title: Development of an Enhanced Recovery After Surgery Guideline and Implementation Strategy Based on the Knowledge-to-action Cycle.
abstract: BACKGROUND
  Enhanced Recovery After Surgery (ERAS) protocols have been shown to increase recovery, decrease complications, and reduce length of stay. However, they are difficult to implement.
  
  
  OBJECTIVE
  To develop and implement an ERAS clinical practice guideline (CPG) at multiple hospitals.
  
  
  METHODS
  A tailored strategy based on the Knowledge-to-action (KTA) cycle was used to develop and implement an ERAS CPG at 15 academic hospitals in Canada. This included an initial audit to identify gaps and interviews to assess barriers and enablers to implementation. Implementation included development of an ERAS guideline by a multidisciplinary group, communities of practice led by multidiscipline champions (surgeons, anesthesiologists, and nurses) both provincially and locally, educational tools, and clinical pathways as well as audit and feedback.
  
  
  RESULTS
  The initial audit revealed there was greater than 75% compliance in only 2 of 18 CPG recommendations. Main themes identified by stakeholders were that the CPG must be based on best evidence, there must be increased communication and collaboration among perioperative team members, and patient education is essential. ERAS and Pain Management CPGs were developed by a multidisciplinary team and have been adopted at all hospitals. Preliminary data from more than 1000 patients show that the uptake of recommended interventions varies but despite this, mean length of stay has decreased with low readmission rates and adverse events.
  
  
  CONCLUSIONS
  On the basis of short-term findings, our results suggest that a tailored implementation strategy based on the KTA cycle can be used to successfully implement an ERAS program at multiple sites.
authors.affiliation: *Department of Surgery, Mount Sinai Hospital, New York, NY †Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada ‡Department of Surgery, Toronto East General Hospital, Toronto, Ontario, Canada §Department of Anaesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada ¶Anesthesia, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada ||Department of Surgery, McMaster University, Hamilton, Ontario, Canada **Departments of Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada ††Department of Surgery, University Health Network, Toronto, Ontario, Canada ‡‡Nursing, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.
authors.forename: Robin S
authors.initials: RS
authors.lastname: McLeod
authors.forename: Mary-Anne
authors.initials: MA
authors.lastname: Aarts
authors.forename: Frances
authors.initials: F
authors.lastname: Chung
authors.forename: Cagla
authors.initials: C
authors.lastname: Eskicioglu
authors.forename: Shawn S
authors.initials: SS
authors.lastname: Forbes
authors.forename: Lesley Gotlib
authors.initials: LG
authors.lastname: Conn
authors.forename: Stuart
authors.initials: S
authors.lastname: McCluskey
authors.forename: Marg
authors.initials: M
authors.lastname: McKenzie
authors.forename: Beverly
authors.initials: B
authors.lastname: Morningstar
authors.forename: Ashley
authors.initials: A
authors.lastname: Nadler
authors.forename: Allan
authors.initials: A
authors.lastname: Okrainec
authors.forename: Emily A
authors.initials: EA
authors.lastname: Pearsall
authors.forename: Jason
authors.initials: J
authors.lastname: Sawyer
authors.forename: Naveed
authors.initials: N
authors.lastname: Siddique
authors.forename: Trevor
authors.initials: T
authors.lastname: Wood
mesh_terms: D002170:Canada; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006785:Hospitals, University; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008485:Medical Audit; D010359:Patient Readmission / Q000706:statistics & numerical data; D019990:Perioperative Care / Q000379:methods* / Q000592:standards; D017410:Practice Guidelines as Topic; D016730:Program Development; D015397:Program Evaluation; D058996:Quality Improvement; D012189:Retrospective Studies