title: Facilitators and barriers of implementing enhanced recovery in colorectal surgery at a safety net hospital: A provider and patient perspective.
abstract: BACKGROUND
  Enhanced Recovery After Surgery (ERAS) pathways are known to decrease complications and duration of stay in colorectal surgery patients. However, it is unclear whether an ERAS pathway would be feasible and effective at a safety-net hospital. The aim of this study was to identify local barriers and facilitators before the adoption of an ERAS pathway for patients undergoing colorectal operations at a safety-net hospital.
  
  
  METHODS
  Semistructured interviews were conducted to assess the perceived barriers and facilitators before ERAS adoption. Stratified purposive sampling was used. Interviews were audiotaped, transcribed verbatim, and analyzed using content analysis. Analytic and investigator triangulation were used to establish credibility.
  
  
  RESULTS
  Interviewees included 8 anesthesiologists, 5 surgeons, 6 nurses, and 18 patients. Facilitators identified across the different medical professions were (1) feasibility and alignment with current practice, (2) standardization of care, (3) smallness of community, (4) good teamwork and communication, and (5) caring for patients. The barriers were (1) difficulty in adapting to change, (2) lack of coordination between different departments, (3) special needs of a highly comorbid and socioeconomically disadvantaged patient population, (4) limited resources, and (5) rotating residents. Facilitators identified by the patients were (1) welcoming a speedy recovery, (2) being well-cared for and satisfied with treatment, (3) adequate social support, (4) welcoming early mobilization, and (5) effective pain management. The barriers were (1) lack of quiet and private space, (2) need for more patient education and counseling, and (3) unforeseen complications.
  
  
  CONCLUSIONS
  Although limited hospital resources are perceived as a barrier to ERAS implementation at a safety-net hospital, there is strong support for such pathways and multiple factors were identified that may facilitate change. Inclusion of patient perspectives is critical to identifying challenges and facilitators to implementing ERAS changes focused on optimizing patient perioperative health and outcomes.
authors.affiliation: Department of General Surgery, The University of Texas Health Science Center, Houston, TX; Center for Surgical Trials and Evidence-based Practice, The University of Texas Health Science Center, Houston, TX.
authors.forename: Zeinab M
authors.initials: ZM
authors.lastname: Alawadi
authors.affiliation: Department of General Surgery, The University of Texas Health Science Center, Houston, TX; Integrative Medicine Program, Department of General Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX.
authors.forename: Isabel
authors.initials: I
authors.lastname: Leal
authors.affiliation: Department of General Surgery, The University of Texas Health Science Center, Houston, TX; Center for Surgical Trials and Evidence-based Practice, The University of Texas Health Science Center, Houston, TX.
authors.forename: Uma R
authors.initials: UR
authors.lastname: Phatak
authors.affiliation: Department of General Surgery, The University of Texas Health Science Center, Houston, TX.
authors.forename: Juan R
authors.initials: JR
authors.lastname: Flores-Gonzalez
authors.affiliation: Department of General Surgery, The University of Texas Health Science Center, Houston, TX; Center for Surgical Trials and Evidence-based Practice, The University of Texas Health Science Center, Houston, TX.
authors.forename: Julie L
authors.initials: JL
authors.lastname: Holihan
authors.affiliation: Department of General Surgery, The University of Texas Health Science Center, Houston, TX.
authors.forename: Burzeen E
authors.initials: BE
authors.lastname: Karanjawala
authors.affiliation: Department of General Surgery, The University of Texas Health Science Center, Houston, TX.
authors.forename: Stefanos G
authors.initials: SG
authors.lastname: Millas
authors.affiliation: Department of General Surgery, The University of Texas Health Science Center, Houston, TX; Center for Surgical Trials and Evidence-based Practice, The University of Texas Health Science Center, Houston, TX. Electronic address: Lillian.S.Kao@uth.tmc.edu.
authors.forename: Lillian S
authors.initials: LS
authors.lastname: Kao
mesh_terms: D001291:Attitude of Health Personnel; D003107:Colorectal Surgery / Q000592:standards* / Q000639:trends; D019091:Critical Pathways / Q000458:organization & administration*; D003430:Cross-Sectional Studies; D005260:Female; D006769:Hospitals, General; D006801:Humans; D007407:Interviews as Topic; D007902:Length of Stay; D008297:Male; D017063:Outcome Assessment, Health Care; D010348:Patient Care Team / Q000458:organization & administration; D010351:Patient Discharge; D017060:Patient Satisfaction / Q000706:statistics & numerical data*; D011182:Postoperative Care / Q000379:methods; D011300:Preoperative Care / Q000379:methods; D064876:Safety-net Providers / Q000458:organization & administration*; D013781:Texas; D013997:Time Factors