INTRODUCTION
Enhanced Recovery After Surgery (ERAS) program, also referred to as Fast Track Surgery, continues to gain increased interest and implementation for colorectal surgeries. Initially pioneered in 2000 by Professor Kehlet and his surgical team in Copenhagen, the ERAS program combines an evidence-based, multimodal, standardized approach to reduce the stress response after surgery, decrease postoperative complications, and enhance recovery to promote early discharge.1 Traditional colonic surgery has been associated with a 15% to 20% complication rate and an average length of stay of 6 to 10 days.1 Remarkably, with the multifaceted, multidisciplinary approach of ERAS, current hospital length of stay has been dramatically reduced. Examples of the innovative patient care management provided with the ERAS program include an emphasis on preoperative education, minimally invasive surgical techniques, newer anesthetics, and aggressive postoperative rehabilitation with early enteral nutrition and ambulation.1-3
In 2006, the Best Practices in General Surgery (BPIGS) group was established with the purpose to standardize general surgical care across the University of Toronto-affiliated hospitals. To date, 6 clinical practice guidelines have been developed including ERAS, Surgical Site Infection, Mechanical Bowel Preparation, Thromboprophylaxis, Intra-Abdominal Infection and Peri-Operative Pain Management (http://www.bpigs.ca).
The ERAS evidence-based guideline for patients undergoing elective colorectal surgery was first implemented in February 2012 at 8 academic teaching hospitals in Toronto. In March 2013, the implementation was extended to 7 additional academic teaching hospitals in the province of Ontario after receiving an Adopting Research to Improve Care (ARTIC) grant from the Council of Academic Hospitals in Ontario (CAHO). All elective colorectal surgery patients with or without an ostomy were included in the ERAS program targeting a length of stay of 3 days for colon surgery and 4 days for rectal surgery.
Early within the implementation phase of the ERAS program, it was identified that the individual needs of a patient requiring an ostomy needed to be met with this new health care delivery model. Gaps were noted in nursing care in terms of efficient preoperative and postoperative ostomy education provided to patients and families within the revised, condensed length of stay as well as nursing resources available to successfully transition the care of patients into the community setting.
This new health care delivery model prompted the development of a Provincial ERAS Enterostomal Therapy Nurse (ETN) Network, led by an ETN Steering Committee. The goal of the committee was to develop best practice guidelines (BPGs) to standardize nursing care for patients requiring a fecal diversion. In November 2013, the ETN Steering Committee surveyed all 15 ERAS organizations to determine the type and level of nursing support available and the preoperative, postoperative and discharge follow-up care provided by each center (Table 1).
Results of the survey indicated provincial variation for access to experienced nursing support and consistent care for this vulnerable patient population within the acute care setting and following discharge into the community setting. Therefore, a standardized approach to ostomy education and care was needed to enhance the immediate postoperative recovery and discharge experience and promote positive patient outcomes.
PROVINCIAL ERAS-ETN NETWORK CONSENSUS MEETING
A 1-day consensus meeting was held with members of the Provincial ERAS-ETN Network to discuss the development of a standardized approach to care (Figure 1). Prior to the meeting, the ETN Steering Committee developed guiding principles to facilitate the meeting and drafted guideline recommendations for preoperative, postoperative, and discharge phases of care, based on an initial literature review. Participants were divided into 3 working groups to refine recommendations related to the respective phases of care. Following the consensus meeting, each subgroup conducted an additional independent search of the literature to support the recommendations for its respective phases. All searches were conducted using MEDLINE and CINAHL databases. Key terms searched were "ileostomy," "colostomy," "ostomy," "stoma," "enhanced recovery after surgery," "fecal diversions," "pre-operative ostomy education," "stoma site marking," and "post-operative complications." Strength of evidence was rated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool (http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=grade).
After reviewing and summarizing the literature, each subgroup finalized recommendations for its respective phases with supporting evidence where available. The Provincial ERAS-ETN Network then reviewed all documents, and a consensus on the recommendations was reached. Evidence-based recommendations for the preoperative, postoperative, and discharge phases of care were developed to meet the new targeted length of stay and need for comprehensive ostomy education. With editorial guidance, a BPG document was created and circulated to external stakeholders, followed by members of the Provincial ERAS-ETN Network for final review and feedback. The BPG will be published in a later edition of the Journal of Wound, Ostomy and Continence Nursing.
FUTURE DIRECTIONS
The Provincial ERAS-ETN Network will reconvene to identify quality indicators and discuss BPG implementation strategies by each ERAS hospital and associated community care provider. Quality indicators will be used to monitor progress during implementation and to identify areas of further study (Figure 2). Provincial implementation plans and dissemination may include oral presentations, in-service education, workshops and discussions, development of teaching material for staff nurses and patients, Web sites, newsletters, laminated cards, and posters. The implementation strategies will be guided by available resources in each area. Engaging and recruiting key stakeholders along the patient's care journey from acute care to the community are imperative to facilitate the necessary change in the delivery of nursing care.
The development of a provincial ERAS BPG for the patient having a fecal diversion that spans the continuum of care will standardize management of this specialized patient population. The work of this group has been supported by the BPIGS Steering Committee. This work was not driven by a single facility but rather by the vision and collaboration of ET nurses committed to improve the care and experience of patients in an ERAS program. Participants have relished the opportunity to learn from one another and feel supported in the work that they do on an ongoing basis in both the hospital and the community setting.
There were some challenges in the development of the guidelines, in particular the time taken to produce and edit the guidelines, given multiple authors. Competing workload demands was also a factor in meeting established deadlines. Participants also found a paucity of strong levels of evidence at this point in time. It was also recognized that moving forward, there needs to be more engagement of community ET nurses and community care leaders involved in the implementation phase in order for this initiative to be fully supported and executed.
REFERENCES