Alawadi Zeinab M, Leal Isabel, Phatak Uma R, Flores-Gonzalez Juan R, Holihan Julie L, Karanjawala Burzeen E, Millas Stefanos G, Kao Lillian S
Department of General Surgery, The University of Texas Health Science Center, Houston, TX; Center for Surgical Trials and Evidence-based Practice, The University of Texas Health Science Center, Houston, TX.
Department of General Surgery, The University of Texas Health Science Center, Houston, TX; Integrative Medicine Program, Department of General Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX.
Surgery. 2016 Mar;159(3):700-12. doi: 10.1016/j.surg.2015.08.025. Epub 2015 Oct 2.
Enhanced Recovery After Surgery (ERAS) pathways are known to decrease complications and duration of stay in colorectal surgery patients. However, it is unclear whether an ERAS pathway would be feasible and effective at a safety-net hospital. The aim of this study was to identify local barriers and facilitators before the adoption of an ERAS pathway for patients undergoing colorectal operations at a safety-net hospital.
Semistructured interviews were conducted to assess the perceived barriers and facilitators before ERAS adoption. Stratified purposive sampling was used. Interviews were audiotaped, transcribed verbatim, and analyzed using content analysis. Analytic and investigator triangulation were used to establish credibility.
Interviewees included 8 anesthesiologists, 5 surgeons, 6 nurses, and 18 patients. Facilitators identified across the different medical professions were (1) feasibility and alignment with current practice, (2) standardization of care, (3) smallness of community, (4) good teamwork and communication, and (5) caring for patients. The barriers were (1) difficulty in adapting to change, (2) lack of coordination between different departments, (3) special needs of a highly comorbid and socioeconomically disadvantaged patient population, (4) limited resources, and (5) rotating residents. Facilitators identified by the patients were (1) welcoming a speedy recovery, (2) being well-cared for and satisfied with treatment, (3) adequate social support, (4) welcoming early mobilization, and (5) effective pain management. The barriers were (1) lack of quiet and private space, (2) need for more patient education and counseling, and (3) unforeseen complications.
Although limited hospital resources are perceived as a barrier to ERAS implementation at a safety-net hospital, there is strong support for such pathways and multiple factors were identified that may facilitate change. Inclusion of patient perspectives is critical to identifying challenges and facilitators to implementing ERAS changes focused on optimizing patient perioperative health and outcomes.
手术加速康复（ERAS）路径已知可减少结直肠手术患者的并发症和住院时间。然而，尚不清楚ERAS路径在安全网医院是否可行且有效。本研究的目的是在安全网医院为接受结直肠手术的患者采用ERAS路径之前，确定当地的障碍和促进因素。
进行半结构化访谈以评估采用ERAS之前感知到的障碍和促进因素。采用分层目的抽样。访谈进行录音，逐字转录，并使用内容分析进行分析。采用分析三角法和研究者三角法来建立可信度。
受访者包括8名麻醉医生、5名外科医生、6名护士和18名患者。不同医学专业确定的促进因素有：（1）可行性以及与当前实践的一致性；（2）护理标准化；（3）社区规模小；（4）良好的团队合作与沟通；（5）关心患者。障碍有：（1）难以适应变化；（2）不同科室之间缺乏协调；（3）高共病性和社会经济弱势患者群体的特殊需求；（4）资源有限；（5）住院医师轮转。患者确定的促进因素有：（1）希望快速康复；（2）得到良好护理并对治疗满意；（3）充足的社会支持；（4）希望早期活动；（5）有效的疼痛管理。障碍有：（1）缺乏安静和私密空间；（2）需要更多患者教育和咨询；（3）不可预见的并发症。
尽管有限的医院资源被视为安全网医院实施ERAS的障碍，但对这类路径有强烈支持，并且确定了多个可能促进变革的因素。纳入患者观点对于识别实施ERAS变革以优化患者围手术期健康和结局的挑战及促进因素至关重要。
