Background
The Enhanced Recovery After Surgery (ERAS) Critical Pathway concept is based upon a protocol of care items applied perioperatively to achieve optimal stress reduction following surgery with subsequent reductions in overall morbidity and accelerated recovery[
1]. The traditional concept dictates that all protocol items are of importance and synergistic effects on recovery are optimal when all items are implemented[
1‐
3]. Recovery, however, is a compound term demanding the fulfilment of several indicators of well-being and is not clearly defined. At the same time, implementing complex interventions like unabridged ERAS protocols is challenging and dependent on smooth cooperation of all groups of health professionals involved in patient care. If health workers from different regions and professions express significantly different views on what recovery implies and on the relative importance of the various ERAS protocol items in achieving this recovery, this may severely undermine successful implementation at ward and institution levels.
Francis D Moore defined surgical convalescence in 1958 in the following way: ‘Convalescence includes all the interlocking physical, chemical, metabolic, and psychological factors commencing with the injury, or even slightly before the injury, and terminating only when the individual has returned to normal physical well-being, social and economic usefulness, and psychological habitus.’[
4]. Whilst FD Moore focused on the importance of functional recovery, length of hospital stay (LOS) has been the dominant outcome in convalescence research in later years[
5].
We wanted to investigate how international experts and dedicated professionals view surgical convalescence today. We aimed to investigate differences and similarities on the views on central recovery targets and care items amongst the different professions and backgrounds.
Discussion
The recovery targets which received the highest score according to importance in all groups of responders in our survey were ‘To be completely free of nausea’, ‘To be independently mobile’ and ‘To be able to eat and drink as soon as possible’. Amongst the 13 protocol care items listed, ‘Optimizing fluid balance’, ‘Preoperative counselling’ and ‘Promoting early and scheduled mobilisation’ were rated as those most important to achieve this recovery.
The present survey shows how targets for recovery and the relative importance of protocol items are perceived by a large international group of enhanced recovery protocol experts and dedicated professionals. Recruited from delegates to the first international ERAS conference and from principal authors of ERAS-related research literature, many of the responders were likely to be opinion leaders in their local and national perioperative pathway environment. As such, they constitute a body of experience and knowledge that probably reflects the current views held by health workers in a wider context. This is especially interesting when dealing with items where robust evidence is wanting. Our response rate is barely within acceptable limits in surveys of this kind[
10], although a higher response rate would have been preferable.
The central finding is the similarities between different professions and regions in terms of scoring the most important recovery targets and care items. This could result from a
de facto agreement or from bias in a sample of respondents drawn from similar backgrounds. This similarity is not statistically tested. Nevertheless, as stated above, this still indicates uniformity in how the relative importance of recovery targets and protocol care items are perceived and hence the attention this will receive in everyday practice across nations. Several international studies have documented incomplete implementation of various evidence-based Enhanced Recovery protocol items, such as avoidance of oral bowel preparation and nasogastric tube[
11‐
13]. Whilst being long-standing core elements of Enhanced Recovery protocols, they are not consistently top rated in our survey.
‘To be completely free of nausea’, ‘To be independently mobile’ and ‘To be able to eat and drink as soon as possible’ are the recovery targets considered most important by the responders. Another survey amongst international experts concluded that a patient is ready for discharge when ‘there is tolerance of oral intake, recovery of lower gastrointestinal function, adequate pain control with oral analgesia, ability to mobilize and self-care, and no evidence of complications or untreated medical problems’[
14]. This is also consistent with the definition of a recovered patient, ready for discharge, used in both the earliest Enhanced Recovery studies and more recent ones[
15,
16]. Functional recovery, as in tolerance of food without nausea and regained mobility, is consistently considered the most important target for recovery and might be used when defining the recovered patient in future research and audits.
In a recent publication, recovery was divided into three distinct phases: the early (from the postoperative care unit to the ward), intermediate (from the ward to discharge) and late (from discharge to return to normal function) phases[
17]. To be free of nausea, independently mobile and being able to eat and drink might serve as a common target for recovery in the intermediate phase. This is also consistent with the thinking of one of the pioneers in surgical recovery research, FD Moore, who divided recovery into four phases: the injury, the turning point, spontaneous nitrogen anabolism and fat redeposition[
4]. ‘The turning point’ corresponds to the intermediate phase of surgical recovery, and the way FD Moore describes this phase has striking similarities to the most important targets for recovery in our survey: ‘…There is an increase in gastrointestinal function, with a return of peristalsis, the passage of flatus by the rectum, a desire for food….’[
4]. The late phase of recovery, when the patient is discharged and struggle to regain normal function has received little attention in research and publications[
5]. This phase might be especially important to patients and society, and it deserves to be investigated in studies with adequate follow-up length.
Interestingly, and somewhat surprising, was the finding that three of the targets and items which consistently received the highest score: ‘Prevention of nausea’, ‘Preoperative counselling’ and ‘Early mobilisation’, were the only items (together with
audit) that were not supported by a Grade A recommendation in the 2009 ERAS consensus guidelines for colorectal surgery[
9]. The level of evidence supporting these three targets and items was also considered low or very low in the latest guidelines for perioperative care in elective pancreaticoduodenectomy, rectal/pelvic surgery and colonic surgery[
6‐
8]. They were, however, strongly recommended[
6‐
8].
This indicates that experts and dedicated professionals' views on target and/or care item importance are not necessarily linked to the level of evidence supporting it, as was also repeatedly the case in the recent guidelines[
6‐
8]. Other surveys have shown that surgeons tend to have higher confidence in their own judgement than all other resources[
18,
19]. Surveys have also shown that there are frequent misconceptions about central terms in evidence-based medicine within the surgical community, like misconceptions concerning important aspects of evidence hierarchy and common terminology in study design[
20]. In the era of evidence-based medicine, this serves as a reminder of the fact that there is no absolute relationship between perceived importance and established evidence.
Most targets and items were rated as important, indicating that our questionnaire lacks discriminatory power. However, any responder would be likely to think that one cannot have too much of a good thing and hence be unlikely to rate any target or item as ‘not important’. Our data should be complemented with patients' ratings on the same targets and items. This would add to our understanding of the causes that impede successful implementation of protocols.
Our survey was intended to be a short mapping of the relative importance of central recovery targets and care items today as perceived by the international expertise. This could serve as a basis for more formal research aimed at creating common definitions of the different phases of recovery. Such research might include the Delphi methodology, both in the selection of targets and items and in the further research process[
21].
Competing interests
All authors are members of the ERAS society. The authors declare that they have no other competing interests. No grant support was received.
Authors' contributions
EKA contributed to the study concepts, study design, data acquisition, data analysis and interpretation, quality control of data and algorithms, manuscript preparation, manuscript editing and manuscript review. MvM, CHCD, OL, KCF, DNL, ND and SJW contributed to the study concepts, study design, quality control of data and algorithms, manuscript editing and manuscript review. AR contributed to the study concepts, study design, quality control of data and algorithms, manuscript editing, manuscript preparation and manuscript review. KL contributed to the study concepts, study design, data acquisition, quality control of data and algorithms, manuscript preparation, manuscript editing and manuscript review. All authors read and approved the final manuscript.