Knowledge, Compliance and Barriers to Implementation of Eras Guidelines by General Surgeons and Residents in Kenyatta National Hospital

Abstract

Background Enhanced Recovery after Surgery (ERAS) Protocol is a set of evidence-based guidelines on perioperative care using a multimodal and multidisciplinary approach at all the phases of surgical care from the pre-admission stage until discharge from hospital. These guidelines are aimed at minimizing surgical stress and accelerating recovery, thus optimizing patient outcomes and lowering the cost of health care. The protocol has been tried and tested globally and found to significantly improve perioperative outcomes and reduce the duration of hospitalization. Subsequently, it has been adopted universally as a means of reducing perioperative morbidity. Despite its adoption in Kenyatta National Hospital (KNH) General Surgery unit four years ago, the compliance to its elements and the hindrances to its effective implementation have not been interrogated. Objective To assess the knowledge, evaluate self-reported compliance and determine perceived barriers to implementation of ERAS guidelines by general surgeons and their residents in KNH. Methodology This was a descriptive cross-sectional study carried out at the KNH General Surgery unit among consultant general surgeons and surgery residents providing surgical care in KNH General Surgery wards. It was a census study. A structured, self-administered two-part online questionnaire was used to collect the data. Independent variables are the demographics of respondents, while the dependent variables are the scores on Knowledge, Compliance and Barriers identified. Descriptive statistics such as means, SD, medians and ranges were used to describe the characteristics of the study participants and their responses. For statistical analysis and evaluation of associations, the student T-test and ANOVA tests were employed. Results were presented in pie charts, graphs, tables and plot diagrams. Results Most of the respondents were residents (83%), majority being in their 5th year of residency (45%). Despite 98% awareness on what ERAS is, knowledge score was low at 57.7%, with preoperative elements recording lowest scores. There were no significant differences in knowledge between the demographic groups. Compliance mean score was 50.2% (SD=17), with the most affected elements including use of preoperative clear carbohydrate drinks and prehabilitation. Notably, compliance decreased across all groups with increase in seniority (by level of training and length of experience). Lack of an ERAS Coordinator and lack of Continuous Medical Education (CME) on ERAS were rated among the top barriers to implementation of ERAS protocols. Conclusion The findings suggest that appointment of an ERAS Coordinator and instituting CME teachings on ERAS may improve knowledge and compliance. Pre-admission nutritional optimization and adherence to pre-operative limited fasting guidelines should also be addressed. Such interventions to address the identified deficits in knowledge and compliance, and the key barriers, may improve patient outcomes and shorten hospital stay, thus lowering the cost of surgical care. 11 Chapter 1: Introduction The ERAS protocol is a compilation of evidence-based guidelines on perioperative care using a multimodal and multidisciplinary approach at pre-admission, preoperative, intraoperative and postoperative phases to minimize surgical stress, accelerate recovery and optimize patient outcomes.1 By employing highly effective approaches to perioperative care, ERAS protocol also seeks to reduce the overall cost of surgical healthcare, mainly by reducing the length of stay. 1, 3 This allows the realization of the ultimate aim of ERAS which is to improve the value of the care provided to both the patient, and the healthcare system as an entity. This value is evaluated, on one hand, in terms of patient-reported outcomes and surgical safety, and on the other hand in terms of the cost of healthcare. 3 The protocol addresses the entire cycle of perioperative care of a surgical patient. This is done by dividing the cycle into the afore-mentioned four phases according to the chronological sequence of events from the time a decision to operate on the patient is made until the time a patient is discharged from in-patient care after surgery. 3 Each of these phases involves different strategies that are not stand-alone items but are interdependent in that the elements in a particular phase actually optimize the patient for the next phase and therefore have a bearing on the effective implementation of elements in the subsequent phase. ERAS protocol elements are thus best viewed as interlinked measures to address the continuum of surgical care as a complete spectrum, rather than singular disjointed efforts. 12 ERAS protocol consists of 24 core elements grounded on evidence-based recommendations, and grouped into the four phases along the pathway taken by the surgical patient. 1, 12 (Appendix 1) The various elements of ERAS protocol employ different modalities such as psychological, dietary, pharmacological, physiotherapy and surgical methods, thereby making it a multimodal approach. 2, 12 This therefore requires the contribution of different specialties for the implementation of the different elements, making it essentially a multidisciplinary tool. The ERAS team will therefore have a varied personnel mix comprising Counselors, Nutritionists, Physicians, Psychiatrists, 12 Anesthesiologists, Surgeons, Nurses, Enterostomal therapists, Clinical Pharmacists, Physiotherapists and Occupational therapists. 3, 12 ERAS Protocol has been validated in several studies and shown to result in significant success regarding its impact on perioperative outcomes as described. 40