Escolar Documentos
Profissional Documentos
Cultura Documentos
Successful Implementation of an
Enhanced Recovery Pathway:
The Nurses Role 1.9 www.aorn.org/CE
Disclaimer
Accreditation AORN recognizes these activities as CE for RNs. This
AORN is accredited as a provider of continuing nursing recognition does not imply that AORN or the American
education by the American Nurses Credentialing Centers Nurses Credentialing Center approves or endorses products
Commission on Accreditation. mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2015.08.015
AORN, Inc, 2015
www.aornjournal.org AORN Journal j 469
Successful Implementation of an
Enhanced Recovery Pathway:
The Nurses Role 1.9 www.aorn.org/CE
ABSTRACT
Enhanced recovery pathways (ERPs) are standardized, multidisciplinary approaches to caring for pa-
tients with a goal of decreasing length of stay and care costs without negatively affecting patient
outcomes. One facility successfully implemented ERPs for patients undergoing abdominal surgery. For
implementation to be successful, nurses were found to be key in providing education, perioperative
care, and postoperative evaluation, as well as cost containment. The implementation team collabo-
rated to dene, design, implement, and audit an ERP for surgical services. Initial audits demonstrated
an increase in compliance with order set use (61% to 93%) and use of ERPs more than standardized
order sets (< 1% to 27%), as well as decreased use of daily laboratory orders (94% to 62%) and
elimination of automatically ordered laboratory tests (38% to 0%). These results led to the conclusion
that the nurses role is essential for education and successful use of the pathways and that best
practices for developing ERPs requires consistency across the care team, diligence to ensure
compliance, and use of an audit tool for quality improvement. AORN J 102 (November 2015) 470-478.
AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2015.08.015
Key words: enhanced recovery, care pathway, ERP, colorectal surgery, patient education.
assistance. The exact needs, roles, and contributions of nurses time in the preoperative holding area, and
have not been dened previously. The purpose of this article is anesthesia and surgical components of the patient
to describe steps we took to successfully implement ERPs in experience.
surgical services and to identify the important role nurses play
in providing preoperative education, perioperative care, and In the surgical services department, care providers obtain
postoperative evaluation and in contributing to the overall baseline information that includes laboratory tests and re-
success of ERPs. sults, anesthesia patient optimization, a frailty score (eg,
patients are rated from very t to terminally ill based on their
activity levels and comorbidities), and a retrospective grade of
METHODS OF CREATING AND tness score12 (Figure 1), which helps identify patients who
IMPLEMENTING ERPS may not progress quickly after surgery and helps clinicians
Our team takes three primary steps to implementing ERPs in anticipate the patients needs at the time of discharge.
our surgical setting. The rst step is dening the population During the preoperative visit, the health care team reviews
and surgical service areas to be involved. For our project, we specic information with the patient and his or her family
dened surgical specialties as those that provided abdominal members regarding what to expect during the hospital
surgery and included the following in the analysis: experience.
colorectal surgery, We developed four surgical care pathways (ie, day cases/
general surgery, overnight abdominal cases, major laparoscopic abdominal,
surgical oncology, major open abdominal, upper gastrointestinal abdominal) that
gynecologic oncology, outlined a standardized regimen of early diet progression; early
urology, and ambulation; consistent medication choices, including opioid-
hepatobiliary surgery. sparing medications; and limited use of tubes, drains, and
Extended recovery pathways have been used successfully in the blood draws. We also established a miscellaneous care pathway
colorectal patient population and have demonstrated decreased to standardize approaches to common postoperative compli-
length of stay, complications, readmissions, and costs.7-11 We cations. This included criteria for blood transfusion,13 wound
replicated the ERP principles across each surgical specialty infection management, disposition issues at discharge, and
within the Department of Surgery in an attempt to realize the discharge criteria. The most important of these is the criteria
same benets. The service areas identied to participate in for discharge because, in our experience, it is helpful to
pathway implementation were outline discharge criteria at the onset of the patient
experience. Patients are considered appropriate candidates for
laparoscopic procedures, discharge after they can tolerate some diet, are experiencing
open procedures, pain relief with oral pain medications, are passing atus or
upper gastrointestinal procedures, having bowel movements, and are ready and amenable to
same-day observation procedures, being discharged home.2 In conjunction with the care
perioperative care, and pathways, we have set up other standard approaches that
miscellaneous procedures. have been implemented to minimize complications and
added days for unnecessary procedures. Care providers start
We chose these service areas because all procedures performed discharge planning at the beginning of the hospital
were easily grouped under these broad categories across all experience to minimize last-minute planning and delays
divisions. in discharge.
The second step is to dene the care processes under each The third step is the process of designing ERPs. Coordination
surgical service area that required ERPs. In our division, we on many fronts is essential to develop the necessary order sets.
identied six care pathways: one preoperative pathway, four Our design team includes medical content experts, electronic
surgical care pathways, and one patient experience pathway. medical record (EMR) personnel, and pharmacists. The hos-
The preoperative pathway typies the stages of comprehensive pitals quality team members also ensure that the order sets
patient preparation. The standards established included include all necessary documentation. After developing the
criteria for order sets, and after they are approved and implemented, it is
preoperative patient consultation, essential that the multidisciplinary care team members
day of surgery care, embrace these as the new standard of care. A process map
Figure 1. Retrospective grade of tness score calculated from review of the patients medical record to help assess
the patients needs at discharge.
illustrating the patient experience from the initial consultation establishing a preoperative education plan for patients and
to discharge is recorded in precise detail in Table 1. We give a their family members;
copy of this table to residents as they rotate onto our service, implementing a standardized preoperative plan (eg, high-
and we also use this to educate nurses to become more familiar protein drink, no bowel prep for colon resections in
with our care pathways and as a way to explain our process. A selected patients);
copy of this pathway is also available on our hospital internal minimizing the administration of intraoperative IV uids;
intranet for reference. As part of the ERP design process, we ensuring early removal of nasogastric tubes;
identied evidence-based best practices, general standards, avoiding postoperative drains;
and specic variables for each pathway. Each surgeon was introducing food early in the postoperative period;
given the opportunity to weigh in on the process; a facilitating early postoperative ambulation (ie, the night of
consensus of all surgeons was reached to facilitate successful surgery);
implementation of this project. Our standardized ERPs for converting patients to taking oral pain medications as
all surgical services include quickly as possible;
Preoperative Evaluation Before Surgery Perioperative Holding Area OR Induction Anesthesia Surgery
Provide procedure or Glucose-controlled drink the Gabapentin 300 mg one to Antibiotics Monitor Standardize
surgical service information evening before OR two hours before surgery o during patients o wound closure
on expectations for surgery Bowel prep (elective) as Alvimopan 12 mg one to two hours induction temperature o electrosurgical
and length of stay directed before laparoscopic colon resection o every four Maintain device use
Explain what to bring from Gabapentin 150 mg to 300 mg procedures with a high risk of hours normothermia Open disposable
home (eg, sleepwear, robe, three times per day (TID) three conversion intraoperatively Limit IV uids products only
slippers, other comfortable days preoperatively (hold if it Bowel preparation (if required) as needed Albumin when required
clothing) causes dizziness) Thromboprophylaxis o then stop protocols Consider
Perform preadmission Modied Nichols oral antibiotic o heparin 5,000 units Corticosteroid Ask about transversus
testing complete with grade bowel prep service specic (ie, subcutaneously TID pulse for repeat abdominis plane
of tness score/ neomycin and metronidazole) o antithromboembolism stockings corticosteroid- antibiotics at block
retrospective grade of or sequential compression dependent four hours
tness score to anticipate devices two hours preoperatively patients
needs IV acetaminophen
at the time of discharge 1,000 mg up to
Perform baseline laboratory four doses
tests, including Ketorolac 15 to 30
o type and screen for mg IV depending
antibiotic allergies or on renal function
o type and cross for blood,
depending on the
procedure
o day of surgery
information: parking,
check-in location
o welcome guide
Brady et al November 2015, Vol. 102, No. 5
choosing consistent medications, including opioid-sparing With pressure on hospital personnel to reduce length of stay,
medications; and there is an increasing responsibility for patient care that falls
performing laboratory blood draws every other day. onto families and caregivers at the time of discharge. As a
result, there is greater emphasis on educating patients and
members of their support system about what to expect.
PERIOPERATIVE EDUCATION Further, promoting their involvement will aid in the success of
Perioperative education for patients and their family members is ERPs.16 Including caregivers in the education process helps
essential for successful navigation through the surgical experi- minimize stress and provides patients and their family
ence. There are limited studies that address the benets of ed- members with more realistic expectations to better prepare
ucation before surgery; however, evidence shows preoperative for the transition to home.15
teaching conducted before hospital admission is most success-
ful.14 After the plan for surgery is conrmed, the patient should
begin to receive information from his or her medical team. The
Fluid Management
education that the patient receives in the ofce will set the tone Before admission, nurses instruct patients to drink high-
for the surgical experience. The goal of an effective patient protein drinks and encourage them to stay hydrated the day
education plan is to inform the patient and his or her family before surgery.2,16 High-protein drinks prevent catabolism
members about what to expect during each phase of the that occurs when patients are not eating or drinking because of
experience. Patients often worry about how long they will be diet limitations during the perioperative period. Intake of
hospitalized, types of dressings, driving restrictions, and when high-protein drinks minimizes this process. The nurses review
they can return to work and household activities, among the information on the protein drinks with the patient when
other things. The goal of education is to address these stresses the patient is given the preoperative paperwork about surgery.
and help the patient adequately prepare for and anticipate To promote hydration, surgeons are discouraged from
needs during recovery. A comprehensive education plan helps ordering routine bowel preparation for patients undergoing
the patient and caregivers engage in the process to prepare for bowel resection because of the risk of postoperative electrolyte
the surgical experience. imbalance and lack of efcacy. Close monitoring of intra-
At our institution, an Abdominal Surgery Patient Education operative uid administration prevents hypovolemia or vol-
Booklet is used to educate patients and their family members ume overload after surgery. Gustafsson et al16 reported a
about their surgical experience. A committee of three surgical benet associated with intraoperative uid sparing; in their
nurse practitioners and two members of the Patient Education study, 32% of participants experienced increased
Department worked to create a comprehensive guide to help postoperative complications with each added liter of
patients and their caregivers successfully navigate through the crystalloid. For infusion, anesthesia professionals prefer to
surgical experience from the preoperative period to discharge. administer crystalloids because there are lower incidences of
Committee members gave each abdominal surgeon the op- volume overload and infection with crystalloid use compared
portunity to review and amend the patient education materials with colloid use.2,17
before nalizing them. The team used health literacy software
to ensure the materials were printed at a basic comprehension INTRAOPERATIVE CARE
level and that all patients could benet from this patient in- The perioperative nursing staff members also are educated
formation. The nurses working in the surgeons ofce provide about and participate in the intraoperative and postoperative
the booklet to all preoperative patients, and it is also available stages of the multimodal pathway. The intraoperative care
for direct download from the hospital intranet. measures provided by nurses include verifying the correct pa-
tient, procedure, and site, if applicable, with the patient and
The stress of a new diagnosis or the realization that surgery is reinforcing education about the planned procedure. The nurses
necessary can prevent a patient from absorbing essential in- help ensure that a proper time-out procedure is performed,
formation presented verbally during consultation. Repetition antibiotics and antithrombotic agents are administered in a
of this information by multiple members of the health care timely fashion, and the patient is positioned and secured
team, including the nurse, helps the patient retain key items appropriately. In keeping with cost containment efforts, nurses
needed for his or her recovery. The use of written materials select reusable equipment (eg, laparoscopic ports) and, to avoid
and audio-visual materials also enables the patient to review waste, do not open instruments (eg, energy devices, staplers)
the education materials several times before surgery to help until the surgeon requests them. Opioid-sparing pain manage-
ensure understanding.15 ment is used even in the OR, and nurses participate in
administration of transversus abdominis plane blocks before the to patients undergoing laparoscopic surgery and provide them
end of the procedure. Before transporting the patient to the automatically on postoperative day one. If liquids are tolerated,
postanesthesia care unit (PACU), the nurse assesses the patients patients then advance to a soft diet. In the major open
skin and temperature. In the PACU, the perioperative nurse abdominal surgery care pathway, nurses provide patients with
provides a standardized hand-over report to ensure that perti- ice chips initially and then automatically advance their diet to
nent information is provided to the PACU RN. clear liquids on postoperative day one and a soft diet on
postoperative day two. Patients are instructed that drinking
POSTOPERATIVE CARE uids is more important than eating, and nurses instruct them
In the PACU, nurses play a key role in patient pain man- to take a few bites initially rather than attempt a full meal.
agement and satisfaction. Even at the early postoperative stage, Small, frequent meals are encouraged for better diet tolerance.
by using standardized ERPs, nurses can directly affect the All patients are offered a high-calorie drink after surgery in the
reduction of postoperative infections and ileus and facilitate care unit to which they are transferred. Because diets are
the patients safe and timely hospital stay. By following ERPs, predated and will change automatically per the standardized
nurses are empowered to discontinue use of Foley catheters, orders, it is the responsibility of the medical team to make
reduce IV uids, change pain medication from IV to PO, individual adjustments to address specic patient needs. In our
discontinue patient-controlled analgesia, and advance patients experience, the postoperative day on which a diet is introduced
diets. The physicians have the option to alter orders, but to do is the fundamental difference between ERPs and other care
this they must manually uncheck the standardized order and regimens across abdominal specialties and varies depending on
address any option that deviates from the standard- the procedure performed.
ized pathway.
After the patient tolerates his or her diet and achieves adequate
oral intake, nursing personnel automatically discontinue IV
Nursing Orders and Interventions uids. The care team also encourages patients to chew sugar-
One way to measure the success of ERPs is through the use of free gum at least three times per day. Studies have shown that
postoperative order sets, which have standardized nursing or- the sorbitol in sugar-free gum enhances return of bowel
ders and interventions. All patients have orders to be out of function.2,18-25 In our institution, nutrition services and
bed a minimum of two times per day, as their condition al- pharmacy personnel are unable to dispense gum to our pa-
lows. Ambulation at least ve times per day in the hallways is tients, so team members in the different surgical services
also prescribed.2 Early activity is benecial in preventing purchase the gum and absorb the cost.
complications such as deep vein thrombosis, pulmonary
embolism, and pneumonia. It is also benecial in limiting Medication
deconditioning, especially in older patients. Other patient
Nurses in the PACU actively survey the patient for pain using
care ordersdsuch as helping patients to use incentive
pain scores and use nonopioid postsurgical pain management
spirometry and sequential compression devices; accurately strategies according to the ERPs, with opioids as needed for
recording intake, output, and daily weights; and knowing pain relief. Acetaminophen and ibuprofen are routinely or-
when to call the care providerdare also detailed in ERPs.
dered medications for mild pain, and oxycodone is ordered for
The patient orders require that indwelling Foley catheters be
moderate or severe pain. Through patient assessment, nurses
removed on postoperative day one for patients who have use their judgement to determine which medication will meet
undergone laparoscopic procedures and by postoperative day the patients need for pain medication. Standardization of
two for patients who have undergone open abdominal medication orders minimizes choices and ensures better
procedures. Catheter removal is important to minimize the
compliance with care pathways and evidence-based practice.
risk of infection. Patients are also more likely to get out of Enhanced recovery pathways use medications that have been
bed and ambulate after catheters are removed. found to be effective, reduce the use of a wide variety of
expensive medications, and control costs. Patient-controlled
Diet analgesia pumps are only used overnight on the day of sur-
The care team reduces maintenance IV rates and introduces gery or until patients are able to tolerate oral uids. The care
oral uids after the patient arrives in the postoperative unit. team initiates oral opioid analgesics on postoperative day one
Diets are automatically advanced based on specic care path- or as soon as the patient can tolerate liquids. Oral opioid
ways. For example, using the major laparoscopic abdominal analgesics and alternatives to opioid analgesics are also avail-
order set, nurses offer liquids the night of surgery as tolerated able on the order sets. Acetaminophen is routinely ordered
around the clock unless contraindicated. Ibuprofen, gaba- from preoperative patient information. The investigators found
pentin, and ketorolac also are available as a multimodal pain that patients who received preoperative education stayed in
control regimen with the goal of limiting narcotics, which the hospital for 1.5 fewer days. Ronco et al15 found that
delay return of bowel function. patient information provided before surgery and reviewed after
admission proved to be more effective than information solely
Laboratory Tests received before surgery.15 Results from Stern and Lockwood14
Excessive orders for laboratory tests are wasteful. To minimize revealed that patients who received preoperative education
these costs, daily automatic laboratory tests are discouraged in were able to recall information and perform skills more
ERPs. Blood draws for tests, including complete blood count quickly than those who did not receive preoperative
and basic metabolic panels, are ordered automatically every education.14 These ndings reinforce the importance of
other day. When more frequent laboratory studies are needed, preoperative patient education and emphasize the benets of
the physician or nurse practitioner may order them separately. repetition for patient recall and positive outcomes.
Our snapshot audit focused on a few key areas: ERP order set resource utilization: a meta-analysis of randomized controlled trials
use, laboratory test ordering practices, use of diet orders that in colorectal surgery. Surgery. 2011;149(6):830-840.
adhered to the pathway, and use of order sets without modi- 3. Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O,
cations. Despite our small samples (ie, 18 procedures at the Lobo DN. The enhanced recovery after surgery (ERAS) pathway for
patients undergoing major elective open colorectal surgery: a
rst time point and 15 procedures at the second time point),
meta-analysis of randomized controlled trials. Clin Nutr. 2010;
we were able to capture useful information. In our rst 29(4):434-440.
snapshot completed in December 2013, we found that 61% of 4. Ren L, Zhu D, Wei Y, et al. Enhanced Recovery After Surgery
the charts reviewed used ERP order sets for postoperative (ERAS) program attenuates stress and accelerates recovery in
orders, compared with an improved 93% in our second patients after radical resection for colorectal cancer: a prospective
sampling in June 2014. Laboratory tests were ordered daily, randomized controlled trial. World J Surg. 2012;36(2):407-414.
despite the every-other-day recommendation, in 94% of charts 5. Teeuwen PH, Bleichrodt RP, Strik C, et al. Enhanced recovery after
reviewed in December, compared with 62% in June. Initially, surgery (ERAS) versus conventional postoperative care in colorectal
surgery. J Gastrointest Surg. 2010;14(1):88-95.
38% of the charts reviewed had daily laboratory tests ordered
6. Fearon KC, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced re-
for the entire hospital stay, using an auto-order feature. In covery after surgery: a consensus review of clinical care for patients
June 2014, we found that no repeating laboratory tests were undergoing colonic resection. Clin Nutr. 2005;24(3):466-477.
ordered. Lastly, we looked at the number of charts that used 7. Delaney CP, Fazio VW, Senagore AJ, Robinson B, Halverson AL,
the order sets as designed without modication. We found Remzi FH. Fast track postoperative management protocol for
that use of the standardized ERP order set as written improved patients with high co-morbidity undergoing complex abdominal
from less than 1% to 27%. and pelvic colorectal surgery. Br J Surg. 2001;88(11):1533-1538.
8. Delaney CP, Zutshi M, Senagore AJ, Remzi FH, Hammel J,
From this sampling, we saw signicant improvement in order Fazio VW. Prospective, randomized, controlled trial between a
pathway of controlled rehabilitation with early ambulation and diet
set use and compliance with the standardized care plan.
and traditional postoperative care after laparotomy and intestinal
However, there are continued areas of improvement needed, resection. Dis Colon Rectum. 2003;46(7):851-859.
including education and ERP awareness. Since this snapshot, 9. Senagore AJ, Duepree HJ, Delaney CP, Brady KM, Fazio VW.
education sessions with the resident teams and nurses have Results of a standardized technique and postoperative care plan
occurred, and future order set compliance audits are planned. for laparoscopic sigmoid colectomy: a 30-month experience. Dis
Adherence to ERPs requires time and resources to educate Colon Rectum. 2003;46(4):503-509.
personnel and to change practice, but even early audits show 10. Delaney CP. Outcome of discharge within 24 to 72 hours after
the benets of this care pathway. laparoscopic colorectal surgery. Dis Colon Rectum. 2008;51(2):
181-185.
11. Delaney CP, Brady K, Woconish D, Parmar SP, Champagne BJ.
Towards optimizing perioperative colorectal care: outcomes for
CONCLUSION
1,000 consecutive laparoscopic colon procedures using enhanced
Enhanced recovery pathways are a multidisciplinary, stan- recovery pathways. Am J Surg. 2012;203(3):353-356.
dardized approach to caring for patients undergoing abdom- 12. Keller DS, Bankwitz B, Nobel T, Delaney CP. Using frailty to predict
inal surgery. The goals of ERPs are to decrease length of stay who will fail early discharge after laparoscopic colorectal surgery
and decrease care costs without affecting patient outcomes or with an established recovery pathway. Dis Colon Rectum. 2014;
increasing complications. The nurses role is essential for 57(3):337-342.
providing education and following the pathways successfully. 13. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for
With proper planning and education of patients, their family acute upper gastrointestinal bleeding. N Engl J Med. 2013;368(1):
11-21.
members, and health care team members, the benets of ERPs
14. Stern C, Lockwood C. Knowledge retention from preoperative
can outweigh the costs of implementation and dramatically patient information. Int J Evid Based Healthc. 2005;3(3):45-63.
improve patient and nancial outcomes. 15. Ronco M, Iona L, Fabbro C, Bulfone G, Palese A. Patient education
outcomes in surgery: a systematic review from 2004 to 2010. Int
J Evid Based Healthc. 2012;10(4):309-323.
References 16. Gustafsson UO, Scott MJ, Schwenk W, et al; Enhanced Recovery
1. Lawrence JK, Keller DS, Samia H, et al. Discharge within 24 to 72 After Surgery (ERAS) Society for Perioperative Care, European
hours of colorectal surgery is associated with low readmission Society for Clinical Nutrition and Metabolism (ESPEN), International
rates when using enhanced recovery pathways. J Am Coll Surg. Association for Surgical Metabolism and Nutrition (IASMEN).
2013;216(3):390-394. Guidelines for perioperative care in elective colonic surgery:
2. Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP. Enhanced Recovery After Surgery (ERAS(R)) Society recommen-
Enhanced recovery pathways optimize health outcomes and dations. World J Surg. 2013;37(2):259-284.
17. Mythen MG, Swart M, Acheson N, et al. Perioperative uid 26. Cakir H, van Stijn MF, Lopes Cardozo AM, et al. Adherence to
management: consensus statement from the enhanced recovery enhanced recovery after surgery and length of stay after colonic
partnership. Perioper Med (Lond). 2012;1:2. resection. Colorectal Dis. 2013;15(8):1019-1025.
18. Abd-El-Maeboud KH, Ibrahim MI, Shalaby DA, Fikry MF. Gum
chewing stimulates early return of bowel motility after caesarean
section. BJOG. 2009;116(10):1334-1339.
Karen M. Brady, MSN, APRN-BC, is a nurse practi-
19. Asao T, Kuwano H, Nakamura J, Morinaga N, Hirayama I, Ide M.
tioner in the Division of Colorectal Surgery, Department
Gum chewing enhances early recovery from postoperative ileus
of Surgery, University Hospitals-Case Medical Center,
after laparoscopic colectomy. J Am Coll Surg. 2002;195(1):
Cleveland, OH. Ms Brady has no declared afliation that
30-32.
could be perceived as posing a potential conict of
20. Bahena-Aponte JA, Cardenas-Lailson E, Chavez-Tapia N, Flores-
interest in the publication of this article.
Gama F. [Usefulness of chewing gum for the resolution of post-
operative ileus in left colon resections.]. Rev Gastroenterol Mex.
2010;75(4):369-373. Deborah S. Keller, MS, MD, was a research fellow
21. Chan MK, Law WL. Use of chewing gum in reducing postoperative for the Division of Colorectal Surgery, Department of
ileus after elective colorectal resection: a systematic review. Dis Surgery, University Hospitals-Case Medical Center,
Colon Rectum. 2007;50(12):2149-2157. Cleveland, OH, at the time this article was written.
22. de Castro SM, van den Esschert JW, van Heek NT, et al. Dr Keller has no declared afliation that could be
A systematic review of the efcacy of gum chewing for the perceived as posing a potential conict of interest in
amelioration of postoperative ileus. Dig Surg. 2008;25(1):39-45. the publication of this article.
23. Fitzgerald JE, Ahmed I. Systematic review and meta-analysis of
chewing-gum therapy in the reduction of postoperative paralytic Conor P. Delaney, MD, MCh, PhD, FRCSI, FACS,
ileus following gastrointestinal surgery. World J Surg. 2009; FASCRS, is a surgeon in the Division of Colorectal Sur-
33(12):2557-2566. gery, Department of Surgery, University Hospitals-Case
24. Noble EJ, Harris R, Hosie KB, Thomas S, Lewis SJ. Gum chewing Medical Center, Cleveland, OH. Dr Delaney has no
reduces postoperative ileus? A systematic review and meta- declared afliation that could be perceived as posing
analysis. Int J Surg. 2009;7(2):100-105. a potential conict of interest in the publication of this
25. Yeh YC, Klinger EV, Reddy P. Pharmacologic options to prevent article.
postoperative ileus. Ann Pharmacother. 2009;43(9):1474-1485.
Continuing Education:
Successful Implementation of an
Enhanced Recovery Pathway:
The Nurses Role 1.9 www.aorn.org/CE
PURPOSE/GOAL
To provide the learner with knowledge specic to the nurses role in implementing an enhanced
recovery pathway (ERP) of patient care.
OBJECTIVES
1. Discuss the ERP care model.
2. Describe the steps to implement an ERP for patients undergoing abdominal surgery.
3. Describe the nurses role in implementing an ERP.
The Examination and Learner Evaluation are printed here for your convenience. To receive
continuing education credit, you must complete the online Examination and Learner Evaluation
at http://www.aorn.org/CE.
Continuing Education:
Successful Implementation of an
Enhanced Recovery Pathway:
The Nurses Role 1.9 www.aorn.org/CE
7A.
Will you change your practice as a result of reading this
article? (If yes, answer question #7A. If no, answer
question #7B.)
3. Describe the nurses role in implementing an ERP. 7B. If you will not change your practice as a result of
Low 1. 2. 3. 4. 5. High reading this article, why? (Select all that apply)
1. The content of the article is not relevant to my
CONTENT practice.
4. To what extent did this article increase your knowledge 2. I do not have enough time to teach others about the
of the subject matter? purpose of the needed change.
Low 1. 2. 3. 4. 5. High 3. I do not have management support to make a
change.
5. To what extent were your individual objectives met? 4. Other: __________________________________
Low 1. 2. 3. 4. 5. High
6. Will you be able to use the information from this article 8. Our accrediting body requires that we verify the time
in your work setting? you needed to complete the 1.9 continuing education
1. Yes 2. No contact hour (114-minute) program: ______________