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Francis, N. K., Walker, T., Carter, F., Hübner, M., Balfour, A., Jakobsen, D. H., . . . Ljungqvist, O. (2018). Consensus on Training and Implementation of Enhanced Recovery After Surgery: A Delphi Study. World Journal of Surgery.
Open this publication in new window or tab >>Consensus on Training and Implementation of Enhanced Recovery After Surgery: A Delphi Study
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2018 (English)In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323Article in journal (Refereed) Epub ahead of print
Abstract [en]

BACKGROUND: Enhanced Recovery After Surgery (ERAS) is widely accepted in current surgical practice due to its positive impact on patient outcomes. The successful implementation of ERAS is challenging and compliance with protocols varies widely. Continual staff education is essential for successful ERAS programmes. Teaching modalities exist, but there remains no agreement regarding the optimal training curriculum or how its effectiveness is assessed. We aimed to draw consensus from an expert panel regarding the successful training and implementation of ERAS.

METHODS: A modified Delphi technique was used; three rounds of questionnaires were sent to 58 selected international experts from 11 countries across multiple ERAS specialities and multidisciplinary teams (MDT) between January 2016 and February 2017. We interrogated opinion regarding four topics: (1) the components of a training curriculum and the structure of training courses; (2) the optimal framework for successful implementation and audit of ERAS including a guide for data collection; (3) a framework to assess the effectiveness of training; (4) criteria to define ERAS training centres of excellence.

RESULTS: An ERAS training course must cover the evidence-based principles of ERAS with team-oriented training. Successful implementation requires strong leadership, an ERAS facilitator and an effective MDT. Effectiveness of training can be measured by improved compliance. A training centre of excellence should show a willingness to teach and demonstrable team working.

CONCLUSIONS: We propose an international expert consensus providing an ERAS training curriculum, a framework for successful implementation, methods for assessing effectiveness of training and a definition of ERAS training centres of excellence.

Place, publisher, year, edition, pages
Springer, 2018
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:oru:diva-64040 (URN)10.1007/s00268-017-4436-2 (DOI)29302724 (PubMedID)
Available from: 2018-01-12 Created: 2018-01-12 Last updated: 2018-01-12Bibliographically approved
McQueen, K., Oodit, R., Derbew, M., Banguti, P. & Ljungqvist, O. (2018). Enhanced Recovery After Surgery for Low- and Middle-Income Countries. World Journal of Surgery.
Open this publication in new window or tab >>Enhanced Recovery After Surgery for Low- and Middle-Income Countries
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2018 (English)In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323Article in journal, Editorial material (Refereed) Epub ahead of print
Place, publisher, year, edition, pages
Springer, 2018
National Category
Surgery
Identifiers
urn:nbn:se:oru:diva-64847 (URN)10.1007/s00268-018-4481-5 (DOI)29383424 (PubMedID)
Available from: 2018-02-07 Created: 2018-02-07 Last updated: 2018-02-07Bibliographically approved
Martin, D., Roulin, D., Grass, F., Addor, V., Ljungqvist, O., Demartines, N. & Hübner, M. (2017). A multicentre qualitative study assessing implementation of an Enhanced Recovery After Surgery program. Clinical Nutrition.
Open this publication in new window or tab >>A multicentre qualitative study assessing implementation of an Enhanced Recovery After Surgery program
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2017 (English)In: Clinical Nutrition, ISSN 0261-5614, E-ISSN 1532-1983Article in journal (Refereed) Epub ahead of print
Abstract [en]

BACKGROUND & AIMS: The existence of enhanced recovery specific guidelines (ERAS) is not enough to change patient management practice since many barriers exist to successful ERAS implementation. The present survey aimed to analyse motivations for implementation as well as encountered difficulties and challenges. Further, relevance and importance of perioperative care items and postoperative recovery targets were assessed.

METHODS: A multicentre qualitative study was conducted between August and December 2016 among surgeons, anaesthesiologists and nurses from implemented ERAS centres in Switzerland (n = 16) and Sweden (n = 14). An online survey (31 closed questions) was sent by email, with reminders at 4, 8 and 12 weeks.

RESULTS: Seventy-seven out of 146 experts completed the survey (response rate 52.7%). Main motivations to implement ERAS were the expectation to reduce complications (91%), higher patient satisfaction (73%) and shorter hospital stay (62%). The application of ERAS program represented major changes in clinical practice for 57% of participants without significant differences between various specialities (surgeons: 63%, nurses: 63%, anaesthesiologists: 36%, p = 0.185). The most important barriers for straightforward implementation were time restraints (69%), opposing colleagues (68%) and logistical reasons (66%). The 3 most frequently cited patient-related barriers to adopt ERAS were opposing personality (52%), co-morbidities (49%) and language barriers (31%).

CONCLUSIONS: Implementing ERAS care into practice was challenging and required important changes in clinical practice for all involved specialities. Main reasons for implementation were the expectation to reduce complications and hospital stay with improved patients' satisfaction. Main barriers were time restraints, reluctance to change and logistics.

Place, publisher, year, edition, pages
Churchill Livingstone, 2017
Keyword
Enhanced recovery after surgery, implementation, qualitative study
National Category
Medical and Health Sciences Nursing Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:oru:diva-64350 (URN)10.1016/j.clnu.2017.10.017 (DOI)29129637 (PubMedID)
Available from: 2018-01-17 Created: 2018-01-17 Last updated: 2018-01-19Bibliographically approved
Barazzoni, R., Deutz, N. E., Biolo, G., Bischoff, S., Boirie, Y., Cederholm, T., . . . Calder, P. C. (2017). Carbohydrates and insulin resistance in clinical nutrition: Recommendations from the ESPEN expert group. Clinical Nutrition, 36(2), 355-363.
Open this publication in new window or tab >>Carbohydrates and insulin resistance in clinical nutrition: Recommendations from the ESPEN expert group
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2017 (English)In: Clinical Nutrition, ISSN 0261-5614, E-ISSN 1532-1983, Vol. 36, no 2, p. 355-363Article, review/survey (Refereed) Published
Abstract [en]

Growing evidence underscores the important role of glycemic control in health and recovery from illness. Carbohydrate ingestion in the diet or administration in nutritional support is mandatory, but carbohydrate intake can adversely affect major body organs and tissues if resulting plasma glucose becomes too high, too low, or highly variable. Plasma glucose control is especially important for patients with conditions such as diabetes or metabolic stress resulting from critical illness or surgery. These patients are particularly in need of glycemic management to help lessen glycemic variability and its negative health consequences when nutritional support is administered. Here we report on recent findings and emerging trends in the field based on an ESPEN workshop held in Venice, Italy, 8-9 November 2015. Evidence was discussed on pathophysiology, clinical impact, and nutritional recommendations for carbohydrate utilization and management in nutritional support. The main conclusions were: a) excess glucose and fructose availability may exacerbate metabolic complications in skeletal muscle, adipose tissue, and liver and can result in negative clinical impact; b) low-glycemic index and high-fiber diets, including specialty products for nutritional support, may provide metabolic and clinical benefits in individuals with obesity, insulin resistance, and diabetes; c) in acute conditions such as surgery and critical illness, insulin resistance and elevated circulating glucose levels have a negative impact on patient outcomes and should be prevented through nutritional and/or pharmacological intervention. In such acute settings, efforts should be implemented towards defining optimal plasma glucose targets, avoiding excessive plasma glucose variability, and optimizing glucose control relative to nutritional support. (C) 2016 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism.

Place, publisher, year, edition, pages
Churchill Livingstone, 2017
Keyword
Clinical nutrition, Carbohydrates, Insulin resistance
National Category
Nutrition and Dietetics
Identifiers
urn:nbn:se:oru:diva-57777 (URN)10.1016/j.clnu.2016.09.010 (DOI)000399624700003 ()27686693 (PubMedID)2-s2.0-84998911197 (Scopus ID)
Available from: 2017-05-23 Created: 2017-05-23 Last updated: 2017-10-18Bibliographically approved
Temple-Oberle, C., Shea-Budgell, M. A., Tan, M., Semple, J. L., Schrag, C., Barreto, M., . . . Ljungqvist, O. (2017). Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations. Plastic and reconstructive surgery (1963), 139(5), 1056E-1071E.
Open this publication in new window or tab >>Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations
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2017 (English)In: Plastic and reconstructive surgery (1963), ISSN 0032-1052, E-ISSN 1529-4242, Vol. 139, no 5, p. 1056E-1071EArticle, review/survey (Refereed) Published
Abstract [en]

Background: Enhanced recovery following surgery can be achieved through the introduction of evidence-based perioperative maneuvers. This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery and to provide evidence-based recommendations for an enhanced perioperative protocol.

Methods: A systematic review of meta-analyses, randomized controlled trials, and large prospective cohorts was conducted for each protocol element. Smaller prospective cohorts and retrospective cohorts were considered only when higher level evidence was unavailable. The available literature was graded by an international panel of experts in breast reconstructive surgery and used to form consensus recommendations for each topic. Each recommendation was graded following a consensus discussion among the expert panel. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society.

Results: High-quality randomized controlled trial data in patients undergoing breast reconstruction informed some of the recommendations; however, for most items, data from lower level studies in the population of interest were considered along with extrapolated data from high-quality studies in non-breast reconstruction populations. Recommendations were developed for a total of 18 unique enhanced recovery after surgery items and are discussed in the article. Key recommendations support use of opioid-sparing perioperative medications, minimal preoperative fasting and early feeding, use of anesthetic techniques that decrease postoperative nausea and vomiting and pain, use of measures to prevent intraoperative hypothermia, and support of early mobilization after surgery.

Conclusion: Based on the best available evidence for each topic, a consensus review of optimal perioperative care for patients undergoing breast reconstruction is presented.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2017
National Category
Surgery
Identifiers
urn:nbn:se:oru:diva-58960 (URN)10.1097/PRS.0000000000003242 (DOI)000404678400008 ()28445352 (PubMedID)2-s2.0-85020314040 (Scopus ID)
Note

Funding Agency:

Nyckelfonden, Örebro, Sweden

Available from: 2017-08-18 Created: 2017-08-18 Last updated: 2017-09-18Bibliographically approved
Ahl, R., Barmparas, G., Riddez, L., Ley, E. J., Wallin, G., Ljungqvist, O. & Mohseni, S. (2017). Does beta-blockade reduce the risk of depression in patients with isolated severe extracranial injuries?. World Journal of Surgery, 41(7), 1801-1806.
Open this publication in new window or tab >>Does beta-blockade reduce the risk of depression in patients with isolated severe extracranial injuries?
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2017 (English)In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 41, no 7, p. 1801-1806Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Approximately half of trauma patients develop post-traumatic depression. It is suggested that beta-blockade impairs trauma memory recollection, reducing depressive symptoms. This study investigates the effect of early beta-blockade on depression following severe traumatic injuries in patients without significant brain injury.

METHODS: Patients were identified by retrospectively reviewing the trauma registry at an urban university hospital between 2007 and 2011. Severe extracranial injuries were defined as extracranial injuries with Abbreviated Injury Scale score ≥3, intracranial Abbreviated Injury Scale score <3 and an Injury Severity Score ≥16. In-hospital deaths and patients prescribed antidepressant therapy ≤1 year prior to admission were excluded. Patients were stratified into groups based on pre-admission beta-blocker status. The primary outcome was post-traumatic depression, defined as receiving antidepressants ≤1 year following trauma.

RESULTS: Five hundred and ninety-six patients met the inclusion criteria with 11.4% prescribed pre-admission beta-blockade. Patients receiving beta-blockers were significantly older (57 ± 18 vs. 42 ± 17 years, p < 0.001) with lower Glasgow Coma Scale score (12 ± 3 vs. 14 ± 2, p < 0.001). The beta-blocked cohort spent significantly longer in hospital (21 ± 20 vs. 15 ± 17 days, p < 0.01) and intensive care (4 ± 7 vs. 3 ± 5 days, p = 0.01). A forward logistic regression model was applied and predicted lack of beta-blockade to be associated with increased risk of depression (OR 2.7, 95% CI 1.1-7.2, p = 0.04). After adjusting for group differences, patients lacking beta-blockers demonstrated an increased risk of depression (AOR 3.3, 95% CI 1.2-8.6, p = 0.02).

CONCLUSIONS: Pre-admission beta-blockade is associated with a significantly reduced risk of depression following severe traumatic injury. Further investigation is needed to determine the beneficial effects of beta-blockade in these instances.

Place, publisher, year, edition, pages
New York: Springer, 2017
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:oru:diva-57385 (URN)10.1007/s00268-017-3935-5 (DOI)000403056400020 ()28265730 (PubMedID)2-s2.0-85014574094 (Scopus ID)
Available from: 2017-05-08 Created: 2017-05-08 Last updated: 2017-10-22Bibliographically approved
Ljungqvist, O., Scott, M. & Fearon, K. C. (2017). Enhanced Recovery After Surgery: A Review. JAMA Surgery, 152(3), 292-298.
Open this publication in new window or tab >>Enhanced Recovery After Surgery: A Review
2017 (English)In: JAMA Surgery, ISSN 2168-6254, E-ISSN 2168-6262, Vol. 152, no 3, p. 292-298Article, review/survey (Refereed) Published
Abstract [en]

IMPORTANCE: Enhanced Recovery After Surgery (ERAS) is a paradigm shift in perioperative care, resulting in substantial improvements in clinical outcomes and cost savings.

OBSERVATIONS: Enhanced Recovery After Surgery is a multimodal, multidisciplinary approach to the care of the surgical patient. Enhanced Recovery After Surgery process implementation involves a team consisting of surgeons, anesthetists, an ERAS coordinator (often a nurse or a physician assistant), and staff from units that care for the surgical patient. The care protocol is based on published evidence. The ERAS Society, an international nonprofit professional society that promotes, develops, and implements ERAS programs, publishes updated guidelines for many operations, such as evidence- based modern care changes from overnight fasting to carbohydrate drinks 2 hours before surgery, minimally invasive approaches instead of large incisions, management of fluids to seek balance rather than large volumes of intravenous fluids, avoidance of or early removal of drains and tubes, early mobilization, and serving of drinks and food the day of the operation. Enhanced Recovery After Surgery protocols have resulted in shorter length of hospital stay by 30% to 50% and similar reductions in complications, while readmissions and costs are reduced. The elements of the protocol reduce the stress of the operation to retain anabolic homeostasis. The ERAS Society conducts structured implementation programs that are currently in use in more than 20 countries. Local ERAS teams from hospitals are trained to implement ERAS processes. Audit of process compliance and patient outcomes are important features. Enhanced Recovery After Surgery started mainly with colorectal surgery but has been shown to improve outcomes in almost all major surgical specialties.

CONCLUSIONS AND RELEVANCE: Enhanced Recovery After Surgery is an evidence- based care improvement process for surgical patients. Implementation of ERAS programs results in major improvements in clinical outcomes and cost, making ERAS an important example of value- based care applied to surgery.

Place, publisher, year, edition, pages
American Medical Association, 2017
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:oru:diva-57072 (URN)10.1001/jamasurg.2016.4952 (DOI)000398101400020 ()28097305 (PubMedID)2-s2.0-85017590240 (Scopus ID)
Note

Funding Agency:

Nyckelfonden, Örebro, Sweden

Available from: 2017-04-18 Created: 2017-04-18 Last updated: 2017-10-18Bibliographically approved
Tanious, M. K., Ljungqvist, O. & Urman, R. D. (2017). Enhanced Recovery After Surgery: History, Evolution, Guidelines, and Future Directions. International Anesthesiology Clinics, 55(4), 1-11.
Open this publication in new window or tab >>Enhanced Recovery After Surgery: History, Evolution, Guidelines, and Future Directions
2017 (English)In: International Anesthesiology Clinics, ISSN 0020-5907, E-ISSN 1537-1913, Vol. 55, no 4, p. 1-11Article, review/survey (Refereed) Published
Abstract [en]

With the desire to improve the quality of care and decrease costs, many health care facilities, both nationally and internationally, have sought to standardize approaches to perioperative care. The major goals are to decrease length of hospital stay (LOS), decrease surgical complications, and increase patient satisfaction after surgery. Enhanced Recovery After Surgery (ERAS®) protocols represent one such standardization—using evidence-based methods to reduce operation-induced stress and preserve anabolic homeostasis—with a considerable potential to revolutionize the care of surgical patients. ERAS concepts incorporate multipronged, data-driven interventions targeting periods before, during, and after surgery; it guides clinical decision-making around factors such as preoperative fasting, intraoperative goal-directed fluid therapy, surgical approaches, timing of postoperative drain removal, and diet advancement, among many others.

Place, publisher, year, edition, pages
Philadelphia, USA: Lippincott Williams & Wilkins, 2017
National Category
Anesthesiology and Intensive Care
Research subject
Anaesthesiology
Identifiers
urn:nbn:se:oru:diva-61223 (URN)10.1097/AIA.0000000000000167 (DOI)000411153700001 ()28901977 (PubMedID)2-s2.0-85031125205 (Scopus ID)
Available from: 2017-10-03 Created: 2017-10-03 Last updated: 2017-12-04Bibliographically approved
Nelson, G., Ramirez, P. T., Ljungqvist, O. & Dowdy, S. C. (2017). Enhanced Recovery Program and Length of Stay After Laparotomy on a Gynecologic Oncology Service: A Randomized Controlled Trial [Letter to the editor]. Obstetrics and Gynecology, 129(6), 1139-1139.
Open this publication in new window or tab >>Enhanced Recovery Program and Length of Stay After Laparotomy on a Gynecologic Oncology Service: A Randomized Controlled Trial
2017 (English)In: Obstetrics and Gynecology, ISSN 0029-7844, E-ISSN 1873-233X, Vol. 129, no 6, p. 1139-1139Article in journal, Letter (Refereed) Published
Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2017
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:oru:diva-58787 (URN)10.1097/AOG.0000000000002083 (DOI)000402714100038 ()28538481 (PubMedID)2-s2.0-85019619400 (Scopus ID)
Available from: 2017-07-26 Created: 2017-07-26 Last updated: 2017-10-05Bibliographically approved
Ljungqvist, O., Thanh, N. X. & Nelson, G. (2017). ERAS-Value based surgery. Journal of Surgical Oncology, 116(5), 608-612.
Open this publication in new window or tab >>ERAS-Value based surgery
2017 (English)In: Journal of Surgical Oncology, ISSN 0022-4790, E-ISSN 1096-9098, Vol. 116, no 5, p. 608-612Article in journal (Refereed) Published
Abstract [en]

This paper reviews implementation of ERAS and its financial implications. Literature on clinical outcomes and financial implications were reviewed. Reports from many different surgery types shows that implementation of ERAS reduces complications and shortens hospital stay. These improvements have major impacts on reducing the cost of care even when costs for implementation, and investment in time for personnel and training is accounted for. The conclusion is that ERAS is an excellent example of value based surgery.

Place, publisher, year, edition, pages
John Wiley & Sons, 2017
Keyword
clinical outcomes; cost of care; ERAS; implementation
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Surgery
Identifiers
urn:nbn:se:oru:diva-62490 (URN)10.1002/jso.24820 (DOI)000415127100007 ()28873501 (PubMedID)
Note

Funding agencies:

Nyckelfonden 

Available from: 2017-11-27 Created: 2017-11-27 Last updated: 2017-11-27Bibliographically approved
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ORCID iD: ORCID iD iconorcid.org/0000-0003-2636-4745

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