title: Understanding surgical residents' postoperative practices and barriers and enablers to the implementation of an Enhanced Recovery After Surgery (ERAS) Guideline.
abstract: BACKGROUND
  An Enhanced Recovery after Surgery (ERAS) Clinical Practice Guideline (CPG) was developed at the University of Toronto. Before implementation, general surgery residents were surveyed to assess their current stated practices and their perceived barriers and enablers to early discharge.
  
  
  METHODS
  The survey, which consisted of 33 questions related to the postoperative management of patients undergoing laparoscopic colectomy (LAC), open colectomy (OC) and open low anterior resection (LAR), was distributed to all residents. Chi-square and Fisher exact tests were used to test differences. Open-ended questions were analyzed using content analysis.
  
  
  RESULTS
  Of 77 residents surveyed, 58 (75%) responded. Residents stated that a fluid diet would be ordered on POD#0 and regular diet on POD#1 by 67.9% and 49.1%, respectively, following LAC, and 50.0% and 25.9%, respectively, following OC. On POD#1, 89.3% expected patients to ambulate following LAC compared with 67.9% following OC. Residents indicated that urinary catheters would be removed on POD#1 by 87% following LAC and by 81.3% following OC, and by POD#3 by 89.1% following LAR. However, in patients with an epidural, approximately 50% of residents stated that they would wait until it was removed. Overall, 76.4% of residents agreed that an ERAS CPG should be adopted. Residents cited setting expectations, encouragement of early ambulation and feeding, and good pain control as enablers to early discharge. However, patient and family expectations, surgeon preferences, and beliefs of the health care team were mentioned as barriers to early discharge.
  
  
  CONCLUSIONS
  Residents have a reasonable approach to the management of patients who underwent LAC, but there are gaps that exist in their management, especially following OC and LAR. Although most residents agreed with the implementation of an ERAS CPG, barriers exist, and strategies aimed at ensuring adherence with the recommendations are required.
authors.affiliation: Division of General Surgery, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Ashlie
authors.initials: A
authors.lastname: Nadler
authors.affiliation: Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada; Zane Cohen Clinical Research Centre, Mount Sinai Hospital, Toronto, Ontario, Canada; Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada.
authors.forename: Emily A
authors.initials: EA
authors.lastname: Pearsall
authors.affiliation: Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
authors.forename: J Charles
authors.initials: JC
authors.lastname: Victor
authors.affiliation: Division of General Surgery, University of Toronto, Toronto, Ontario, Canada; Toronto East General Hospital, Toronto, Ontario, Canada.
authors.forename: Mary-Anne
authors.initials: MA
authors.lastname: Aarts
authors.affiliation: Division of General Surgery, University of Toronto, Toronto, Ontario, Canada; Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Allan
authors.initials: A
authors.lastname: Okrainec
authors.affiliation: Division of General Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada; Zane Cohen Clinical Research Centre, Mount Sinai Hospital, Toronto, Ontario, Canada; Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Electronic address: rmcleod@mtsinai.on.ca.
authors.forename: Robin S
authors.initials: RS
authors.lastname: McLeod
mesh_terms: D000328:Adult; D020878:Device Removal / Q000592:standards; D013505:Digestive System Surgical Procedures / Q000592:standards; D004434:Early Ambulation; D017558:Elective Surgical Procedures / Q000534:rehabilitation*; D005260:Female; D013502:General Surgery / Q000193:education*; D006801:Humans; D007396:Internship and Residency; D008297:Male; D011182:Postoperative Care / Q000592:standards*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D020127:Recovery of Function; D011795:Surveys and Questionnaires; D062885:Urinary Catheters
keywords: ERAS; Medical Knowledge; Patient Care; Practice-Based Learning and Improvement; Systems-Based Practice; barriers; clinical practice guidelines; colorectal surgery; enablers