DOI: 10.1111/tog.

12061 2013;15:263–8
The Obstetrician & Gynaecologist
Reviews
http://onlinetog.org

Enhanced recovery in gynaecology

Emma Torbe
a
BM PgDip (leadership, quality and safety in healthcare) MRCOG, Robin Crawford MD FRCOG FRCS Eng,
b
c d,
Andy Nordin MBBS FRCOG, Nigel Acheson MD PGCert (Patient safety and risk management) FRCOG *
a
NHS South Central Service Improvement Fellow and Specialist Trainee in Obstetrics and Gynaecology, Princess Anne Hospital, Coxford Road,
Southampton, SO16 5YA
b
Consultant Gynaecological Oncologist and National Clinical Adviser for the Enhanced Recovery Programme Partnership, Cambridge University
Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, CB2 0QQ, UK
c
Consultant Gynaecological Oncologist and National Clinical Adviser for NHS Improvement – Cancer, East Kent Gynaecological Oncology Centre,
East Kent Hospitals University Foundation Trust, Margate, CT9 4AN, UK
d
Regional Medical Director (South), NHS England, Consultant Gynaecological Oncologist and adviser to NHS Improving Quality, South West
House, Blackbrook Park Avenue, Taunton, TA1 2PX, UK
*Correspondence: Nigel Acheson. Email: nigel.acheson@nhs.net

Accepted on 12 February 2013

Key content Learning objectives

 Enhanced recovery pathways improve the quality and
experience of care for patients undergoing elective gynaecology
surgery.
 Enhanced recovery pathways enable patients to recover more
quickly and leave hospital sooner.
 Enhanced recovery pathways reduce physical and psychological
stress on patients.
 Enhanced recovery pathways involve patients in their own care,
which leads to better outcomes.
 To understand the principles and benefits of enhanced recovery pathways.
 To share learning and experience of enhanced recovery pathways.
Ethical issues
 Further research in the form of a randomised controlled trial of
enhanced recovery versus ‘old fashioned’ care would be difficult as
denying aspects of care would not be ethical.
Keywords: enhanced recovery / fast-track surgery / gynaecological
surgery / length of stay / quality

Please cite this paper as: Torb
e E, Crawford R, Nordin A, Acheson N. Enhanced recovery in gynaecology. The Obstetrician & Gynaecologist 2013;15:263–8.

It remains true that the bulk of the evidence for ER has

Introduction
Enhanced recovery (ER) has also been described as
‘fast-track’, ‘rapid’ or ‘accelerated’ recovery. In fact, the
combination of evidenced based elements of care into a
pathway (Figure 1) for elective surgery results in a reduction
in the physiological stress response and organ dysfunction
caused by surgery, which facilitates more rapid recovery,
shortened length of stay,1–3 and return to normal activity.4
The aim of the pathway is to optimise care, and the resulting
reduction in the stress response to surgery can now be
described as standard practice. At the time these pathways
were described initially by Kehlet in Denmark in 1990s,5 for
patients undergoing colorectal surgery, patients recovered
more quickly, allowing discharge after 2–3 days at a time
when the length of stay in UK hospitals for a colon resection
was longer than 2 weeks.5 One of the key challenges to the
implementation of these pathways is the dogma that
accompanies many current surgical pathways based on
familiarity rather than evidence.
been published for colorectal surgical pathways – two
meta-analyses demonstrated the benefits of reduced length
of stay, hospital morbidities and complication rates.6,7 A
Cochrane review of ER in gynaecological cancer8 contained
no randomised trials in ER, but non-randomised
evidence in gynaecology and other specialties is building.
Following the compelling evidence from colorectal
surgery, and emerging evidence of benefit in gynaecology,
current research is directed towards optimising elements
of the pathways in gynaecology such as postoperative
analgesia.
Gynaecology was included as one of four surgical
specialties as part of the Enhanced Recovery Partnership
Programme, from 2009 to 2011. An initiative between the
Department of Health, the National Cancer Action Team,
NHS Improvement and NHS Institute of Innovation and
Improvement, only one procedure, hysterectomy, was
included for gynaecology, and early work commenced in
gynaecological oncology. Implementation and support for the

ª 2013 Royal College of Obstetricians and Gynaecologists 263

 Enhanced recovery in gynaecology
Figure 1. Enhanced recovery pathway
development of enhanced recovery in gynaecology continues
to be supported nationally by NHS Improving Quality.
As momentum builds, many bodies are supporting this
approach. At the National Enhanced Recovery Summit in April
2012, a pan-specialty multidisciplinary consensus statement
was signed by representatives of national bodies including the
presidents of the Royal College of Obstetricians and
Gynaecologists and the British Gynaecological Cancer Society:9
‘The enhanced recovery approach to pre-operative,
peri-operative and post-operative care has major benefits
for many patients in relation to quicker recovery following
major surgery. This facilitates shorter hospital stay with no
increase in readmission rates. This has clear benefits for
patients and their families and for the NHS.
‘Enhanced recovery is now being implemented across the
NHS in patients undergoing elective procedures in four
specialties: orthopaedics, colorectal, gynaecological and
urological surgery. There is considerable scope to extend the
relevant components of enhanced recovery to patients
admitted as emergencies and to other specialties. We
believe that enhanced recovery should now be considered as
standard practice for most patients undergoing major surgery
across a range of procedures and specialties.’
The RCOG Scientific Advisory Committee produces a
range of Scientific Impact Papers providing up to date
264
reviews of emerging scientific issues of relevance to obstetrics
and gynaecology. Scientific Impact Paper No 36 “Enhanced
recovery in gynaecology” was published in 2013 and, as the
authors of that paper, we present the elements of enhanced
recovery pathways described in it to further raise awareness
of the approach.10 Some of the elements of enhanced
recovery pathways, such as pre assessment clinics, antibiotic
and thromboembolic prophylaxis, will be familiar elements
of care, whilst others such as carbohydrate loading and
individualised goal directed fluid therapy may not.
Enhanced recovery
Preoperative care
If possible, preoperative risk assessment of the patient’s health
and fitness for surgery should be organised so that any problems
identified can be addressed in order to reduce complications
and perioperative mortality.11 The process starts in primary care
prior to GP referral. The use of formal pre-admission clinics is
recommended. Verbal and written patient information ensures
that patients understand their treatment pathway, and the active
part they play in their care. Preoperative patient education can
reduce the need for pain relief12 and improves patients’
experience of the hospital admission.11 Procedure-specific
information and consent can greatly aid the
information-giving phase of the pre-admission process. The
key role of specialist nurses in ER must be emphasised.
ª 2013 Royal College of Obstetricians and Gynaecologists

One of the key advantages of a standardised pathway for a
surgical pathway is the ability to plan with accuracy the date of
discharge from hospital. As part of the patient’s responsibility
for their care information about the anticipated length of stay
and expected recovery for a particular procedure, so that they,
together with carers, can ensure that the appropriate support
is available on discharge.
Perioperative care
Admission on the day of surgery has many advantages – these
include reduction in preoperative bed usage. Dehydration is
avoided by reducing the period of fluid fasting to 2 hours
prior to anaesthetic, which has been shown to be safe without
an increase the risk of aspiration.13 The use of complex
carbohydrate drinks have been shown to be beneficial in
colorectal surgery,14 reducing the length of stay and liked by
patients.15 Mechanical bowel preparation can be associated
with morbidity and there is no evidence that it improves the
outcome for patients having elective rectal surgery, in whom
bowel continuity is restored.16 The role of mechanical bowel
preparation should therefore be investigated and generally
avoided in patients undergoing gynaecological surgery.
Long-acting sedative premedication can impair
postoperative mobility.17 Antibiotics prior to incision and
venous thromboembolic prophylaxis should be included as
there is evidence for their benefit.18,19
Enhanced recovery pathways advocate minimal access
techniques.20,21 If considered necessary for the procedure to
be performed safely, abdominal incisions should be as small as
possible. Nasogastric, abdominal and vaginal drains have little
benefit and should be avoided as they increase morbidity and
prolong hospital stay.22–24 The routine use of vaginal packs
has been questioned, not only because they are uncomfortable
for patients but also because they may hinder, if not prevent,
mobilisation. However, because of the lack of evidence, a
departmental approach for their use should be adopted to
ensure consistency. This is another area for research.
Avoidance of intraoperative hypothermia has long been
shown to reduce postoperative complications.25 In colorectal
surgery, individualised goal-directed fluid therapy using stroke
volume to guide intraoperative fluid management reduces
peri-operative mortality and length of stay.26 The benefit of
this approach relates to a reduction in the risk of bowel
hypo-perfusion, but the role in gynaecological surgery is less
clear. However, the use of intraoperative fluid management
technologies is now recommended in patients undergoing major
or high-risk surgery (including major surgery with an anticipated
blood loss greater than 500 ml and major abdominal surgery) or
high-risk patients (including patients aged over 80 years)
undergoing intermediate-risk surgery.27,28
Standardising anaesthetic protocols by focusing on the
stress response to surgery, analgesia and fluid management
improves patient outcomes and promotes patient safety.29–32
ª 2013 Royal College of Obstetricians and Gynaecologists

et al.
Torbe
A standard protocol to manage postoperative pain is required
to reduce the adverse effects of the surgical stress response
which can prolong recovery.29 Spinal, epidural and regional
regimens can reduce opiate requirements, which in turn
allows a more rapid return to oral fluid intake. In addition,
there is evidence of improved patient satisfaction and an
association with a rapid return to work.30–32
Postoperative care
In routine surgery, early feeding and a reduction in the volume
of routine intravenous fluids is a safe approach. Associated
with a reduction in nausea, and higher patient satisfaction, this
part of the pathway contributes to the shortened length of stay
and higher patient satisfaction observed.33,34 Early
mobilisation is key to ER and is achievable regardless of age
with appropriate education and support. Encouraged by
effective analgesia (in a protocol with reduced use of systemic
opiates) early mobilisation reduces the risks of muscle loss and
thromboembolism.35 Protocols should also include
anti-emetics to manage postoperative nausea and vomiting,
and laxatives to prevent constipation. Catheters, drains,
vaginal packs and intravenous drips should be removed as
soon as possible, to enable mobilisation and prevent
developing associated secondary infections. Women are at
risk of developing short-term voiding problems following
pelvic surgery – after catheter removal voiding should be
monitored using post-void residual checks. If necessary, it is
safe for patients to be discharged with an indwelling catheter
and to return for a trial without catheter as an outpatient.
Discharge
Discharge for ER patients is criteria-based, and can effectively
be nurse-led, once patients are mobilising, eating and
drinking, passing flatus and their pain is controlled by oral
analgesia. It is essential that patients are provided with
written information on discharge that includes emergency
contact information, practical advice to aid recovery and
expected length of time until they return to normal function.
Models that have been applied for follow-up after initial
discharge include: telephone calls to patients after 24/
48 hours by nursing staff or patient-triggered follow-up
contacting the ward with concerns or questions via a
dedicated phone number.
Patient involvement
Involving patients and their carers at every step of the process
from decision to discharge in partnership with the clinical
team is fundamental to ER. Empowering patients to take a
significant role contrasts with the passive ‘sick’ role patients
play in traditional care pathways.
Crucial to a patient’s psychological preparation is accurate
and consistent information about ER.36 This starts in primary
265
 Enhanced recovery in gynaecology
care at the time of referral, aligning their expectations with
the expectations of the clinical team at the earliest stage.
Shared decision making helps women take ownership over
their decisions with respect to whether surgery is necessary or
appropriate, through to how they want to be treated and to
decisions around discharge. Informing patients and their
carers about the ER pathway reduces the fear of the unknown
and challenges preconceived ideas about the operation, pain,
recovery and length of stay, that may be based on experiences of
friends and family from a bygone era. My Role and
Responsibilities in Helping to Improve My Recovery is a generic
patient information leaflet produced by The Enhancing Patient
Experience Working Group and promoted by NHS Improving
Quality, that details the patient’s role in their care.37 By taking
an active role and responsibility for enhancing their own
recovery, patients are involved, motivated and overall have an
improved experience.2,30,34
Patients must receive the same messages about what to
expect from all members of the multidisciplinary team, at all
stages of the pathway. Some trusts have introduced new ways
to educate patients, such as information evenings and DVDs.
If patients require further information they need to know
where to go for answers, advice or support.
Patient feedback from those who have used the service is
key to maintaining and improving a quality service. Patients’
experience may be very different than what was intended or
assumed to have occurred. Formal evaluation is necessary to
understand what does and does not work and what can be
improved. This can be done using a variety of methods from
questionnaires through to interviews and innovative ways
such as patient parties.36
Quality and cost
Patients on ER pathways recover more quickly and have
shortened length of stay.1–3,38 Length of stay is taken as a
surrogate marker for quality of care, as shorter stays suggest
fewer complications. It is also used for inter-hospital
comparison because it is readily available as Hospital Episode
Statistics data. Complication rates are comparable to, or better
than, those seen in the UK following conventional surgery.1
Typically, there is no increase in readmissions or postoperative
work for primary care.38,39 In addition, ER pathways have
better patient satisfaction,38 better nurse satisfaction2 and
improved quality of life following surgery than traditional
pathways.40 The costs and investment required for
implementing ER varies depending on what infrastructure is
currently in place. However, there are financial gains to be
made by releasing beds for savings or increasing activity.
ER advocates to use the safest, most appropriate, least
invasive procedure for each woman. Despite the development
of minimal access techniques, an abdominal approach for
hysterectomy was used in around 79% of benign cases in
266
England (2010–2011 HES data) which does not compare
favourably with other published national data (Finland
24%).2 There would be a significant benefit for patients
and the UK health economy if there was a shift away from
abdominal procedures to a minimal access approach.
Implementation
Adopting ER challenges traditional practice – it can be
difficult to persuade colleagues to adopt unfamiliar elements
of a pathway such as carbohydrate loading, and further
training may be required in laparoscopic surgical techniques.
Successful implementation requires a commitment from all
stakeholders in primary, secondary and social care, including
high-level clinical and management teams within hospitals.
Without this support, the change will not be sustainable.
Experience in England over the past 4 years suggests that a
core team of stakeholders should be identified – this
comprises a surgeon, anaesthetist, specialist nurses and
managers. Training is required to ensure that this core
team understand the current service, and can then identify
and implement improvements, measure the impact and feed
back to the wider clinical team. A designated local ‘ER
champion’can facilitate this work.41
Education is fundamental to facilitating change. Locally
agreed pathways and protocols, based on the ER Pathway
documentation, must be developed to ensure local
“ownership”. Unless these are advertised and promoted,
staff may remain unaware of the changes or do not value
their importance so do not change practice. All members of
the multidisciplinary team need to understand the pathway
and that their role is vital to its success.
Baseline and continuing data collection of both clinical and
service evaluation outcomes is important to be able to
demonstrate progress of implementing ER and its impact on
the service. A national ER audit tool was developed to assist
with this, which enabled benchmarking against other sites (see
www.natcansatmicrosite.net/enhancedrecovery/Default.aspx).
Dissemination of the results may help compliance with
pathways and empower and inform frontline staff.
There is further support and information available to
trusts considering implementation from NHS Improving
Quality. Online resources remain available through the NHS
Improving Quality website (www.improvement.nhs.uk/
enhancedrecovery/) and from the document Delivering
Enhanced Recovery published by the NHS Enhanced
Recovery Partnership Programme.42
Commissioning
In these times of financial pressure, commissioners want to
commission cost-effective and high-quality services, which
improve outcomes for patients. ER fulfils those criteria and
ª 2013 Royal College of Obstetricians and Gynaecologists

aligns with the NHS Outcomes Framework Domains 3, 4
and 5.27 Commissioners have used contractual levers, such
as Commissioning for Quality and Innovation payments
and service specifications, to encourage providers to
establish or further develop ER within their service. This
has been seen in areas across the country for example, in
London, the south east and south west.36
Further research and developments
Randomised studies typically look at changes in components
of care pathways. Some of the benefit of ER is a change of
philosophy, putting the patient at the centre of the approach
and developing and implementing an integrated care
pathway that an entire multidisciplinary team has
developed and signed up to. If one breaks down the
pathway to evaluate individual components the key benefit
of patient-centred care maybe lost.
Construction of a randomised controlled trial of a pathway
containing no ER elements versus a fully implemented ER
pathway, in a particular hospital would be difficult to carry
out. For some elements such as early post operative feeding,
there is strong evidence from randomised controlled trials.34
Other elements where evidence is lacking, for example,
regarding the use of vaginal packs, are best evaluated by a
randomised controlled trial.
The ER model offers the opportunity to improve the care
of emergency admissions. Early work in obstetrics has begun
in the pathway for elective caesarean section. To date there is
little experience incorporating support of the newborn and
the establishment of breastfeeding into ER. However, given
the increasing numbers of elective and emergency caesarean
sections, application of the ER principles could be of
importance in obstetric care.
Conclusion
ER leads to improved patient satisfaction, less variation in
patient care, shorter length of hospital stay, and a reduction
in complications and re-admissions. There is a need for trusts
to move forward using the ER principles for the benefit of the
patients undergoing gynaecological surgery and for the NHS
as a whole.
Disclosure of interests
All authors are also authors of the RCOG SAC paper on
Enhanced Recovery for Gynaecology. NA is an advisor to
NHS IQ and former member of the steering board for
Enhanced Recovery (ERAS) UK and received a speaker fee
from Baxter (UK) for a talk on Enhanced Recovery. NA and
RC were previously national advisors to the Enhanced
Recovery Partnership Programme, Department of Health.
AN was an advisor to NHS Improvement.
ª 2013 Royal College of Obstetricians and Gynaecologists

et al.
Torbe
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ª 2013 Royal College of Obstetricians and Gynaecologists