Version May 2024
INTRODUCTION — Enhanced recovery after surgery (ERAS) programs are perioperative protocols of evidence-based interventions that have been grouped together with the goals of speeding functional recovery and improving postoperative outcomes. Also known as "enhanced recovery protocols" (ERP) or "fast-track surgery," ERAS programs typically include multidisciplinary and multimodal interventions aimed at minimizing the physiologic changes associated with surgery. Patient benefits associated with ERAS include reduction in postoperative opioid use and length of stay.
This topic will review ERAS programs as they apply to gynecologic surgery with a planned overnight stay, although many elements of the ERAS programs discussed here can be adapted for same-day major gynecologic surgery, such as same-day hysterectomy. Related topics on ERAS in colorectal surgery and general postoperative care are presented separately.
●(See "Enhanced recovery after colorectal surgery".)
●(See "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)".)
●(See "Overview of post-anesthetic care for adult patients".)
●(See "Overview of postoperative fluid therapy in adults".)
DEFINITION — ERAS programs combine evidence-based elements of care during the pre-, intra-, and postoperative experiences to decrease physiological stress and organ dysfunction, and thus, enable patients to recover more quickly, have decreased hospital length of stay, and resume routine activity more quickly than with standard surgical care [1]. The patient is a fundamental component of ERAS protocols and is involved in every step from the decision for surgery through discharge. Importantly, elements of ERAS pathways will continue to evolve as new evidence emerges.
The initial ERAS outlined techniques to decrease perioperative physiologic stress to reduce perioperative morbidity and mortality, accelerate recovery, and decrease cost of care [2]. Founded in 2010, the ERAS Society develops international consensus guidelines and resources for the implementation of ERAS bundles [3].
CANDIDATES — Patients undergoing planned gynecologic surgery with an overnight stay are candidates for participation in an ERAS protocol. Although an ERAS pathway can broadly apply to the majority of patients undergoing gynecologic surgery, such a pathway should always be individualized when and where medically indicated. As examples, older adult patients or patients with renal or hepatic dysfunction may require dose adjustment (or elimination) of certain medications (eg, nonsteroidal anti-inflammatory drugs, acetaminophen).
COMPONENTS — ERAS protocols vary among subspecialties, surgical routes, and institutions [4-7]. In general, enhanced recovery focuses on optimizing patient education and perioperative expectations, decreasing the perioperative fasting period, maintaining euvolemia and normothermia, increasing mobilization, providing multimodal pain relief, providing multimodal nausea and vomiting prophylaxis, and decreasing unnecessary or prolonged use of catheters and drains [8]. A guideline of general components for gynecologic surgery has been published by the ERAS Society (table 1) [9,10]. Modified guidelines have been proposed for gynecologic oncology patients [11]. Importantly, while ERAS pathways are formalized for the sake of standardization and ease of ordering, careful attention should be placed to ensure that each component is ultimately safe and applicable to the individual patient undergoing the specific surgery performed.
Preoperative
Patient education — Preoperative education sets patient expectations for the surgery and recovery process, which may in turn reduce fear, fatigue, and pain while increasing early discharge [12]. Effective patient education can take many forms, including access to on-line care modules [13]. One author's institution takes a fourfold approach to patient education that includes:
●Surgeon's office – The surgeon discusses with the patient that she will be on an enhanced recovery pathway to facilitate surgical recovery and sets the expectation of discharge on the morning of postoperative day 1. The surgeon also informs the patient of the postoperative follow-up plan, including a postoperative phone call from the surgeon's office within two to three days following hospital discharge, as well as scheduled postoperative visits.
●Preprocedure assessment visit with the anesthesiology team – Patients on the ERAS pathway receive a 15-minute educational session about the ERAS pathway from a nurse practitioner in addition to undergoing a separate presurgical risk assessment if medically indicated.
Information provided includes the following:
-Preoperatively, the patient may eat solid food until midnight the night before surgery.
-She may drink only clear liquids until two hours before surgery.
-She will receive chlorhexidine soap with which she should cleanse the night before and the morning of surgery.
-She will receive an incentive spirometer, and its use will be reviewed.
-If there is concern for malnutrition, she will receive preoperative nutritional supplements.
-Postoperatively, she will plan to spend one night in the hospital.
-She should be able to eat a regular diet and ambulate beginning the night of surgery.
-Following that, she should ambulate in the hallway three times per day.
-She will receive scheduled pain medications before and after surgery to provide pain control and reduce the need for opioid use, with fewer adverse side effects.
-She will receive scheduled medications to promote bowel function.
-The plan for discharge the morning after surgery will be reviewed.
●Written information – Patients receive a brochure summarizing the ERAS elements and answering frequently asked questions.
●Phone call – On the night before surgery, patients are contacted by a nurse in the surgical scheduling division to remind them of the preoperative dietary guidelines and to ensure they are consuming the preoperative drink as instructed.
Health status optimization — Preoperative optimization of medical comorbidities, including cardiovascular, respiratory, and/or renal disease, are typically part of ERAS programs and are discussed in separate topics:
●(See "Evaluation of cardiac risk prior to noncardiac surgery".)
●(See "Management of cardiac risk for noncardiac surgery".)
●(See "Evaluation of perioperative pulmonary risk".)
●(See "Preoperative evaluation for anesthesia for noncardiac surgery".)
Examples specific to gynecologic surgery include correction of anemia and improved glucose control [9]. In addition, patients should be screened for tobacco, alcohol, and other substance use or abuse. Some experts advise patients to stop tobacco and alcohol use four weeks prior to surgery [9]. Reduced postoperative complication rates have been demonstrated with cessation of alcohol consumption [14]. While smoking cessation may not improve surgical outcomes, there is no risk to stopping and such counseling may encourage patients to quit altogether, particularly when adjunct pharmacotherapy is used [15]. Related information can be found in the following topics:
●(See "Screening for unhealthy use of alcohol and other drugs in primary care".)
●(See "Overview of smoking cessation management in adults".)
●(See "Pharmacotherapy for smoking cessation in adults".)
Patient preparation
●Preoperative fasting – ERAS pathways for gynecologic surgery typically allow consumption of solids up to six hours prior to anesthetic induction, clear liquids up to two hours prior to anesthetic induction, and encourage preoperative carbohydrate loading (table 2) [9,16].
●Bowel preparation – Mechanical bowel preparation is not indicated for most gynecologic surgery. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Bowel preparation' and "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Preoperative preparation'.)
●Prevention of surgical site infections – In an attempt to reduce postoperative surgical site infections, surgical site infection reduction bundles are being incorporated into ERAS pathways to optimize postoperative patient outcomes. The United States Centers for Disease Control and Prevention guideline on surgical site infections advises that "before surgery, patients should shower or bathe (full body) with soap (antimicrobial or non-antimicrobial) or an antiseptic agent on at least the night before the operative day" [17]. Although the risk of infection following preoperative showering with 4% chlorhexidine gluconate alone prior to gynecologic surgery has not been studied in isolation, a lower risk of surgical site infection, from 6to 1.1 percent, was reported following implementation of preoperative showering with 4% chlorhexidine gluconate as part of a perioperative bundle among patients undergoing open uterine or ovarian cancer surgery [18]. Other elements of the bundle included patient education, 2% chlorhexidine gluconate and 70% isopropyl alcohol preparation of the planned area of incision, re-dosing of the prophylactic antibiotic at three to four hours following incision, sterile closing tray, staff glove change for abdominal wall closure, dressing removal at 24 to 48 hours postoperatively, postoperative showering at home with 4% chlorhexidine gluconate, and follow-up phone call by a nurse. As noted above, some practices provide the patient with the chlorhexidine cleansing soap or wipes to be used prior to surgery. Hair in the operative field should be clipped, not shaved, and skin is cleaned. (See 'Patient education' above.)
Antibiotic prophylaxis is administered according to established guidelines. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Preoperative evaluation'.)
●Preoperative thromboprophylaxis – Preoperative thromboprophylaxis is administered according to established guidelines. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Preoperative preparation'.)
●Preoperative analgesia – Patients in ERAS pathways usually receive preoperatively administered oral acetaminophen, gabapentin, and celecoxib with the goal of reducing postoperative pain (table 2) [19]. Other potential analgesic modalities include infiltration of the surgical site with local anesthetic, the possible use of transversus abdominis plane (TAP) blocks, or the possible use of neuraxial anesthesia (spinal or thoracic epidural anesthesia). In a systematic review of 46 studies assessing the role of nonopioid preoperative analgesia in women undergoing hysterectomy, patients treated with preoperative acetaminophen, gabapentin, bupivacaine (regional or local infiltration), and phenothiazine used less opioid compared with women treated with placebo [20]. While multiple nonopioid medications and combinations are available, the optimal treatment combination is not yet known and more than one combination may be effective.
The multimodal approach to pain management is discussed below. (See 'Multimodal analgesia and anesthesia' below.)
Intraoperative
Multimodal analgesia and anesthesia — Intraoperative elements of ERAS protocols are directed at both the anesthesia and surgical teams (table 1). Multimodal perioperative analgesia is a truly interdisciplinary ERAS intervention determined by both surgeons and anesthesiologists prior to the surgery. Potential interventions for consideration include the types of preoperative analgesia, quickest approach for the intended surgery, and opportunities to minimize physiologic disruption (eg, blood loss). Details of anesthetic management for adult patients undergoing surgery with ERAS are presented separately. (See "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)".)
Importantly, elements of ERAS pathways will continue to evolve as new evidence emerges. As an example, liposomal bupivacaine, while not described in earlier ERAS pathways, has emerged as an adjunct for perioperative pain control when injected into surgical incisions or injected during a TAP block. Although data directly comparing liposomal bupivacaine use in direct surgical site infiltration versus liposomal bupivacaine use in TAP blocks remain limited, surgical site infiltration with liposomal bupivacaine is a low-risk intervention that appears to work synergistically within ERAS pathways to lower need for opioid analgesics [21,22] and has anecdotally worked well compared with ERAS alone in patients undergoing laparotomy at one author's institution.
Neuraxial anesthesia (ie, spinal or epidural anesthesia) has demonstrated efficacy regarding improved pain control and reduced postoperative opioid consumption in open gynecologic surgery. However, these potential benefits must be weighed against the potential risks of neuraxial anesthesia, including possible delayed time to ambulation and voiding, and increased hospital length of stay [10].
Interventions specific to the surgical team — Potential ERAS interventions specific to the surgical team include selecting the least invasive route of surgery, determining the need for and duration of bladder catheterization, avoiding (or intraoperatively removing) nasogastric tubes, and minimizing the use of other drainage tubes (table 2).
●Route of surgery – Surgeons are advised to perform the least invasive surgery to address the problem. As an example, consistent with society guidelines, the vaginal approach is the preferred route for hysterectomy, followed by laparoscopy, and lastly, abdominal surgery if the other routes are not feasible [23].
●Bladder catheterization – Bladder catheters should be utilized for the shortest duration necessary. One strategy for minimizing bladder catheter use is to utilize straight catheterization for procedures in which prolonged postoperative drainage is not anticipated. When the bladder catheter is left in place, a voiding trial should be performed on postoperative day 0 or postoperative day 1, depending on the type of gynecologic surgery, for non-radical hysterectomy.
●Nasogastric tubes – Routine use of nasogastric tubes should be avoided, but if used, a nasogastric tube should be removed at the conclusion of the operation [9].
●Intraperitoneal drainage tubes – Routine use of intraperitoneal drainage tubes should be avoided [10].
Interventions specific to the anesthesia team — At the time of preoperative briefing in the operating room, applicable ERAS elements are discussed among the surgical, anesthesiology, and nursing teams. Potential ERAS interventions specific to the anesthesia team include use of short-acting anesthetic agents, lung protective ventilation strategies, maintenance of normothermia, standardized prophylaxis for postoperative nausea and vomiting, and perioperative euvolemia (table 2).
●To reduce postoperative nausea/vomiting, the ERAS Society recommends administering two classes of antiemetics intraoperatively as prophylaxis and adding a third class of drugs if postoperative nausea and vomiting is experienced [9].
●The rationale for perioperative normovolemia/euvolemia is that excessive perioperative fluid administration is believed to be associated with numerous physiologic disruptions that impair recovery, including cardiopulmonary complications, impaired gut motility secondary to bowel edema, and impaired wound healing [24]. A meta-analysis found decreased postoperative morbidity when perioperative euvolemia was achieved with goal-directed fluid therapy in colorectal surgery [25]. A retrospective cohort study of an ERAS pathway in gynecologic surgery reported reduced opioid use and shorter length-of-stay for patients in the pathway, which included restrictive intravenous fluid resuscitation, with no increase in adverse events such as renal failure or [26].
A detailed discussion of the use of short-acting anesthetic agents, standardized ventilation strategies, maintenance of normothermia, by the anesthesia team is presented elsewhere. (See "Enhanced recovery after colorectal surgery" and "Enhanced recovery after colorectal surgery", section on 'Intraoperative strategies'.)
Postoperative — Postoperative ERAS elements typically focus on pain management, bowel function, diet, and patient mobilization (table 1). Patients undergoing gynecologic surgery for benign indications are typically expected to be discharged within one to two days following surgery. A standardized, streamlined order set can facilitate execution of important postoperative interventions such as initiating the regular diet, bowel regimen, and ambulation on postoperative day 0 (table 2). Patient-controlled analgesia (PCA) is avoided, and patients are started on scheduled oral acetaminophen and nonsteroidal anti-inflammatory drugs, with oral oxycodone for breakthrough pain. Only those patients who have persistent pain despite the above regimen receive intravenous opioids. PCA is begun only after all other options have been inadequate for pain control, which is rare.
Establishing a bladder management plan early in the postoperative care process facilitates discharge planning. In cases where a transurethral or suprapubic catheter is being used to drain the bladder, trial of voiding and/or catheter training should be conducted early on postoperative day 1, or even preoperatively, if applicable.
For vaginal prolapse repair, abdominal sacrocolpopexy, robotic sacrocolpopexy (with or without hysterectomy, sling), we take the following approach based on a prospective study of women undergoing prolapse surgery that reported no change in patient satisfaction with reduced postoperative opioid prescribing [27]:
●If a patient needed no opioids during the hospitalization, she can be sent home without an opioid prescription (0 tablets).
●If a patient needs the routine opioids ordered in the hospital order set, she is prescribed 15 tablets of oxycodone 5 mg (or equivalent dosing of another opioid).
●If a patient needs more than the routine opioids ordered in the hospital set, postoperative opioid prescribing is individualized.
●Women with isolated slings are prescribed 10 tablets of oxycodone 5 mg.
●Lastly, we counsel all patients to dispose all unused opioids by either bringing them to the nearest Drug Enforcement Administration authorized collector or by flushing them down the toilet. Authorized collectors can be found online.
Discharge — Criteria for discharge for any patient undergoing gynecologic surgery include tolerance of a regular diet, ambulation, and pain control with oral pain medications. For patients on an ERAS pathway, it is helpful to identify any potential barriers to discharge prior to surgery when known, or as soon as feasible following surgery. It is the authors' practice to identify for the nursing staff all patients planned to undergo discharge on postoperative day 1 using a "predischarge" or "conditional discharge" order so that the nursing and case management teams can ensure that discharge readiness goals are met. At the time of discharge, patient education is conducted by the nursing team, which consists of a review of the elements discussed preoperatively.
Postoperative follow-up — In addition to conventional postoperative office visits with the surgeon, a follow-up telephone call shortly after the patient’s arrival home can decrease patient anxiety, answer questions, review instructions, provide reassurance, identify potential problems or complications as they arise, facilitate the patient’s transition from the hospital to the home environment, and potentially reduce preventable calls to the hospital and/or emergency department visits [28]. At the authors' institutions, such a postoperative phone call is typically conducted by a nurse or clinician within one to two days of discharge. This concept is also being increasingly applied to same-day (ambulatory) surgery.
As ERAS programs continue to evolve, some programs are evaluating smartphone apps as an additional tool to facilitate communication between patients and clinicians post-hospital discharge [29-32].
OUTCOMES
●Benefits – When compared with traditional postoperative care, ERAS protocols have been associated with decreased pain, opioid use, length of stay, use of nursing time, and cost, while simultaneously improving functional outcomes, patient satisfaction, and quality of life [26,33,34]. Benefits have been reported for women undergoing gynecologic procedures for cytoreduction, surgical staging, pelvic organ prolapse repair, and for minimally invasive transabdominal gynecologic surgery (ie, laparoscopy or robot-assisted laparoscopy) [26,35-40].
•Decreased pain and opioid use – ERAS protocols have been associated with decreased pain and opioid use. In one retrospective study of patients undergoing open surgery for gynecologic malignancy, when compared with patients receiving routine postoperative care, patients in the ERAS pathway used 44 percent fewer opioids and 36 percent less patient-controlled analgesia [41]. In another retrospective study that included women undergoing cytoreductive surgery, surgical staging for gynecologic malignancy, or transvaginal prolapse repair, ERAS use resulted in a four day reduction in hospital stay and less opioid use with similar readmission and postoperative complication rates when compared with historic care [26]. The decrease in opioid use reported with ERAS pathways has also been associated with stable or decreased pain scores in different postoperative phases of care [26,41].
•Length of stay – Studies of ERAS protocols for gynecologic surgery have mostly reported decreased length of stay compared with traditional postoperative care [4,26,33,36,37,39,42-49]. Reductions have been reported for women undergoing cytoreductive surgery (two to three days) [26,42,46-48], surgical staging (one day) [26], vaginal surgery (one day) [26,43,50], and open benign gynecologic surgery (one to two days) [44,45]. Although one trial of women undergoing laparotomy for gynecologic cancer did not report a reduction in length of stay for the ERAS program compared with routine care, the routine care group was not strictly defined and "permitted the use of any or all enhanced recovery after surgery tenets" [51]. In a separate retrospective cohort study of patients undergoing open surgery for gynecologic malignancy, length of stay decreased by >3 days compared with historic controls [52]. In another study, in which >85 percent of patients undergoing surgery for gynecologic malignancy underwent surgery via a minimally invasive route, a reduction in length of stay of 0.5 days was observed following the implementation of an enhanced recovery pathway when compared with historic controls [53].
•Cost reduction – ERAS protocols have been associated with decreased cost compared with traditional postoperative care, even for open surgery or suspected malignancy [26,48,50,54,55]. Cost reduction reflects the decreased use of medication, nursing resources, and length of stay. In one retrospective cohort study of women undergoing cytoreductive surgery, women in the ERAS protocol had reduced total 30-day costs of >$7600 USD per patient compared with the routine care group [26]. In the same study, >$3000 USD was saved per women undergoing vaginal surgery in the ERAS care group, although this difference was not statistically significant.
•Improved functional outcomes – Even for women undergoing open abdominal surgery, ERAS pathways shorten the duration of postoperative fatigue and disability. In a retrospective cohort study of women undergoing open gynecologic surgery for both benign and malignant disease that compared an ERAS protocol with historic care, ERAS patients reported a faster return to "no or mild fatigue" (10 versus 30 postoperative days), "no or mild interference with walking" (5 versus 13 days), and "mild to no total interference" (3 versus 13 days) [56].
•Unchanged surgical outcomes – Importantly, use of ERAS programs, and resultant early discharge, does not worsen surgical outcomes [4,26]. In a meta-analysis of studies comparing ERAS programs with traditional care among patients undergoing open surgery for both benign and malignant gynecologic disease, use of the ERAS protocol was not associated with increased morbidity, mortality, or readmission [4].
•Patient satisfaction and quality of life – ERAS protocols in gynecologic surgery are associated with high patient satisfaction scores for the overall patient perioperative care experience and for specific elements of care, such as control of nausea and vomiting [26,57]. Compared with patients receiving traditional care, patients on an enhanced recovery pathway reported higher measures of quality of life [47].
●Concerns – Initial concerns that reduced length of stay would decrease patient access to information and education and increase postoperative complications or readmissions have generally not been validated [4,33,58]. A retrospective analysis of 258 women undergoing pelvic reconstructive surgery reported similar 30 day postoperative complication rates pre- and post-ERAS implementation, but ERAS patients did have higher 30-day readmission rates (6.7 versus 1.5 percent) [37]. The main challenges to ERAS implementation are the time and cost to establish ERAS programs [42].
IMPLEMENTATION — Successful implementation of an ERAS program requires a multidisciplinary team effort as well as active participation by the patient [5]. Initiation of such a pathway in a timely, cost-effective manner can be logistically challenging (table 3) [5,59]. That said, without active implementation, diffusion of some or most best-practice elements of enhanced recovery can take years to occur [7,42]. A coordinated, multidisciplinary effort is required not only for the program creation but also to determine the outcomes that will be tracked prospectively as part of a quality improvement initiative [3,43,49]. When developing an ERAS program, it can be helpful to reach out to an institution that has successfully implemented ERAS.
Stakeholders — The successful execution of an enhanced recovery pathway involves coordinated efforts and education across multiple departments and members of the health care team, also known as "stakeholders." Stakeholders include [8-10,60]:
●Patients, as the recipients of the interventions in the enhanced recovery pathway
●Surgeon's office, including surgical scheduler, nurse team
●Gynecologic surgeon and surgical team, including advanced practice providers and trainees
●Anesthesiologist and anesthesia team, including nurse anesthetists
●Preoperative, intraoperative, and postoperative nursing teams
●Inpatient pharmacists
●Information technology (IT) department
Institutional and departmental steering committees can facilitate inclusion of stakeholders to ensure that everyone agrees upon the goal of establishing and executing an institutional enhanced recovery pathway. Following buy-in, the steering committee then guides the implementation of the agreed-upon ERAS protocol [8]. Such a steering committee typically consists of senior representatives from the stakeholder groups listed above, a project manager for the hospital and the departments, as well as representatives from the different surgical subspecialties (table 3).
Timeline — The following is an example of a project management grid outlining implementation of an ERP over a four-month period in a gynecology division at an urban academic hospital (table 3). Steps of implementation, along with key stakeholders for each step, are identified. The project management timeline can be adapted based on the needs and resources of the individual institution.
Upon the identification of a "Clinical Go-Live" date, steps can be generally applied as follows:
●Prior to Go-Live:
•Establish Steering Committee representatives; identify literature and ERAS program resources for dissemination within department and steering committee.
•Read specialty-specific ERAS literature.
•Establish intra-department consensus on ERAS program target populations and elements for adoption.
•Meet to obtain interdisciplinary consensus on ERAS elements and executors.
•Work on order sets with IT department; announce initiative to departments/stakeholders.
•Plan site(s) of preoperative education, the specific preoperative patient education materials, and the preoperative letter.
•Create formal educational materials for surgeons, anesthesiologists, and nurses containing rationale and ERAS elements.
•Begin mailing new preoperative letter; surgeons begin scheduling patients as "ERAS."
•Send reminders of scheduling ERAS surgical patients, preoperative ordering, and Go-Live dates to all stakeholders.
•Preoperative patient education begins/obtain preoperative drink.
•Sign off on order sets.
Active participation by all members of the surgical team is critical to achieving success. To that end, it can be helpful to have a division or another institution who has implemented ERAS present the program’s benefits and address any concerns. Additionally, the institution may elect to pilot the program and use the preliminary data to educate others regarding the benefits of implementing the practice change prior to a larger-scale rollout.
●Go-Live:
•Perioperative briefings
•Use perioperative order sets
●Following Go-Live:
•Conduct periodic clinical huddles/education
•Conduct Quality Improvement data collection/audits
•Adaptation and incorporation of new evidence and best practices
Metrics — As with any quality improvement initiative, ongoing implementation and clinical audits are important. Hospitals can conduct quality improvement audits independently; however, the ERAS Society has developed an audit tool to facilitate the study of implementation and clinical outcomes [3].
The following are examples of implementation-specific metrics, or process measures:
●Proportion of enhanced recovery-eligible patients who were placed on an enhanced recovery pathway
●Proportion of enhanced recovery pathway participants who received specific elements of the enhanced recovery pathway
The following are examples of clinical metrics:
●Length of hospital stay
●Cost of hospital stay
●Perioperative opioid use
●Perioperative fluid balance
●Perioperative pain scores
●Postoperative day of first ambulation
●Performance of ambulation three times per day
●Postoperative day of tolerance of regular diet
●Time to resumption of voiding function
●Postoperative day of resumption of bowel function
●Patient satisfaction
●Unanticipated emergency department visit and/or readmission
●Postoperative infection (urinary tract infection, surgical site infection)
●Ileus
Balancing measures, or adverse outcomes of the process change, should be included as metrics, for example:
●Proportion of patients experiencing an adverse reaction to a medication or intervention on the enhanced recovery pathway
Most of these metrics can be collected from the electronic medical record by members of a dedicated ERAS Quality Improvement team, including surgeons, fellows, residents, clinical research nurses, medical students, and/or a dedicated study coordinator. At the authors' institutions, the IT departments are able to produce automated reports of some of the metrics to accelerate data collection. Data, which are collected out to 30 postoperative days for each patient, are reviewed on a monthly basis by the ERAS team leaders as well as by the steering committee. If an ERAS component or metric is not progressing in the desired direction, an intervention can be quickly undertaken. To fully assess the impact of implementation of an ERAS protocol, it is beneficial to compare the results following of ERAS implementation with an historic cohort of similar patients from the same institution that were treated prior to the implementation.
RESOURCES FOR PATIENTS AND CLINICIANS
●The ERAS Society provides clinical guidelines in different subspecialties, including gynecologic surgery, as well as implementation and audit resources, all available online.
SUMMARY AND RECOMMENDATIONS
●Enhanced recovery after surgery (ERAS) programs combine evidence-based elements of care during the pre-, intra-, and postoperative experiences to decrease physiological stress and organ dysfunction, and thus, enable patients to recover more quickly, have decreased hospital length of stay, and resume routine activity more quickly than with standard surgical care. Importantly, elements of ERAS pathways will continue to evolve as new evidence emerges. (See 'Definition' above.)
●Patients undergoing planned gynecologic surgery with an overnight stay are candidates for participation in an ERAS protocol. Although an ERAS pathway can broadly apply to the majority of patients undergoing gynecologic surgery, such a pathway should always be individualized when and where medically indicated. (See 'Candidates' above.)
●In general, enhanced recovery focuses on optimizing patient education and perioperative expectations, decreasing the perioperative fasting period, maintaining euvolemia and normothermia, increasing mobilization, providing multimodal pain relief, providing multimodal nausea and vomiting prophylaxis, and decreasing unnecessary or prolonged use of catheters and drains. A guideline of general components for gynecologic surgery has been published by the ERAS Society (table 1), and modifications have been suggested for patients with gynecologic malignancy. (See 'Components' above.)
•Preoperative ERAS elements include specific patient education instructions (verbal and written), health status optimization, preoperative patient preparation. (See 'Preoperative' above.)
•Intraoperative elements of ERAS protocols are directed at both the anesthesia and surgical teams (table 1 and table 2). Both the anesthesia team and surgeons perform interventions aimed at perioperative pain control. Potential ERAS interventions for the anesthesia team also include use of short-acting anesthetic agents, standardized ventilation strategies, standardized prophylaxis for postoperative nausea and vomiting, maintenance of normothermia and euvolemia, and avoidance (or intraoperative removal) of nasogastric tubes. Surgeons are advised to perform the least invasive surgery to address the problem. (See 'Intraoperative' above.)
•Postoperative ERAS elements typically focus on pain management, bowel function, diet, and patient mobilization (table 1 and table 2). Patients undergoing gynecologic surgery should typically expect to be discharged within one to two days following surgery. (See 'Postoperative' above.)
•Criteria for discharge for any patient undergoing gynecologic surgery include tolerance of a regular diet, ambulation, and pain control with oral pain medications. For patients on an ERAS pathway, it is helpful to identify any potential barriers to discharge prior to surgery when known, or as soon as feasible following surgery. (See 'Discharge' above.)
●When compared with traditional postoperative care, ERAS protocols have been associated with decreased pain, length of stay, use of nursing time, and cost, while simultaneously improving patient satisfaction and quality of life. (See 'Outcomes' above.)
●Successful implementation of an ERAS program requires a multidisciplinary team effort as well as active participation by the patient. Initiation of such a pathway in a timely, cost-effective manner can be logistically challenging (table 3). That said, without active implementation, diffusion of some or most best-practice elements of enhanced recovery can take years to occur. When developing an ERAS program, it can be helpful to reach out to an institution that has successfully implemented ERAS. (See 'Implementation' above.)
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