Transforming surgical recovery through collaboration

The BC Enhanced Recovery After Surgery Collaborative seeks to build enhanced recovery capacity throughout the province’s surgical programs. Sponsored by the Specialist Services Committee, a partnership of the Ministry of Health and Doctors of BC, the collaborative’s activities include learning sessions, data collection support, clinical guidance, site visits, and a website of resources.

The 14-month collaborative has brought together 11 multidisciplinary hospital teams from across the province to learn from and support each other, while implementing Enhanced Recovery programs for elective colorectal surgery at their sites. Since the collaborative’s launch, eight more sites around BC have connected with the collaborative to support Enhanced Recovery implementation.

The Enhanced Recovery story in BC started as an effort by frontline clinicians, simultaneously and independently at several sites around the province, and has evolved into a provincial, multidisciplinary effort on a transformational scale. Together, the collaborative’s teams are aiming to reach 80% compliance with all pathway elements, cut complication rates by 50%, and decrease hospital length of stay, all without affecting the re-admission rate. There are some interesting lessons to be extracted from this effort. 

Enhanced Recovery for colorectal surgery is not a single pathway etched in stone. Rather, it is an evidence-based approach to the multidisciplinary collaboration required to provide each patient with the best possible opportunity to recover to his or her defined functional status. Given that colorectal patients have a disproportionately high rate of complications, and that complications have a lasting negative effect on cancer survival and functional outcomes, this is no small challenge.

Patients and families can become partners in their recovery provided that the resources to enable and support them are embedded in the effort. Literature suggests that this focus may be the single most important element in implementing Enhanced Recovery. The collaborative has developed some useful approaches toward this end. Patient education templates are available at www.enhancedrecoverybc.ca, and an online patient education video, available in multiple languages, is in production.

Implementing multiple new processes of care along the entire patient journey, from the decision to operate until several weeks postoperatively, crosses many disciplines, and each process of care may have significant upstream and downstream impacts. The BC Enhanced Recovery Collaborative has been structured to ensure that the voices of the entire team of providers who touch the patient’s journey are represented. The result is a very different set of conversations about each process of care, making the planning process more thorough, actionable, and sustainable. The entire team takes ownership of the outcomes, which improves commitment to the proposed changes and the effort to implement them. Sharing this journey also brings fellowship to the effort and a shared joy in the success.

The evidence base supporting a process of care or outcome is not always clear; in contrast, there are persuasive bodies of evidence that have not yet been distilled to a defined and actionable process of care. Rather than paralyze our efforts to improve outcomes, these situations represent opportunities. 

The Enhanced Recovery Collaborative is using a community-of-practice approach to address these opportunities—specifically regarding mechanical bowel preparation, goal-directed fluid therapy, preoperative carbohydrate loading, and opioid-sparing technique—ensuring that subject experts develop consensus recommendations in a multidisciplinary environment. While the initial scale of these recommendations is at the population level, subject experts help to create an ever-nuanced model reflecting the individual patient’s complexity and journey.

It has been refreshing to discover that participation in a community of practice has been accepted by many providers as more akin to a privilege than a burden, enabling them to provide the best possible evidence-based care to their patients.

There is an unfortunate acceptance among caregivers that undesired outcomes are inescapable—a part of the cost of doing business. Enhanced Recovery challenges that perspective, forcing clinicians to consider that complications emerge as a direct consequence of processes of care throughout the patient journey. The literature is clear that greater adherence to evidence-based elements of care improves outcomes in a dose-response fashion. 

Our own data demonstrate that compliance with recommended processes of care cannot be assumed. It is essential to develop an effective measurement strategy, one that sets targets, measures compliance, and uses data to drive further improvement. In particular, comparison of the processes of care that contributed to outcomes can provide insight into causal relationships that undermine desired outcomes; this can inform further improvement cycles.

Significant and unresolved barriers to implementing large-scale, evidence-based recommendations remain, such as perceived threats to clinical autonomy, the cost of continuous process and outcome measurement, a lack of infrastructure, and the effort to find good evidence, develop actionable processes of care based on that evidence, and bring those processes to the bedside. 

Ultimately none of these issues is an adequate reason for not trying; good outcomes are not accidental, they are the result of engagement, clear focus, sustained effort, measurement, and shared accountability. It is clear that efforts under the banner of Enhanced Recovery have and will continue to promote a call to action by clinicians and patients alike through collaboration.

To learn more about the BC ERAS Collaborative, please visit www.enhancedrecoverybc.ca.
—Ron Collins, MD
Co-chair, Anesthesia, ERAS Collaborative
—Ahmer Karimuddin, MD
Co-chair, Surgery, ERAS Collaborative
—Garth Vatkin, RN, MHA 
Co-chair, Nursing, ERAS Collaborative
—Angie Chan, MPA 
Project Manager, Surgical Improvement, Specialist Services Committee

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This article is the opinion of the Specialist Services Committee and has not been peer reviewed by the BCMJ Editorial Board.