative complications and length of stay in ERAS programs across various surgical subspecialties (How Kwang Yeong, 2020).

The most overlooked aspect of ERAS is the philosophy of breaking down traditional models of perioperative care. There are fragmented systems of care that create a huge source of waste and unwanted variations in clinical practice which leads to poor outcomes. The concept of ERAS is to ensure that all the stakeholders in the surgical journey are brought together including the patients and their families. The goals are better achieved through better collaboration, communication, shared responsibility and accountability.

The implementation of new evidence based practice creates changes that require overcoming some obstacles and challenges to ensure the success of any endeavor. Some of these obstacles can be related to administrative support specifically human and financial resource including time allocation. To facilitate sustainability of any change endeavor, there is a need to assess dimension of the obstacles and formulate feasible solutions specifically in the role of an ERAS nurse and coordinator.

Most of the main areas of responsibility for an ERAS nurse always include data collection and audit, patient education and support throughout the pathway and training of colleagues involved in the ERAS endeavor. Inclusive of the responsibility is providing ERAS education for the patients pre-operatively, rounding on the hospital ERAS patients post-operatively, collecting and compiling patient data pertaining to ERAS protocol adherence and evaluating patient outcomes. There is a need to conduct at least one or two weekly meetings with key stakeholders from upper management, finance as well as members of the multidisciplinary team including EPIC analysts, physician/surgeon champions, nurse champions and nurse managers, physical and occupational therapies, and dietitians/nutritionists. This opportunity allows continuity to address concerns as they arise.

Recognizing that ERAS nurses are expected to think out of the box strategies, they may also undertake development of new pathways, project management, pre-assessment and post-operative support.

As time progresses, the role of the ERAS nurse has been an incredibly challenging and rewarding opportunity as it remains a dual-role position; cited in the American Association of Nurse Anesthesiology. Performing the role of a clinical bedside nurse and assuming an additional role as ERAS nurse remains a challenge on a daily work schedule. All ERAS in-patients are visited daily to collect key data points to evaluate compliance of ERAS protocol as well as patient outcomes The main challenge in this role is to maintain a balance between time taking care of patients and seeing patients for pre-operative evaluations as well as performing other duties like being ERAS coordinator.

The success of an ERAS program can be attributed to the ability to network within and outside of any healthcare institution, as well as the work of a multidisciplinary team, endorsement and support from staff and upper management and personal and professional time investment.

Identified burdens include time, resource allocation as well as coordination of the team, have been our hardest obstacles to overcome. For any healthcare institution considering creating an ERAS program, it is critical that endorsement and support for the program is obtained from the healthcare institution's key stakeholders and upper management. Proper time and role delineation should also be addressed and allotted as this will promote and ideally expedite proper expansion of the program to be instituted.

One of the critical issues in ERAS is the increasing complexity of the protocols. It is difficult to truly quantify the impact each ERAS element has on the outcomes. Other elements have not shown significant effect on postoperative outcomes on their own. However, some evidences have also shown that a high level of compliance to the ERAS protocol revealed better postoperative outcomes, implying that the ERAS components have a synergistic effect when performed well together.

It is worthy to note that instead of viewing ERAS as a protocol, it is important to recognize the elements complement and augment each other. What is the value in surgery specifically to the patients considering the rising healthcare costs? The value proposition of ERAS lies in its ability to improve outcomes, reduce complications, hospital length of stay, and thereby decreasing healthcare costs.

Evidences in perioperative care needs to constantly and rigorously be reviewed, ERAS protocols must be updated to stay relevant with focus on improving patient recovery from surgery.