Recovery after surgery: tipping accepted wisdom on its head

How the ERAS approach can help nurses promote evidence-based perioperative care

Picture: iStock

How the ERAS approach can help nurses promote evidence-based perioperative care

For patients having surgery, fasting from midnight and bed rest for several days afterwards have long been among the traditional standards for perioperative care.

Now an evidence-based approach is turning much of this accepted wisdom on its head.

The concept of enhanced recovery after surgery (ERAS) dates back to the mid-1990s. The principles have since spread across the world and been customised for various operations, after being pioneered for colorectal surgery by Danish clinical professor Henrik Kehlet.

ERAS Society

Founded in 2010, the ERAS Society has a nursing and allied healthcare professional group. Its free patient information booklets, available on the ERAS Society website, explain the approach. The website also has a patient diary template, examples of care plans and videos of patients talking about their experiences.

‘He was able to demonstrate that by adapting your programme you could influence recovery and reduce length of stay considerably,’ explains Angie Balfour, who is senior ERAS nurse and a clinical trial site manager for NHS Lothian, as well as chairing the ERAS Society’s nursing group.

Dispelling myths

Numerous research reports suggest that when using this approach, recovery times are shortened by 30%, with postoperative complications decreasing by as much as 50%.

A key component is giving patients much more information about what they can expect post-surgery, which often means challenging their preconceptions and dispelling myths. ‘What makes the difference is changing patients’ physiological recovery,’ says Ms Balfour, who qualified in 1994 and worked in critical care before moving into research.

‘Patients come into hospital thinking they will be stuck here for a week, unable to do anything, even lift a kettle,’ she says. ‘There’s a lot of misunderstanding. They need to understand they have a role to play in their own recovery.’

‘The majority of patients get it, they approve and they want to participate’

Angie Balfour, chair of ERAS Society’s nursing group

Alongside optimising their health before surgery, this means patients knowing they will be sitting up soon after their operation, encouraged to move and discharged home in a couple of days. Once it’s explained, their reactions are usually favourable. ‘The majority of patients get it, they approve and they want to participate,’ says Ms Balfour. ‘What they don’t like is conflicting information.’

Healthcare professionals also need to appreciate that most patients aren’t ill when they are admitted for an operation, says Ms Balfour. ‘They are having a procedure, but they are not sick, so we’re trying to maintain their normality. We’re trying to reduce the stress response to surgery by keeping them fed, watered and pain-free, but not sedated and immobile.’

‘You wouldn’t run a marathon having starved yourself’

Other aspects of ERAS include using improved analgesia, providing nutritious food and having a discharge plan from the outset, with agreed, realistic expectations.

‘We have learned what we don’t need to do,’ says Ms Balfour. ‘But in surgical terms, we are very stuck in tradition. Even today in our hospitals we are still not following evidence-based healthcare.’

This includes the customary advice on preoperative fasting: no food for six to eight hours beforehand and no liquids for two hours. ‘The fast from midnight guidance will never go away because everyone is taught it,’ says Ms Balfour.

‘But you wouldn’t turn up to run a marathon having starved yourself, feeling completely malnourished and dehydrated. That analogy can be used for surgery.’

In practice, this can mean giving some patients carbohydrate drinks up to two hours before their operation. ‘They help make sure patients are hydrated and well-nourished, so they feel better,’ she says.

Key principles of enhanced recovery

NHS Choices describes enhanced recovery as ‘a modern evidence-based approach that helps people recover more quickly after having major surgery’.

Crucially, patients are encouraged to take responsibility, playing an active role in their own care, with GPs and healthcare professionals giving advice about how to get into the best possible shape before surgery.

For patients, key principles include:

  • Being as healthy as possible before their operation, including eating well and losing or gaining weight as applicable; exercising before surgery, perhaps even being walked to the operating theatre; relaxing and trying not to worry; and ideally giving up or at least reducing smoking and alcohol
  • Receiving the best possible care and management during their operation, which may include using minimally invasive techniques such as keyhole surgery, local anaesthesia and minimal use of drains and nasogastric tubes
  • Receiving the best possible care while recovering, supporting them to get back to normal as soon as possible. Research shows that the earlier someone gets out of bed and starts walking, eating and drinking after surgery the shorter their recovery time will be. To speed up rehabilitation, patients have access to services such as physiotherapy

Tips include keeping a diary in which patients can chart their feelings, goals, activities, eating, drinking and sleeping.


    As patients are much more likely to be ready to go home sooner, keeping in touch with them after they do is vital. ‘A fundamental part of enhanced recovery is phone call follow-ups,’ says Ms Balfour.

    At NHS Lothian, patients are called 24 hours after discharge, then at seven days and 30 days post-surgery.

    ‘It’s important not only to check on them, but to measure outcomes,’ she says. ‘After 30 days, you can see if they have been readmitted and whether there have been any complications. If you’re implementing a programme of care, and some of it is controversial, you need to know it’s safe, effective and recommended.’

    Picture: iStock

    While the principles of enhanced recovery are increasingly being adopted in hospitals, it is yet to become universally used. ‘Most people have heard of it and have taken aspects, incorporating them into practice, but it’s not sustained and that’s the challenge,’ says Ms Balfour.

    ‘People are averse to change because they don’t want to take risks. It’s much easier to leave a patient lying in bed than it is to get them up and risk them falling over.’

    ‘It leads you to think about the patient as an individual, so you can give them tailored care, which is what nursing should be all about’

    Anne-Marie McAuliffe, RCN perioperative nursing forum chair

    Nurses are crucial to the success of ERAS, she believes, with a role to play in both pre and postoperative care. ‘But we’re still basing our practice on what we’ve been doing for years,’ says Ms Balfour.

    ‘The backbone of nursing is still to mollycoddle patients and restrict their ability to do things for themselves. There’s a mismatch in what we expect patients to be able to do and what they can actually do.’

    ERAS training as standard

    Part of the problem is that universities don’t teach ERAS as standard care, Ms Balfour says. ‘In my experience there are some lectures, but it’s not the default, so students are still coming out with “fast from midnight”, which is ridiculous.

    ‘Over time, I’d like to see the role of the ERAS nurse disappearing as it becomes normal practice, but at the moment we’re still very much needed.’

    Nurses also have the ability to make more clinical decisions than they allow themselves to, she argues, suggesting an evidence-based agreed care pathway could increase their authority. ‘In some departments, patients are left sitting with a catheter and are not fed, because the surgeon hasn’t said it can happen – and that’s sad,’ says Ms Balfour.

    Looking to the future, nurses can be pivotal in transforming care. ‘The whole face of surgery has completely altered from five or ten years ago,’ says Ms Balfour. ‘I’d like us to look at what we do and rationalise why we’re doing it. If we’re asking questions and the answer is “that’s what we’ve always done” then that’s not good enough.’

    Good for the hospital – but even better for the patient

    RCN perioperative nursing forum chair Anne-Marie McAuliffe would like to see ERAS become standard practice. ‘It focuses on every stage of the patient journey, from their initial assessment through to follow-up care,’ says Ms McAuliffe, a senior orthopaedic surgical practitioner at East Surrey Hospital.

    ‘It’s a complete package and leads you to think about the patient as an individual so you can give them tailored care, which is what nursing should be all about.’

    But she also recognises it’s something of an uphill battle to have it adopted across the board, not least because it needs a multidisciplinary approach. ‘There’s a struggle to coordinate it all into one seamless process,’ she says.

    ‘The benefits far outweigh any perceived difficulties’

    ‘There are so many disciplines involved – nurses, physiotherapists, occupational therapists, surgeons, anaesthetists, social services. Getting a lot of people to agree on anything is difficult and this needs a change of culture. But for me the benefits far outweigh any perceived difficulties.’

    It also suffers from being seen as a cost-cutting exercise, says Ms McAuliffe. ‘It’s not portrayed to be in the patient’s best interests but as good for the hospital, because it reduces length of stay,’ she says. ‘Perhaps we need to flip that on its head and emphasise that it’s better for the patient.’

    Studies show high levels of patient satisfaction, she says. ‘The research clearly shows this. It’s evidence-based, not something that has been chosen because it’s financially beneficial. Essentially it’s a win-win for everyone.’

    Lynne Pearce is a freelance health journalist

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