CONTINUING EDUCATION
Successful Implementation of an
Enhanced Recovery Pathway:
The Nurses Role 1.9
KAREN M. BRADY, MSN, APRN-BC; DEBORAH S. KELLER, MS, MD;
CONOR P. DELANEY, MD, MCh, PhD, FRCSI, FACS, FASCRS
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Purpose/Goal
To provide the learner with knowledge specic to the nurses
role in implementing an enhanced recovery pathway (ERP) of
patient care.
Objectives
1. Discuss the ERP care model.
2. Describe the steps to implement an ERP for patients un-
dergoing abdominal surgery.
3. Describe the nurses role in implementing an ERP.
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education by the American Nurses Credentialing Centers
Commission on Accreditation.
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Conict-of-Interest Disclosures
Karen M. Brady, MSN, APRN-BC; Deborah S. Keller, MS,
MD; and Conor P. Delaney, MD, MCh, PhD, FRCSI,
FACS, FASCRS, have no declared afliations that could be
perceived as posing potential conicts of interest in the pub-
lication of this article.
The behavioral objectives for this program were created by
Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor,
with consultation from Susan Bakewell, MS, RN-BC, director,
Perioperative Education. Ms Starbuck Pashley and Ms Bakewell
have no declared afliations that could be perceived as posing
potential conicts of interest in the publication of this article.
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article.
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mentioned in the activity.
AORN Journal j 469
Successful Implementation of an
Enhanced Recovery Pathway:
The Nurses Role 1.9 www.aorn.org/CE

KAREN M. BRADY, MSN, APRN-BC; DEBORAH S. KELLER, MS, MD;

CONOR P. DELANEY, MD, MCh, PhD, FRCSI, FACS, FASCRS

ABSTRACT
Enhanced recovery pathways (ERPs) are standardized, multidisciplinary approaches to caring for pa-
tients with a goal of decreasing length of stay and care costs without negatively affecting patient
outcomes. One facility successfully implemented ERPs for patients undergoing abdominal surgery. For
implementation to be successful, nurses were found to be key in providing education, perioperative
care, and postoperative evaluation, as well as cost containment. The implementation team collabo-
rated to dene, design, implement, and audit an ERP for surgical services. Initial audits demonstrated
an increase in compliance with order set use (61% to 93%) and use of ERPs more than standardized
order sets (< 1% to 27%), as well as decreased use of daily laboratory orders (94% to 62%) and
elimination of automatically ordered laboratory tests (38% to 0%). These results led to the conclusion
that the nurses role is essential for education and successful use of the pathways and that best
practices for developing ERPs requires consistency across the care team, diligence to ensure
compliance, and use of an audit tool for quality improvement. AORN J 102 (November 2015) 470-478.
AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2015.08.015
Key words: enhanced recovery, care pathway, ERP, colorectal surgery, patient education.

I n the traditional care model for surgical services, sur-

geons, anesthesia professionals, and nurses deliver care in
individual silos. Enhanced recovery pathways (ERPs) are
standardized, multidisciplinary approaches to caring for pa-
tients; they represent a paradigm shift away from the tradi-
tional model of care to guide the entire health care team
toward working together to ensure positive patient outcomes.
The goals of the perioperative ERP model are to integrate all
elements of preoperative, intraoperative, and postoperative
patient care and to provide education that empowers patients
and their caregivers to better understand and participate in the
recovery process, as well as decrease length of stay and care
costs. At our facility, use of ERPs has improved the effec-
tiveness of patient care, accelerated recovery, reduced length of
470 j AORN Journal
stay without compromising safety or increasing readmission
rates, and optimized health care use for patients undergoing
colorectal surgery.1-6 To realize these clinical and nancial
benets, more hospitals and health care providers are consid-
ering introducing ERPs into their practice; however, the
implementation process is not well described.
Since the early 2000s, our colorectal surgery division has
developed, implemented, and rened a multimodal ERP. We
focused on the population of patients undergoing colorectal
surgery as a representative sample of patients undergoing
abdominal surgery. Our progress with ERPs has been previ-
ously reported.7-11 In our experience, one component we have
found to be essential for successful implementation is nursing
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November 2015, Vol. 102, No. 5
assistance. The exact needs, roles, and contributions of nurses
have not been dened previously. The purpose of this article is
to describe steps we took to successfully implement ERPs in
surgical services and to identify the important role nurses play
in providing preoperative education, perioperative care, and
postoperative evaluation and in contributing to the overall
success of ERPs.
METHODS OF CREATING AND
IMPLEMENTING ERPS
Our team takes three primary steps to implementing ERPs in
our surgical setting. The rst step is dening the population
and surgical service areas to be involved. For our project, we
dened surgical specialties as those that provided abdominal
surgery and included the following in the analysis:
 colorectal surgery,
 general surgery,
 surgical oncology,
 gynecologic oncology,
 urology, and
 hepatobiliary surgery.
Extended recovery pathways have been used successfully in the
colorectal patient population and have demonstrated decreased
length of stay, complications, readmissions, and costs.7-11 We
replicated the ERP principles across each surgical specialty
within the Department of Surgery in an attempt to realize the
same benets. The service areas identied to participate in
pathway implementation were
 laparoscopic procedures,
 open procedures,
 upper gastrointestinal procedures,
 same-day observation procedures,
 perioperative care, and
 miscellaneous procedures.
We chose these service areas because all procedures performed
were easily grouped under these broad categories across all
divisions.
The second step is to dene the care processes under each
surgical service area that required ERPs. In our division, we
identied six care pathways: one preoperative pathway, four
surgical care pathways, and one patient experience pathway.
The preoperative pathway typies the stages of comprehensive
patient preparation. The standards established included
criteria for
 preoperative patient consultation,
 day of surgery care,
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Implementation of an Enhanced Recovery Pathway
 time in the preoperative holding area, and
 anesthesia and surgical components of the patient
experience.
In the surgical services department, care providers obtain
baseline information that includes laboratory tests and re-
sults, anesthesia patient optimization, a frailty score (eg,
patients are rated from very t to terminally ill based on their
activity levels and comorbidities), and a retrospective grade of
tness score12 (Figure 1), which helps identify patients who
may not progress quickly after surgery and helps clinicians
anticipate the patients needs at the time of discharge.
During the preoperative visit, the health care team reviews
specic information with the patient and his or her family
members regarding what to expect during the hospital
experience.
We developed four surgical care pathways (ie, day cases/
overnight abdominal cases, major laparoscopic abdominal,
major open abdominal, upper gastrointestinal abdominal) that
outlined a standardized regimen of early diet progression; early
ambulation; consistent medication choices, including opioid-
sparing medications; and limited use of tubes, drains, and
blood draws. We also established a miscellaneous care pathway
to standardize approaches to common postoperative compli-
cations. This included criteria for blood transfusion,13 wound
infection management, disposition issues at discharge, and
discharge criteria. The most important of these is the criteria
for discharge because, in our experience, it is helpful to
outline discharge criteria at the onset of the patient
experience. Patients are considered appropriate candidates for
discharge after they can tolerate some diet, are experiencing
pain relief with oral pain medications, are passing atus or
having bowel movements, and are ready and amenable to
being discharged home.2 In conjunction with the care
pathways, we have set up other standard approaches that
have been implemented to minimize complications and
added days for unnecessary procedures. Care providers start
discharge planning at the beginning of the hospital
experience to minimize last-minute planning and delays
in discharge.
The third step is the process of designing ERPs. Coordination
on many fronts is essential to develop the necessary order sets.
Our design team includes medical content experts, electronic
medical record (EMR) personnel, and pharmacists. The hos-
pitals quality team members also ensure that the order sets
include all necessary documentation. After developing the
order sets, and after they are approved and implemented, it is
essential that the multidisciplinary care team members
embrace these as the new standard of care. A process map
AORN Journal j 471
print & web 4C=FPO
Brady et al
Figure 1. Retrospective grade of tness score calculated from review of the patients medical record to help assess
the patients needs at discharge.
illustrating the patient experience from the initial consultation
to discharge is recorded in precise detail in Table 1. We give a
copy of this table to residents as they rotate onto our service,
and we also use this to educate nurses to become more familiar
with our care pathways and as a way to explain our process. A
copy of this pathway is also available on our hospital internal
intranet for reference. As part of the ERP design process, we
identied evidence-based best practices, general standards,
and specic variables for each pathway. Each surgeon was
given the opportunity to weigh in on the process; a
consensus of all surgeons was reached to facilitate successful
implementation of this project. Our standardized ERPs for
all surgical services include
472 j AORN Journal
November 2015, Vol. 102, No. 5
 establishing a preoperative education plan for patients and
their family members;
 implementing a standardized preoperative plan (eg, high-
protein drink, no bowel prep for colon resections in
selected patients);
 minimizing the administration of intraoperative IV uids;
 ensuring early removal of nasogastric tubes;
 avoiding postoperative drains;
 introducing food early in the postoperative period;
 facilitating early postoperative ambulation (ie, the night of
surgery);
 converting patients to taking oral pain medications as
quickly as possible;
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Table 1. Process Map Illustrating the Patient Experience

Preoperative Evaluation Before Surgery Perioperative Holding Area OR Induction Anesthesia Surgery

 Provide procedure or
surgical service information
on expectations for surgery 
and length of stay
 Explain what to bring from 
home (eg, sleepwear, robe,
slippers, other comfortable
clothing)
 Perform preadmission
testing complete with grade
of tness score/
retrospective grade of
tness score to anticipate
needs
at the time of discharge
 Perform baseline laboratory
tests, including
o type and screen for
antibiotic allergies or
o type and cross for blood,
depending on the
procedure
 Glucose-controlled drink the  Gabapentin 300 mg one to Antibiotics  Monitor  Standardize
evening before OR two hours before surgery o during patients o wound closure
Bowel prep (elective) as  Alvimopan 12 mg one to two hours induction temperature o electrosurgical
directed before laparoscopic colon resection o every four  Maintain device use
Gabapentin 150 mg to 300 mg procedures with a high risk of hours normothermia  Open disposable
three times per day (TID) three conversion intraoperatively  Limit IV uids products only
days preoperatively (hold if it  Bowel preparation (if required) as needed  Albumin when required
causes dizziness)  Thromboprophylaxis o then stop protocols  Consider
 Modied Nichols oral antibiotic o heparin 5,000 units Corticosteroid  Ask about transversus
bowel prep service specic (ie, subcutaneously TID pulse for repeat abdominis plane
neomycin and metronidazole) o antithromboembolism stockings corticosteroid- antibiotics at block
or sequential compression dependent four hours
devices two hours preoperatively patients
IV acetaminophen
1,000 mg up to
four doses
 Ketorolac 15 to 30
mg IV depending
on renal function

Implementation of an Enhanced Recovery Pathway

 Provide standard
postoperative prescriptions
o oral antibiotics
o anti-inammatory
medications
 Provide
o standardized handout
information in written
format
o night before surgery: diet,
medications, selective
bowel preparation
AORN Journal j 473

o day of surgery
information: parking,
check-in location
o welcome guide
Brady et al
 choosing consistent medications, including opioid-sparing
medications; and
 performing laboratory blood draws every other day.
PERIOPERATIVE EDUCATION
Perioperative education for patients and their family members is
essential for successful navigation through the surgical experi-
ence. There are limited studies that address the benets of ed-
ucation before surgery; however, evidence shows preoperative
teaching conducted before hospital admission is most success-
ful.14 After the plan for surgery is conrmed, the patient should
begin to receive information from his or her medical team. The
education that the patient receives in the ofce will set the tone
for the surgical experience. The goal of an effective patient
education plan is to inform the patient and his or her family
members about what to expect during each phase of the
experience. Patients often worry about how long they will be
hospitalized, types of dressings, driving restrictions, and when
they can return to work and household activities, among
other things. The goal of education is to address these stresses
and help the patient adequately prepare for and anticipate
needs during recovery. A comprehensive education plan helps
the patient and caregivers engage in the process to prepare for
the surgical experience.
At our institution, an Abdominal Surgery Patient Education
Booklet is used to educate patients and their family members
about their surgical experience. A committee of three surgical
nurse practitioners and two members of the Patient Education
Department worked to create a comprehensive guide to help
patients and their caregivers successfully navigate through the
surgical experience from the preoperative period to discharge.
Committee members gave each abdominal surgeon the op-
portunity to review and amend the patient education materials
before nalizing them. The team used health literacy software
to ensure the materials were printed at a basic comprehension
level and that all patients could benet from this patient in-
formation. The nurses working in the surgeons ofce provide
the booklet to all preoperative patients, and it is also available
for direct download from the hospital intranet.
The stress of a new diagnosis or the realization that surgery is
necessary can prevent a patient from absorbing essential in-
formation presented verbally during consultation. Repetition
of this information by multiple members of the health care
team, including the nurse, helps the patient retain key items
needed for his or her recovery. The use of written materials
and audio-visual materials also enables the patient to review
the education materials several times before surgery to help
ensure understanding.15
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November 2015, Vol. 102, No. 5
With pressure on hospital personnel to reduce length of stay,
there is an increasing responsibility for patient care that falls
onto families and caregivers at the time of discharge. As a
result, there is greater emphasis on educating patients and
members of their support system about what to expect.
Further, promoting their involvement will aid in the success of
ERPs.16 Including caregivers in the education process helps
minimize stress and provides patients and their family
members with more realistic expectations to better prepare
for the transition to home.15
Fluid Management
Before admission, nurses instruct patients to drink high-
protein drinks and encourage them to stay hydrated the day
before surgery.2,16 High-protein drinks prevent catabolism
that occurs when patients are not eating or drinking because of
diet limitations during the perioperative period. Intake of
high-protein drinks minimizes this process. The nurses review
the information on the protein drinks with the patient when
the patient is given the preoperative paperwork about surgery.
To promote hydration, surgeons are discouraged from
ordering routine bowel preparation for patients undergoing
bowel resection because of the risk of postoperative electrolyte
imbalance and lack of efcacy. Close monitoring of intra-
operative uid administration prevents hypovolemia or vol-
ume overload after surgery. Gustafsson et al16 reported a
benet associated with intraoperative uid sparing; in their
study, 32% of participants experienced increased
postoperative complications with each added liter of
crystalloid. For infusion, anesthesia professionals prefer to
administer crystalloids because there are lower incidences of
volume overload and infection with crystalloid use compared
with colloid use.2,17
INTRAOPERATIVE CARE
The perioperative nursing staff members also are educated
about and participate in the intraoperative and postoperative
stages of the multimodal pathway. The intraoperative care
measures provided by nurses include verifying the correct pa-
tient, procedure, and site, if applicable, with the patient and
reinforcing education about the planned procedure. The nurses
help ensure that a proper time-out procedure is performed,
antibiotics and antithrombotic agents are administered in a
timely fashion, and the patient is positioned and secured
appropriately. In keeping with cost containment efforts, nurses
select reusable equipment (eg, laparoscopic ports) and, to avoid
waste, do not open instruments (eg, energy devices, staplers)
until the surgeon requests them. Opioid-sparing pain manage-
ment is used even in the OR, and nurses participate in
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November 2015, Vol. 102, No. 5
administration of transversus abdominis plane blocks before the
end of the procedure. Before transporting the patient to the
postanesthesia care unit (PACU), the nurse assesses the patients
skin and temperature. In the PACU, the perioperative nurse
provides a standardized hand-over report to ensure that perti-
nent information is provided to the PACU RN.
POSTOPERATIVE CARE
In the PACU, nurses play a key role in patient pain man-
agement and satisfaction. Even at the early postoperative stage,
by using standardized ERPs, nurses can directly affect the
reduction of postoperative infections and ileus and facilitate
the patients safe and timely hospital stay. By following ERPs,
nurses are empowered to discontinue use of Foley catheters,
reduce IV uids, change pain medication from IV to PO,
discontinue patient-controlled analgesia, and advance patients
diets. The physicians have the option to alter orders, but to do
this they must manually uncheck the standardized order and
address any option that deviates from the standard-
ized pathway.
Nursing Orders and Interventions
One way to measure the success of ERPs is through the use of
postoperative order sets, which have standardized nursing or-
ders and interventions. All patients have orders to be out of
bed a minimum of two times per day, as their condition al-
lows. Ambulation at least ve times per day in the hallways is
also prescribed.2 Early activity is benecial in preventing
complications such as deep vein thrombosis, pulmonary
embolism, and pneumonia. It is also benecial in limiting
deconditioning, especially in older patients. Other patient
care ordersdsuch as helping patients to use incentive
spirometry and sequential compression devices; accurately
recording intake, output, and daily weights; and knowing
when to call the care providerdare also detailed in ERPs.
The patient orders require that indwelling Foley catheters be
removed on postoperative day one for patients who have
undergone laparoscopic procedures and by postoperative day
two for patients who have undergone open abdominal
procedures. Catheter removal is important to minimize the
risk of infection. Patients are also more likely to get out of
bed and ambulate after catheters are removed.
Diet
The care team reduces maintenance IV rates and introduces
oral uids after the patient arrives in the postoperative unit.
Diets are automatically advanced based on specic care path-
ways. For example, using the major laparoscopic abdominal
order set, nurses offer liquids the night of surgery as tolerated
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Implementation of an Enhanced Recovery Pathway
to patients undergoing laparoscopic surgery and provide them
automatically on postoperative day one. If liquids are tolerated,
patients then advance to a soft diet. In the major open
abdominal surgery care pathway, nurses provide patients with
ice chips initially and then automatically advance their diet to
clear liquids on postoperative day one and a soft diet on
postoperative day two. Patients are instructed that drinking
uids is more important than eating, and nurses instruct them
to take a few bites initially rather than attempt a full meal.
Small, frequent meals are encouraged for better diet tolerance.
All patients are offered a high-calorie drink after surgery in the
care unit to which they are transferred. Because diets are
predated and will change automatically per the standardized
orders, it is the responsibility of the medical team to make
individual adjustments to address specic patient needs. In our
experience, the postoperative day on which a diet is introduced
is the fundamental difference between ERPs and other care
regimens across abdominal specialties and varies depending on
the procedure performed.
After the patient tolerates his or her diet and achieves adequate
oral intake, nursing personnel automatically discontinue IV
uids. The care team also encourages patients to chew sugar-
free gum at least three times per day. Studies have shown that
the sorbitol in sugar-free gum enhances return of bowel
function.2,18-25 In our institution, nutrition services and
pharmacy personnel are unable to dispense gum to our pa-
tients, so team members in the different surgical services
purchase the gum and absorb the cost.
Medication
Nurses in the PACU actively survey the patient for pain using
pain scores and use nonopioid postsurgical pain management
strategies according to the ERPs, with opioids as needed for
pain relief. Acetaminophen and ibuprofen are routinely or-
dered medications for mild pain, and oxycodone is ordered for
moderate or severe pain. Through patient assessment, nurses
use their judgement to determine which medication will meet
the patients need for pain medication. Standardization of
medication orders minimizes choices and ensures better
compliance with care pathways and evidence-based practice.
Enhanced recovery pathways use medications that have been
found to be effective, reduce the use of a wide variety of
expensive medications, and control costs. Patient-controlled
analgesia pumps are only used overnight on the day of sur-
gery or until patients are able to tolerate oral uids. The care
team initiates oral opioid analgesics on postoperative day one
or as soon as the patient can tolerate liquids. Oral opioid
analgesics and alternatives to opioid analgesics are also avail-
able on the order sets. Acetaminophen is routinely ordered
AORN Journal j 475
Brady et al
Table 2. 2013-2014 Audit Results Showing Compliance and Outcome Changes
December 2013
18 procedures were reviewed from ve surgical services
Percent of patients cared for using
 Enhanced recovery pathway (ERP) order setsd61%
 Documented daily laboratory testsd94%
 Repeating order setsd38%
 Daily repeating laboratory tests at the time of the initial
order setd16%
 Used order sets as writtend< 1% (1/18)
 Diets that did not follow the ERP set as written and
were advanced more quicklyd< 50%
 Wrong order set used (ie, after one Whipple
procedure)d< 1% (1/18)
 IV acetaminophen used correctly, but diets were
advanced sooner than oral medications had been
ordereddpercentage not available
around the clock unless contraindicated. Ibuprofen, gaba-
pentin, and ketorolac also are available as a multimodal pain
control regimen with the goal of limiting narcotics, which
delay return of bowel function.
Laboratory Tests
Excessive orders for laboratory tests are wasteful. To minimize
these costs, daily automatic laboratory tests are discouraged in
ERPs. Blood draws for tests, including complete blood count
and basic metabolic panels, are ordered automatically every
other day. When more frequent laboratory studies are needed,
the physician or nurse practitioner may order them separately.
MEASURING RESULTS
Successful use of ERPs requires a multidisciplinary team
approach. All providers must work cohesively to accomplish the
goals of enhanced recovery, and nurses play a vital role in suc-
cessful implementation. By working alongside the patient during
his or her hospital stay, the nurse is able to provide continuity of
care and consistent reinforcement of ERP components. The role
of the nurse or nurse practitioner also is important for patient
education. Although physicians advise patients of their diagnosis
and planned procedures, nurses spend the majority of their time
caring for and instructing patients and their family members and
reinforcing information passed on by the physician. This edu-
cation is best given before surgery and hospital admission. A
meta-analysis by Stern and Lockwood14 documented the
benets of preoperative education and knowledge retention
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November 2015, Vol. 102, No. 5
June 2014
15 procedures reviewed from ve surgical services
Percent of patients cared for using
 ERP order setsd93%
 Documented daily laboratory testsd62%
 Repeating order setsd0%
 Daily repeating laboratory tests at the time of the initial
order setd< 10%
 Used order sets as writtend27% (4/15)
 Diets that did not the follow ERP set as written and were
advanced more quicklydpercentage not available
 Wrong order set used (ie, after major laparoscopic procedure
and enhanced recovery program)d< 1% (1/15)
 IV acetaminophen per order setd13% (approximately 2/15) of
patients did not receive IV acetaminophen, and 46% (7/15)
of patients received less than the four doses ordered
from preoperative patient information. The investigators found
that patients who received preoperative education stayed in
the hospital for 1.5 fewer days. Ronco et al15 found that
patient information provided before surgery and reviewed after
admission proved to be more effective than information solely
received before surgery.15 Results from Stern and Lockwood14
revealed that patients who received preoperative education
were able to recall information and perform skills more
quickly than those who did not receive preoperative
education.14 These ndings reinforce the importance of
preoperative patient education and emphasize the benets of
repetition for patient recall and positive outcomes.
The success of ERPs is based on adherence to the protocols
and reducing variation in patient care.26 Studies have
demonstrated improved patient outcomes, including
decreased length of stay, with adherence to ERPs.2,16,26 All
members of the health care team should take an active role
to ensure they understand ERP principles and can provide
consistent care on all levels. We developed an independent
learning education module to explain the EMR order sets.
Nurses also attended an inservice program on the individual
components of the care pathways and standardized
postoperative orders to ensure a thorough understanding of
the plan of care. For our ERPs, we are developing audit
tools to study adherence to protocols. Six months after our
ERP order sets were released into practice, we captured a
snapshot audit of data at two separate points to determine
use in the EMR and identify teaching opportunities (Table 2).
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November 2015, Vol. 102, No. 5
Our snapshot audit focused on a few key areas: ERP order set
use, laboratory test ordering practices, use of diet orders that
adhered to the pathway, and use of order sets without modi-
cations. Despite our small samples (ie, 18 procedures at the
rst time point and 15 procedures at the second time point),
we were able to capture useful information. In our rst
snapshot completed in December 2013, we found that 61% of
the charts reviewed used ERP order sets for postoperative
orders, compared with an improved 93% in our second
sampling in June 2014. Laboratory tests were ordered daily,
despite the every-other-day recommendation, in 94% of charts
reviewed in December, compared with 62% in June. Initially,
38% of the charts reviewed had daily laboratory tests ordered
for the entire hospital stay, using an auto-order feature. In
June 2014, we found that no repeating laboratory tests were
ordered. Lastly, we looked at the number of charts that used
the order sets as designed without modication. We found
that use of the standardized ERP order set as written improved
from less than 1% to 27%.
From this sampling, we saw signicant improvement in order
set use and compliance with the standardized care plan.
However, there are continued areas of improvement needed,
including education and ERP awareness. Since this snapshot,
education sessions with the resident teams and nurses have
occurred, and future order set compliance audits are planned.
Adherence to ERPs requires time and resources to educate
personnel and to change practice, but even early audits show
the benets of this care pathway.
CONCLUSION
Enhanced recovery pathways are a multidisciplinary, stan-
dardized approach to caring for patients undergoing abdom-
inal surgery. The goals of ERPs are to decrease length of stay
and decrease care costs without affecting patient outcomes or
increasing complications. The nurses role is essential for
providing education and following the pathways successfully.
With proper planning and education of patients, their family
members, and health care team members, the benets of ERPs

can outweigh the costs of implementation and dramatically
improve patient and nancial outcomes.
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7. Delaney CP, Fazio VW, Senagore AJ, Robinson B, Halverson AL,
Remzi FH. Fast track postoperative management protocol for
patients with high co-morbidity undergoing complex abdominal
and pelvic colorectal surgery. Br J Surg. 2001;88(11):1533-1538.
8. Delaney CP, Zutshi M, Senagore AJ, Remzi FH, Hammel J,
Fazio VW. Prospective, randomized, controlled trial between a
pathway of controlled rehabilitation with early ambulation and diet
and traditional postoperative care after laparotomy and intestinal
resection. Dis Colon Rectum. 2003;46(7):851-859.
9. Senagore AJ, Duepree HJ, Delaney CP, Brady KM, Fazio VW.
Results of a standardized technique and postoperative care plan
for laparoscopic sigmoid colectomy: a 30-month experience. Dis
Colon Rectum. 2003;46(4):503-509.
10. Delaney CP. Outcome of discharge within 24 to 72 hours after
laparoscopic colorectal surgery. Dis Colon Rectum. 2008;51(2):
181-185.
11. Delaney CP, Brady K, Woconish D, Parmar SP, Champagne BJ.
Towards optimizing perioperative colorectal care: outcomes for
1,000 consecutive laparoscopic colon procedures using enhanced
recovery pathways. Am J Surg. 2012;203(3):353-356.
12. Keller DS, Bankwitz B, Nobel T, Delaney CP. Using frailty to predict
who will fail early discharge after laparoscopic colorectal surgery
with an established recovery pathway. Dis Colon Rectum. 2014;
57(3):337-342.
13. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for
acute upper gastrointestinal bleeding. N Engl J Med. 2013;368(1):
11-21.
14. Stern C, Lockwood C. Knowledge retention from preoperative
patient information. Int J Evid Based Healthc. 2005;3(3):45-63.
15. Ronco M, Iona L, Fabbro C, Bulfone G, Palese A. Patient education
outcomes in surgery: a systematic review from 2004 to 2010. Int
J Evid Based Healthc. 2012;10(4):309-323.
16. Gustafsson UO, Scott MJ, Schwenk W, et al; Enhanced Recovery
After Surgery (ERAS) Society for Perioperative Care, European
Society for Clinical Nutrition and Metabolism (ESPEN), International
Association for Surgical Metabolism and Nutrition (IASMEN).
Guidelines for perioperative care in elective colonic surgery:
Enhanced Recovery After Surgery (ERAS(R)) Society recommen-
dations. World J Surg. 2013;37(2):259-284.
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17. Mythen MG, Swart M, Acheson N, et al. Perioperative uid
management: consensus statement from the enhanced recovery
partnership. Perioper Med (Lond). 2012;1:2.
18. Abd-El-Maeboud KH, Ibrahim MI, Shalaby DA, Fikry MF. Gum
chewing stimulates early return of bowel motility after caesarean
section. BJOG. 2009;116(10):1334-1339.
19. Asao T, Kuwano H, Nakamura J, Morinaga N, Hirayama I, Ide M.
Gum chewing enhances early recovery from postoperative ileus
after laparoscopic colectomy. J Am Coll Surg. 2002;195(1):
30-32.
20. Bahena-Aponte JA, Cardenas-Lailson E, Chavez-Tapia N, Flores-
Gama F. [Usefulness of chewing gum for the resolution of post-
operative ileus in left colon resections.]. Rev Gastroenterol Mex.
2010;75(4):369-373.
21. Chan MK, Law WL. Use of chewing gum in reducing postoperative
ileus after elective colorectal resection: a systematic review. Dis
Colon Rectum. 2007;50(12):2149-2157.
22. de Castro SM, van den Esschert JW, van Heek NT, et al.
A systematic review of the efcacy of gum chewing for the
amelioration of postoperative ileus. Dig Surg. 2008;25(1):39-45.
23. Fitzgerald JE, Ahmed I. Systematic review and meta-analysis of
chewing-gum therapy in the reduction of postoperative paralytic
ileus following gastrointestinal surgery. World J Surg. 2009;
33(12):2557-2566.
24. Noble EJ, Harris R, Hosie KB, Thomas S, Lewis SJ. Gum chewing
reduces postoperative ileus? A systematic review and meta-
analysis. Int J Surg. 2009;7(2):100-105.
25. Yeh YC, Klinger EV, Reddy P. Pharmacologic options to prevent
postoperative ileus. Ann Pharmacother. 2009;43(9):1474-1485.
478 j AORN Journal
November 2015, Vol. 102, No. 5
26. Cakir H, van Stijn MF, Lopes Cardozo AM, et al. Adherence to
enhanced recovery after surgery and length of stay after colonic
resection. Colorectal Dis. 2013;15(8):1019-1025.
Karen M. Brady, MSN, APRN-BC, is a nurse practi-
tioner in the Division of Colorectal Surgery, Department
of Surgery, University Hospitals-Case Medical Center,
Cleveland, OH. Ms Brady has no declared afliation that
could be perceived as posing a potential conict of
interest in the publication of this article.
Deborah S. Keller, MS, MD, was a research fellow
for the Division of Colorectal Surgery, Department of
Surgery, University Hospitals-Case Medical Center,
Cleveland, OH, at the time this article was written.
Dr Keller has no declared afliation that could be
perceived as posing a potential conict of interest in
the publication of this article.
Conor P. Delaney, MD, MCh, PhD, FRCSI, FACS,
FASCRS, is a surgeon in the Division of Colorectal Sur-
gery, Department of Surgery, University Hospitals-Case
Medical Center, Cleveland, OH. Dr Delaney has no
declared afliation that could be perceived as posing
a potential conict of interest in the publication of this
article.
www.aornjournal.org
EXAMINATION

Continuing Education:
Successful Implementation of an
Enhanced Recovery Pathway:
The Nurses Role 1.9 www.aorn.org/CE

PURPOSE/GOAL
To provide the learner with knowledge specic to the nurses role in implementing an enhanced
recovery pathway (ERP) of patient care.

OBJECTIVES
1. Discuss the ERP care model.
2. Describe the steps to implement an ERP for patients undergoing abdominal surgery.
3. Describe the nurses role in implementing an ERP.

The Examination and Learner Evaluation are printed here for your convenience. To receive
continuing education credit, you must complete the online Examination and Learner Evaluation
at http://www.aorn.org/CE.

QUESTIONS 4. The rst step to implementing an ERP in the surgical

1. Enhanced recovery pathways are standardized, multidis- setting is
ciplinary approaches to caring for patients. a. dening the patient population and surgical service
a. true b. false areas involved.
b. identifying the cost of implementation.
2. Enhanced recovery pathways represent __________ the c. dening the care processes that require ERPs.
traditional model of care to guide the entire health care d. identifying which care providers will participate.
team toward working together to ensure positive patient
5. The second step to implementing an ERP in the surgical
outcomes.
setting is
a. a paradigm shift toward
a. dening the patient population and surgical service
b. a paradigm shift away from
areas involved.
c. an adherence to
b. identifying the cost of implementation.
d. an adherence to nurse-led care in line with
c. dening the care processes that require ERPs.
d. identifying which care providers will participate.
3. The goals of the perioperative ERP model are to
1. empower patients and their caregivers. 6. When developing surgical care pathways, some important
2. integrate all the elements of perioperative care. standardized regimens include
3. provide patient education. 1. early diet progression.
a. 1 and 2 b. 1 and 3 2. early ambulation.
c. 2 and 3 d. 1, 2, and 3 3. consistent medication choices.

www.aornjournal.org AORN Journal j 479

Brady et al November 2015, Vol. 102, No. 5

4. use of opioid-sparing medications. 4. administering antithrombotic agents.

5. wound infection management. 5. limiting the use of tubes, drains, and blood draws.
6. limited use of tubes, drains, and blood draws. a. 1, 3, and 5 b. 1, 2, 3, and 4
a. 1, 3, and 5 b. 2, 4, and 6 c. 2, 3, 4, and 5 d. 1, 2, 3, 4, and 5
c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6
9. Opioid-sparing pain management is not used in the OR,
7. Nurses can contribute to improving a patients surgical and nurses do not participate in the administration of
experience by transversus abdominis plane blocks.
1. providing information only about discharge. a. true b. false
2. helping patients and their caregivers successfully
navigate the surgical experience. 10. Patient care orders that nurses are responsible for carrying
3. providing education only to patients. out include
4. creating a comprehensive perioperative education 1. helping patients to use incentive spirometry.
plan. 2. recording accurate intake and output and daily
a. 2 and 4 b. 1 and 3 weights.
c. 1, 2, and 4 d. 1, 2, 3, and 4 3. assisting patients in using sequential compression
devices.
8. Intraoperative care measures provided by nurses include 4. removing indwelling Foley catheters as ordered.
1. performing a proper time-out procedure. 5. knowing when to call the care provider.
2. administering antibiotics on time. a. 1, 3, and 5 b. 1, 2, 3, and 4
3. positioning and securing the patient appropriately. c. 2, 3, 4, and 5 d. 1, 2, 3, 4, and 5

480 j AORN Journal www.aornjournal.org

LEARNER EVALUATION

Continuing Education:
Successful Implementation of an
Enhanced Recovery Pathway:
The Nurses Role 1.9 www.aorn.org/CE

T his evaluation is used to determine the extent to

which this continuing education program met
your learning needs. The evaluation is printed
here for your convenience. To receive continuing education
credit, you must complete the online Examination and
7.

7A.
Will you change your practice as a result of reading this
article? (If yes, answer question #7A. If no, answer
question #7B.)

How will you change your practice? (Select all that

Learner Evaluation at http://www.aorn.org/CE. Rate the items
apply)
as described below.
1. I will provide education to my team regarding why
change is needed.
OBJECTIVES 2. I will work with management to change/implement
To what extent were the following objectives of this a policy and procedure.
continuing education program achieved? 3. I will plan an informational meeting with physicians
1. Discuss the enhanced recovery pathway (ERP) care to seek their input and acceptance of the need for
model. change.
Low 1. 2. 3. 4. 5. High 4. I will implement change and evaluate the effect of
the change at regular intervals until the change is
2. Describe the steps to implement an ERP for patients
incorporated as best practice.
undergoing abdominal surgery.
5. Other: __________________________________
Low 1. 2. 3. 4. 5. High

3. Describe the nurses role in implementing an ERP. 7B. If you will not change your practice as a result of
Low 1. 2. 3. 4. 5. High reading this article, why? (Select all that apply)
1. The content of the article is not relevant to my
CONTENT practice.
4. To what extent did this article increase your knowledge 2. I do not have enough time to teach others about the
of the subject matter? purpose of the needed change.
Low 1. 2. 3. 4. 5. High 3. I do not have management support to make a
change.
5. To what extent were your individual objectives met? 4. Other: __________________________________
Low 1. 2. 3. 4. 5. High

6. Will you be able to use the information from this article 8. Our accrediting body requires that we verify the time
in your work setting? you needed to complete the 1.9 continuing education
1. Yes 2. No contact hour (114-minute) program: ______________

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