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Implementing Enhanced Recovery Pathways:
a literature review with realist synthesis
Astrid Coxon¹, Karina Nielsen², Chris Fox¹ & Jane Cross³
University of East Anglia ¹Norwich Medical School, ²Norwich Business School, ³School of Health Sciences
Contact: a.coxon@uea.ac.uk
Background
Enhanced Recovery Pathways (ERPs, also known as Enhanced Recovery After Surgery) were
first introduced in Denmark in the 1990’s¹, and in the UK NHS in the early 2000’s
Originally used in colorectal surgery, ERPs have now been developed for a broad range of
surgical procedures, including gynaecological, urological and orthopaedic surgeries
Multi-modal, evidence-based approach, designed to streamline the surgical process from
pre-admission to discharge & recovery
When successfully implemented, ERPs have been shown to reduce patients’ length of
hospital stay, reduced recovery time, and improve functional outcomes²
However, implementing an ERP can require significant changes in a variety of ward
procedures, across a range of staff groups
Adherence to ERP protocols varies; most notably, adherence to post-operative & recovery
stages is often low, but it is unclear why³
Issues with adherence limit potential impact of improving outcomes
If an evidence-based ERP is ineffectively implemented, it will have limited impact: to
improve healthcare, implementation must also be evidence-based
Discussion
Through a process of realist synthesis, we developed a number of CMO configurations
which highlight and explain current strategies in ERP implementation –an example is given
in the figure above
Although all papers included in this review each described at least one implementation
strategy used, these were described in limited detail, were outcomes focussed, and no
rationale was given for why particular approaches were used in favour of others
Regardless of surgical speciality, a theoretically-based and planned process of
implementation results in sustained ERP adherence (and subsequent improvements for
patients)
The findings highlight the importance of stakeholder involvement at all stages of the ERP, to
maximise pathway adherence –by supporting, valuing, and involving members from all staff
groups, an effective implementation strategy can influence capability, opportunities,
motivation and ultimately behaviour
The available evidence used in this review did present instances in which desired outcomes
were not achieved (e.g. low adherence in post-operative stages of the pathway) –however,
due to limited detail given regarding context, we can only currently speculate as to the
reasons why the mechanisms of action were not fully triggered in these instances
Conclusion
Currently, high quality data detailing the process of ERP implementation in the UK is limited,
which limits the transferability of findings to other contexts
ERP research has a strong focus on design and content, and the impact on outcomes, but
little detail is reported regarding implementation strategies used to ensure fidelity
This may explain why adherence rates are often lower than expected, and inconsistent
across different stages of the pathway; future ERP research should focus on multi-site
implementation and provide adequate detail of implementation strategies used
Next Steps
Compare findings with international literature to explore transferable concepts
Detailed evaluation of ERP implementation across multiple sites, with a particular focus on
describing contexts & how these interact with mechanisms of action to affect outcomes
Synthesise findings to develop list of key considerations to be made when developing ERP
implementation strategies
References
1. H. Kehlet, Br. J. Anaesth., vol. 78, no. 5, pp. 606–617, 1997 // 2. F. Paton, D. et al, BMJ Open, vol. 4, no. 7, 2014 // 3. J. Maessen, C. H. C. et al, Br. J. Surg., vol. 94, no. 2,
pp. 224–31, 2007 // 4. R. Pawson, Evidence-Based Policy: A Realist Perspective. SAGE Publications Ltd, 2006 // 5. C. Rooth and A. Sidhu, Br. J. Nurs., vol. 21, no. 10, pp. 4–
15, 2012 // 6. D. Lee et al, J Eval Clin Pr., vol. 17, no. 6, pp. 1243–1245, 2011 // 7. J. Billyard, S. Boyne, and J. Watson, Gastrointest. Nurs., vol. 5, no. 9, 2007 // 8. P. M.
Meale and J. Cushion, Curr. Anaesth. Crit. Care, vol. 21, no. 3, pp. 125–128, 2010 // 9. E. Torbé, et al, Obstet. Gynaecol., vol. 15, no. 4, pp. 263–268, 2013 // 10.
Association of Surgeons of Great Britain and Ireland, “Guidelines for Implementation of Enhanced Recovery Protocols”, 2009 // 11. J. Ahmed et al, Color. Dis., vol. 14, pp.
1045–1051, 2012 // 12. Royal College of Obstetricians & Gynaecologists, “Enhanced Recovery in Gynaecology”, 2013 // 13. T. Wainwright and R. Middleton, Curr.
Anaesth. Crit. Care, vol. 21, pp. 114–120, 2010 // 14. I. J. Wrench et al, Int. J. Obstet. Anesth., vol. 24, no. 2, pp. 124–30, 2015 // 15. Correspondence to “Enhanced
Recovery in Obstetrics”, Int. J. Obs. Anaesth., 22, pp. 349-361, 2013 // 16. R. Slater, ” Br. J. Nurs., vol. 19, no. 17, pp. 1091–1099, 2010 // 17. J. Smith et al, BJU Int., pp.
375–383, 2014 // 18. Mount Vernon Hospital, “Enhanced Recovery Partnership Programme Case Studies,” 2011 // 19. Royal Berkshire Hospital, “Enhanced Recovery
Partnership Programme Case Studies,” 2011 // 20. Medway NHS Foundation Trust, “Enhanced Recovery Partnership Programme Case Studies,” 2011
Aims
To explore how, when, why, under which circumstances, and to what extent ERPs are
successfully implemented
To identify which implementation strategies, under which circumstances, result in the
successful integration of ERPs into existing hospital practice
Method
Consulted literature on ERPs, process implementation, behaviour change theory and
knowledge translation to guide search and review strategy
Developed initial propositions to be tested through main search and data synthesis. These
were:
Staff who feel valued and involved in the ERP implementation process are more
motivated to adhere to the pathway
If ERPs are tailored to take into account local context (including resources, staffing
levels, existing practices), they are more likely to be adhered to
Searched electronic databases to identify candidate papers for data extraction and synthesis
All identified papers mined for data relevant to review aims and used to test initial
propositions and develop explanatory models of ERP implementation
Instead of using data extraction forms (which can be rigid and limiting⁴), the data was
analysed and extracted iteratively, being constantly related back to the review aims
Data was purposively extracted and synthesised, highlighting areas of convergence and
divergence
Synthesised data was then used to develop abstract Context-Mechanism-Outcome (CMO)
configurations
CMO configurations related back to initial propositions and cross-referenced with further
analysis of contributing literature to test relevance and develop explanatory model
Identified any significant gaps in current ERP implementation research and understanding
Results
Although the literature related to ERPs is continually increasing, we found that the number
of articles which describe the process of ERP implementation to be limited
Even in articles including “implementation” or “introduction of ERP” in the title or main
body, description of the process or strategies of implementation used was often limited to a
few sentences
All of the original research papers included in the review described findings from single-
centre studies
All papers included in the review described at least one implementation strategy used
Implementation strategies fell within one of two broad categories: “staff
consultation/multidisciplinary working group” or “use of a change agent/ERP champion”
Description of implementation strategies was outcomes-focused; identifying mechanisms of
action was more challenging, and detail of context was further limited
Review Methodology
A review of current literature involves synthesising a diverse range of research concerning
complex interventions in complex settings
As such, it would be impossible for a single causal theory to consistently predict the
outcomes of implementing ERPs in different contexts
A systematic review approach was deemed unsuitable as systematic reviews are summative
but not explanatory –they can assess to what extent an intervention works, but cannot
explain how, why, to what extent or under what circumstances
Instead, a realist synthesis approach⁴was used, focussing on exploring the underlying
mechanisms of ERP implementation, and developing explanatory models for how those
mechanisms operate in different contexts
1235 articles
identified from
initial database
search
•Duplicates removed
(333)
902 titles and
abstracts
screened
•Articles not meeting
inclusion criteria
rejected (884)
18 full text
articles
reviewed
•Papers with
insufficient data
rejected (4)
14 papers
reviewed and
reference lists
checked
•Further articles
identified through
reference lists (3)
17 full text
articles
included in
review², ⁵⁻²⁰
Outcomes
Mechanisms
Context
Strategy Staff
consultation
Staff feel
valued &
supported
Staff motivated &
engaged with
consultation
process
Staff able to
identify &
manage practical
barriers
Staff have trusting
& respectful
interdisciplinary
relationships
Facilitates
effective
communication
Staff feel involved
& invested in ERP
- are support &
motivate
colleagues
Staff have
opportunities to
contribute to
multidisciplinary
discussions
Facilitates open
discussion
between different
staff groups
Gain greater
understanding
of whole ERP
roles within it
This poster presents independent research related to a project funded by the National Institute for Health Research (NIHR)
under its Programme Grants for Applied Research Programme (Reference Number DTC-RP-PG-0311-12004). The views
expressed here are those of the authors and not necessarily of the NHS, the NIHR or the Department of Health. © Queen’s
Printer and Controller of the HMSO 2015. This work was produced by the authors listed above under the terms of a
commissioning contract issued by the Secretary of State for Health