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How to spread the adoption of enhanced recovery throughout your hospital

2011 September 2
by webmaster

Across the country there are many hospitals who have made great progress with introducing enhanced recovery to specific clinical areas, but who have then struggled to spread adoption of the ER principles to other specialties within their own hospital. In this post we feature the work being undertaken at Nottingham and their structured approach to spreading adoption. We are delighted to feature the work as an example for others to adapt and replicate and the post is authored by Helen Scrimshire who has lead the work.

Enter Helen……

NUH is one of the country’s biggest acute teaching hospitals serving a population of over 2.5 million locally and a further 4 million in the Midlands region; across three sites it employs over 13,000 staff and treats over 88,000 day case and in-patients in 87 wards and 1700 beds. The ERAS project formed an integral part of an existing Trust-wide transformational programme (Better for You), which was initiated in December 2009.  Better for You aims to create a continuous culture of service improvement led by multi-professional teams.

The following 5 key steps are employed:

  1. Set up and plan
  2. Discovery
  3. Design and Trial
  4. Implementation
  5. Embed.

Selection of specialty areas

Prior to my appointment, protocols for the adoption of ERAS within Hepatobiliary and Upper Gastrointestinal Surgery were under development. Selection of other specialities was based on those involved in the Trust transformational programme and included Gynaecology (oncology and benign), Urology Thoracics, and Orthopaedics.  Each specialty formed a multi professional development team who received my support for a period of 12 months.


All specialities followed the process outlined on the left. Each speciality had its own project plan and timelines, meeting at least fortnightly. My role was to check and challenge the current practice against the key clinical elements of ERAS.

Once current practice and length of stay (LOS) were identified, the development of the ERAS care grid protocols began.  Where information was available, LOS was benchmarked against peer Trusts using Dr Foster data and information from the East Midlands Quality Observatory.  Benchmarking for Hepatobiliary and Upper Gastrointestinal Surgery was not possible as no other Trusts ran an ERAS programme within these specialties, therefore clinical expertise and best practice evidence were used to determine LOS.

I provided each development team with example protocol formats; however the final choice of format for the care grid remained with the individual speciality groups. Key to the success of this stage was commencing the ERAS programme based on a pilot protocol, rather than waiting for the ‘finished product’.  Numerous iterations of the protocol were developed during the process of change, however accepting the pilot as a starting point prevented elongation of ERAS implementation.

Communication and education were essential components and prior to commencing the ERAS programme all relevant staff received a short introduction to its principles and aims.  The vital role of patient education was acknowledged in order to establish effective partnership and informed decision making (DH 2010) and information was placed in the Pre-Operative Assessment Units to alert patients to the ERAS programme.

For each specialty a patient information or “milestone” document was developed. This mirrors the care protocol and identifies key stages in the patient journey. It is given out in the Out-patient or Pre-Operative setting, outlining what patients should expect to take place and their role in their recovery.

I organised and chaired monthly steering groups attended by all specialities. These have now evolved into a monthly advisory group where implementing specialties can share ideas, issues and current literature around ERAS. The group allows specialties to support each other as they implement ERAS and discuss challenges or problems incurred during the early weeks of implementation


The table below illustrates the key outcomes at 6 months according to specialty area.  A 12 month projected reduction in LOS is also presented. Thoracic and orthopaedic data is not included as they remain in the early pilot phase.

Financial Impact

All specialties saw a reduction in LOS, with 1715 bed days saved. Assuming a cost of £250 per bed day, this suggests a notional saving of £428,750. The co-morbidities of some patient groups were taken into account when determining the target LOS, for example,  Upper Gastrointestinal Surgery estimated that only 40% of patients would achieve a maximum 8 day LOS. The wider contributions of ERAS to the Trust as a whole, enabled NUH to reduce the overall number of beds by 96 by March 2011, a saving estimated at around £5 million. Staff feedback was obtained via informal discussions during the implementation process and identified benefits regarding the standardisation of care and improved communication to patients and carers. The main difficulties reported related to the reluctance of junior medical staff to implement ERAS protocols in the absence of senior colleagues. Patient feedback was collected locally using postal questionnaire, telephone follow up and wards surveys. The responses have been positive with patients identifying the use of the milestone documents as the biggest benefit.


Implementation of ERAS via a nurse project lead has shown successful outcomes across 5 speciality areas. In addition to a reduction in LOS and cost saving, it has been a positive experience for staff and patients, findings that support those in earlier studies. Similar to other implementation sites challenges were faced when attempting to change the culture of nursing and medical practice.  I identified that education and early involvement of all staff groups assisted in breaking this barrier, in addition to senior medical and Trust executive support. The key to our implementation programme is clarity of structure, ownership and communication; the integration of ERAS within the structure of the wider Better for You programme, firmly places it as a cultural as well as process change. This also demonstrates the long term commitment to ERAS. The role of project lead is vital in facilitating and supporting the process, whilst developing ownership at specialty level.  In this role, I have developed a range of skills and knowledge which supplement my previous clinical skills, combined with the leadership of fellow clinical colleagues to provide credibility with the surgical specialties and theatre teams. NUH is continuing to support the further development of ERAS, having recognised the benefits to both quality and outcomes for patients and staff.


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