Summary
Every year, thousands of young and elderly patients go through various surgical procedures. The speed and effectiveness of patients’ recovery after surgeries depend on numerous factors. The quality of nursing care plays one of the crucial roles in how patients recover from surgeries. Enhanced patient recovery (EPR, ERAS) after surgeries has already become one of the top priorities in nursing care. Unfortunately, not all nurses know how to facilitate patients’ reintegration into their home and workplace environments after surgeries. Not all EPR strategies are universally effective. The goal of this paper is to review what contemporary researchers have to say about enhanced patient recovery and its best methods.
Literature Search Strategies
For this review, a detailed search of empirical and analytical literature was performed. The following databases were used: ProQuest, CINAHL, Cochrane, Academic Search Premier (EBSCOHost), and Google Scholar. A total of 10 articles meeting the search criteria were identified. The following search criteria had to be met: (a) all articles had to be published between 2008 and 2013; (b) all articles had to be published in peer-reviewed journals. Both primary and secondary research findings were included. The keywords used in this library search were: “enhanced patient recovery”, “surgery”, “nursing.”
Literature Review
Enhanced Patient Recovery after Surgery
The current state of literature provides rich information on the benefits and principles of enhanced patient recovery after surgeries. Unfortunately, most researchers and clinical professionals take its meaning for granted. Meanwhile, not all nurses understand the meaning and practical implications of the concept. Here, the description of enhanced patient recovery by Burch (2012) could create a good basis for the development of effective EPR strategies. According to Burch (2012), enhanced recovery is associated with less stress during surgery and faster recovery following the surgery.
Enhanced recovery transcends all aspects of the surgical process, from preoperative procedures to post-operative interventions (Burch, 2012). The basic intent behind enhanced recovery interventions is to prepare patients for fast and easy discharge, by making them tolerant to oral intake and mobilizing them without external assistance (Burch, 2012). Enhanced recovery implies that patients go through the process of hospital-to-home transition smoothly and without any damage to their emotional and physical health. At home, such patients always know whom they need to contact in case of an emergency.
Burch (2011) also lists the chief elements of the enhanced recovery process. These include pre-admission information, no prolonged fasting, no pre-medication, and no bowel preparation (Burch, 2011). In the context of enhanced recovery, patients do not need any nasogastric tubes, and only epidural analgesia is provided (Burch, 2011). The EPR framework also includes peri- and post-operative management of fluids and implies that no drains are to be used (Burch, 2011). EPR always entails the use of post-operative analgesia, which facilitates early patient mobilization (Burch, 2011). Due to smaller incisions and the use of oral analgesia in the postoperative period, patients quickly return to their daily activities (Burch, 2011).
Nursing Ways to Ensure Enhanced Patient Recovery after Surgery
Researchers discuss numerous ways, in which nurses can ensure enhanced patient recovery after surgeries. To make enhanced patient recovery possible, nurses should develop and implement effective strategies at all stages of nursing care. In the context of pre-operative assessment and preparation, Foss (2011) recommends providing patients with the fullest information about the surgery and its outcomes. The proposition is justified by the fact that patients who receive information during the pre-operative assessment are less likely to access healthcare services after the surgery (Foss, 2011).
Enhanced patient recovery is impossible without educating patients before admission, as such education was found to reduce post-operative pain and facilitate self-care and prevention of possible complications by patients (Foss, 2011). In addition, nurses can use the measurement instrument proposed by Barham and Devlin (2011): the Patient-Reported Outcome Measures is a tool for routine measurement of patients’ health before and after the medical intervention. The PROM program was first introduced in 2009 in England, but Barham and Devlin (2011) suggest that it could be successfully incorporated into other nursing procedures provided as part of various EPR models.
No less important are the models and approaches used by nurses to facilitate patients’ enhanced recovery after surgeries. At times, nurses choose to follow their patients to their homes (Anonymous, 2011). Many outpatient surgery patients are older and face numerous acute health problems; therefore, delivering quality nursing support at home can become the best option for such patients (Anonymous, 2011).
Anonymous (2011) writes that, depending on the patient’s health state, home nurses can perform regular health evaluations, monitor patient incisions, and administer medications. In most cases, nurses visit patients 2-3 times a week. They visit patients, who are at higher risks for post-surgical complications or need complex therapies to fully recover (Anonymous, 2011). At times, making a phone call can be enough to ensure enhanced patient recovery after surgeries. According to Burch (2012), telephone follow-ups are intended to facilitate a smooth transition from hospitals to homes and monitor how patients are improving their health.
The growing amount of evidence supports the necessity of enhanced patient recovery, but researchers are also coming to realize the value of multidisciplinary nursing interventions. Olsson, Hansson, Ekman, and Karlsson (2009) proposed the so-called “patient-centered integrated care pathway” (p.1626). ICPs are integrated multidisciplinary protocols that include the elements of nursing, medical, and paramedical care (Olsson et al., 2009). The goal of the protocol is to streamline the provision of quality post-operative care, while also making it cost-effective (Olsson et al., 2009). The evidence supporting the effectiveness of these protocols is quite extensive, and nurses could use them to support patients in their recovery efforts after surgeries (Olsson et al., 2009).
Limitations and Critical Appraisal
The growing importance of multidisciplinary care justifies the development and implementation of enhanced recovery protocols. Researchers provide various arguments to support the validity of EPR. Wind et al. (2008) claim that enhanced patient recovery programs help optimize perioperative care, leading to reduced mortality, morbidity, and hospital stay. Teeuwen et al. (2010) support these findings and confirm that the education provided through EPR protocols before the surgery reduces patients’ anxiety and improves their health outcomes. According to Abraham and Albayati (2011), the use of enhanced recovery protocols reduces the length of primary hospital stay by 2.45 days. Fast recovery does not lead to higher readmission rates (Abraham & Albayati, 2011).
One of the greatest limitations is that most studies are focused on the analysis of enhanced patient recovery, as related to colorectal surgery (Abraham & Albayati, 2011; Ahmed et al., 2010; Teeuwen et al., 2010; Wind et al., 2008). The interest towards this type of surgery is logical: enhanced recovery was initially used in colorectal surgery and was later extended to other specialties (Burch, 2012). Still, many researchers fail to expand their focus, which makes the implementation of EPR protocols in other nursing settings quite problematic. In addition, while the benefits of EPR in nursing care are well-established, only one study mentioned the importance of patient compliance with the protocol: Ahmed, Khan, Gatt, Kallam, and MacFie (2010) suggest that compliance with the principles of enhanced recovery can be problematic, mainly because the EPR protocol differs considerably from traditional care practices.
Implications for Future Research and Practice
The results of this literature review imply that future researchers should focus on the analysis of enhanced patient recovery protocols in fields and settings other than colorectal surgery. At the same time, “despite the current evidence supporting the benefits of ERAS protocols, such protocols have not yet been widely adopted, probably due to the cost and resources required to train medical, nursing, and allied health staff” (Abraham & Albayati, 2011, p.3). Therefore, researchers and clinical nurses will have to develop new models of patient recovery, which will be multidisciplinary and cost-effective.
Conclusion
Enhanced patient recovery is one of the most essential nursing priorities. EPR protocols transcend all aspects of nursing care, from preoperative assessment to patients’ transition from hospital to home. The current state of literature provides sufficient evidence to confirm the benefits of enhanced patient recovery. Researchers suggest possible ways to improve the quality of nursing care and patient outcomes. However, advances in the nursing care areas beyond colorectal surgery are needed. Issues of compliance with EPR have to be reviewed. Also, future researchers will have to focus on the development of new EPR protocols, which will be both multidisciplinary and cost-effective.
References
Abraham, N. & Albayati, S. (2011). Enhanced recovery after surgery programs hasten recovery after colorectal resections. World Journal of Gastrointestinal Surgery, 3(1), 1-6.
Ahmed, J., Khan, M., Kallam, R. & MacFie, J. (2010). Compliance with enhanced recovery programs in elective colorectal surgery. British Journal of Surgery, 97, 754-758.
Anonymous. (2011). Agency nurses follow patients to their homes. Same-Day Surgery, 51-52.
Barham, L. & Devlin, N. (2011). Patient-reported outcome measures: Implications for nursing. Nursing Standard, 25(18), 42-45.
Burch, J. (2011). What does enhanced recovery mean for the community nurse? British Journal of Community Focus, 14(11), 490-494.
Burch, J. (2012). Enhanced recovery and nurse-led telephone follow-up post surgery. British Journal of Nursing, 21(16), S24-S29.
Foss, M. (2011). Enhanced recovery after surgery and implications for nurse education. Nursing Standard, 25(45), 35-39.
Olsson, L.E., Hansson, E., Ekman, I. & Karlsson, J. (2009). A cost-effectiveness study of a patient-centered integrated care pathway. Journal of Advanced Nursing, 65(8), 1626-1635.
Teeuwen, P.H., Bleichrodt, R.P., Strik, C., Groenewoud, J.M., Brinkert, W., Laarhoven, C.J. & Bremers, A.J. (2010). Enhanced recovery after surgery (ERAS) versus conventional postoperative care in colorectal surgery. Journal of Gastrointestinal Surgery, 14, 88-95.
Wind, J., Polle, S.W.,Jin, F.K., Dejong, C.H., Meyenfeldt, M.F., Ubbink, D.T. […] Bemelman, W.A. (2008). Systematic review of enhanced recovery programs in colonic surgery. British Journal of Surgery, 93, 800-809.