Implementation of Enhanced Recovery After Surgery: a strategy to transform surgical care across a health system
Implementation of Enhanced Recovery After Surgery: a strategy to transform surgical care across a health system
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DOI：
10.1186/s13012-017-0597-5
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发表时间：
2017-05-19
影响因子：
7.2
通讯作者：
Nelson, Gregg
中科院分区：
文献类型：
--
作者：
Gramlich, Leah M.;Sheppard, Caroline E.;Nelson, Gregg
背景：术后增强恢复（ERAS）计划已被证明对结果有积极的影响。ERAS护理系统包括循证指南、实施计划和交互式审计系统，以支持实践改变。本研究的目的是描述使用理论领域框架（TDF）在改变外科护理和应用质量增强研究计划（QUERI）模型来分析ERAS在单个卫生系统内多个站点的结直肠手术中的端到端实施。这项工作的最终目的是为了让ERAS在阿尔伯塔卫生服务（AHS）的传播，规模和可持续性的模型的发展。方法：ERAS结直肠手术实施在两个网站，然后蔓延到另外四个网站。ERAS交互式审计系统（EIAS）用于评估对指南的依从性、住院时间、再入院和并发症。知识转化的数据来源包括调查、焦点小组、访谈和其他定性数据来源，如会议记录和状态更新。使用QUERI模型和TDF对189篇文献进行主题分析，其中2188条引文符合纳入标准。数据源进行了分析的障碍或使能因素，组织成一个框架，包括个人对组织的影响，和重点领域的指南implementation.Results：符合ERAS在结直肠手术的循证指南在基线为40%。与采用最佳做法一致的实施后合规率提高到65%。障碍和推动因素被归类为临床实践（22%），个人提供者（26%），组织（19%），外部环境（7%）和患者（25%）。在阿尔伯塔省的背景下，ERAS实施的26%的障碍和推动因素发生在站点和单位层面，其中26%的时间以提供者为重点，26%的时间以患者为重点，22%的时间以系统为重点。使用ERAS护理系统并应用QUERI模型和TDF，可以识别可以支持增强型创新的传播和维持的策略。在医疗保健系统内的多个地点进行手术后恢复。
Background: Enhanced Recovery After Surgery (ERAS) programs have been shown to have a positive impact on outcome. The ERAS care system includes an evidence-based guideline, an implementation program, and an interactive audit system to support practice change. The purpose of this study is to describe the use of the Theoretic Domains Framework (TDF) in changing surgical care and application of the Quality Enhancement Research Initiative (QUERI) model to analyze end-to-end implementation of ERAS in colorectal surgery across multiple sites within a single health system. The ultimate intent of this work is to allow for the development of a model for spread, scale, and sustainability of ERAS in Alberta Health Services (AHS).Methods: ERAS for colorectal surgery was implemented at two sites and then spread to four additional sites. The ERAS Interactive Audit System (EIAS) was used to assess compliance with the guidelines, length of stay, readmissions, and complications. Data sources informing knowledge translation included surveys, focus groups, interviews, and other qualitative data sources such as minutes and status updates. The QUERI model and TDF were used to thematically analyze 189 documents with 2188 quotes meeting the inclusion criteria. Data sources were analyzed for barriers or enablers, organized into a framework that included individual to organization impact, and areas of focus for guideline implementation.Results: Compliance with the evidence-based guidelines for ERAS in colorectal surgery at baseline was 40%. Post implementation compliance, consistent with adoption of best practice, improved to 65%. Barriers and enablers were categorized as clinical practice (22%), individual provider (26%), organization (19%), external environment (7%), and patients (25%). In the Alberta context, 26% of barriers and enablers to ERAS implementation occurred at the site and unit levels, with a provider focus 26% of the time, a patient focus 26% of the time, and a system focus 22% of the time.Conclusions: Using the ERAS care system and applying the QUERI model and TDF allow for identification of strategies that can support diffusion and sustainment of innovation of Enhanced Recovery After Surgery across multiple sites within a health care system.