ERAS in Orthopedic Surgeries

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Introduction   

Enhanced recovery after surgery (ERAS) is a protocol (or pathway) that promotes fast recovery in post-surgical clients by reducing the client’s surgical stress, risk for complications, and long-term impairment by utilizing a multimodal, multidisciplinary, and evidence-based system that focuses on optimizing client outcomes [3,7,9,17]. ERAS breaks down the traditional perioperative care model that was fractured and costly to ensure that evidence-based practices are implemented to benefit the client [11]. 

Henrik Kehlet, a Danish surgeon at the University of Copenhagen, introduced ERAS in 1997 during a colorectal surgery. The ERAS protocol has since spread to other specialties, including orthopedics, and has been shown to reduce healthcare costs and improve client outcomes [7].  

The first orthopedic surgeries to utilize ERAS were total knee arthroplasty (TKA) and total hip arthroplasty (THA) because they are high-volume surgeries that require expensive, lengthy hospital stays [8]. The first countries to implement ERAS in orthopedics were Denmark and the United Kingdom, which have been instrumental in ensuring ERAS as accepted best practice in TKA and THA surgeries. Additional surgeries that have utilized ERAS with success include rectal, urological, pancreatic, gastric, breast (including reconstructive surgery), head and neck cancer, bariatric, gynecological, thoracic, and hepatic [13,17]. 

The ERAS Society, a global organization that is governed by an advisory council of healthcare providers and administrators, researchers, and educators, is committed to developing and maintaining a pathway that promotes early recovery in clients undergoing major surgery [8]. The organization evaluates traditional practices to ensure that they are following current, evidence-based guidelines and that these practices encompass a holistic approach that covers all areas of the client’s journey through the surgical process. The ERAS Society maintains that the key factors that delay surgical recovery are the client’s need for parenteral analgesia, intravenous fluids secondary to gastrointestinal dysfunction, and increased need for bed rest due to lack of mobility [8]. The Society has published guidelines for TKA, THA, and spine surgeries that are used by healthcare personnel around the world. However, obstacles arise when healthcare providers and clients are not compliant with ERAS and deviate from the protocol [7,8]. 

ERAS in orthopedic surgery has reduced client length of stay from four to ten days to one to three days following surgery with no increased effect on morbidity or mortality [10,17]. In 2020, the average hospital length of stay in the United States after THA was 1.9 days, and it was 1.0 day following TKA [10]. Thirty-day readmission rates after THA are reported to be 4% and 90-day readmission rates after THA are 8% [10]. TKA 30-day readmission rates are 4% and 90-day readmission rates are 7% [10]. The risk-standardized complication rates at 90 days following total joint arthroplasty (TJA) are 2.7% to 3.6% [10]. ERAS has been shown to decrease readmission rates for orthopedic surgeries [10]. 

Frailty is a common high risk client factor when it comes to surgical procedures that can lead to higher complications and longer hospital stays [12]. However, for frail clients receiving transforaminal lumbar interbody fusion (TLIF) surgery, the ERAS protocol led to improved return of physiological function, decreased length of postsurgical hospitalization, decreased complications, and fewer readmissions and reoperations [12]. The improved postsurgical outcomes in the frail clients with ERAS were similar to those in their non-frail counterparts, indicating that ERAS is capable of closing the gap in this vulnerable population [12]. 

Nurses play a critical role in the successful implementation of the ERAS pathway since they are observers, implementers, coordinators, and evaluators at each stage of the ERAS protocol [9]. Key nursing tasks of ERAS include providing client and family education, ensuring client optimization prior to admission, administering multimodal analgesia, and assisting the client in returning to a normal diet and activities of daily living shortly after surgery [11]. 

Principles of the Orthopedic ERAS Pathway 

The ERAS pathway in orthopedic surgery is divided into four stages, per the ERAS Society. These four stages are [7,8,17]: 

1. Preoperative stage: This stage focuses on the client’s preoperative physical and psychological state. The identification of conditions that can disrupt post-surgical healing, such as anemia, is prioritized, along with preoperative client education and psychological counseling. Discharge arrangements are also explored to ensure that the client receives the post-surgical physical and emotional support they require. 
2. Intraoperative stage: In this stage, standardized anesthesia and analgesia protocols, including opioid sparing analgesia, are emphasized. Additional measures include atraumatic surgical techniques, hemodynamic stability, normovolemia, normothermia, and maintenance of respiratory status.  
3. Postoperative stage: Effective analgesia that avoids opioid administration (if possible), early ambulation, and removal of catheters, drains, and intravenous lines (if indicated) are implemented. The client is encouraged to eat and drink early, maintain personal hygiene, dress themselves (as much as possible), and socialize with loved ones as soon as possible. 
4. Discharge stage: Clients are discharged home as agreed upon by the multidisciplinary team, with clear written instructions provided and home care support secured. 

There is also a common variation to the above pathway in the literature that includes the same elements, but with slightly different categorizations. 

These stages are [3,7,17]: 

1. Preadmission stage: The client receives counseling and education about the surgical procedure, expectations, and their role in the recovery process, especially during hospitalization. Diagnostic blood tests and imaging, as well as a comprehensive client history, are used to detect underlying conditions. If the client smokes, they are encouraged to quit at least four weeks prior to total joint arthroplasty. If the client drinks alcohol, they are advised to quit prior to the surgery. If malnutrition and anemia exist, these are corrected prior to the procedure. Clients are also encouraged to engage in exercise, as tolerated. 
2. Preoperative stage: Clients are discouraged from prolonged fasting and routine intake of carbohydrates prior to orthopedic surgery. Solid foods (preferably from healthy protein and fat sources) can be eaten six hours before surgery and clear fluids are permitted two hours before the induction of anesthesia. Multimodal analgesics may be administered, such as non-steroidal anti-inflammatory (NSAID) medications and acetaminophen (Tylenol). Opioids and gabapentinoids are discouraged. Duloxetine (Cymbalta) can be used to reduce nausea and opioid use. Pregabalin (Lyrica) can be combined with an NSAID and corticosteroid as a preemptive analgesic. Postoperative nausea and vomiting can be controlled in the preoperative stage with dexamethasone (Decadron), ondansetron (Zofran), and droperidol (Inapsine). Preoperative hair removal is not recommended to prevent surgical site infection, but prophylactic antibiotics and dilute betadine lavage can be utilized. 
3. Interoperative stage: Anesthesia techniques (neuraxial versus general) are not specified, but spinal opioids or epidural analgesia is not preferred. Warming intravenous (IV) fluids, using warming blankets, and prewarming and humidification of anesthetic gases help maintain normal body temperature. The goals of fluid management are to maintain normal body fluid compartments, facilitate waste excretion, and return to oral intake as soon as possible after surgery. Urinary catheterization should be removed within 24 hours after surgery. Tranexamic acid (Cyklokapron) is used to prevent blood loss and decrease transfusion rate. Local infiltration analgesia (LIA) is preferred over a nerve block, which can block the motor nerve and inhibit early mobilization. Tourniquets and drains are not routinely used. Ice, compression, and elevation (ICE) therapy treats pain, reduces swelling, and improves range of motion (ROM).  
4. Postoperative stage: Returning to a regular diet as soon as possible is encouraged, as well as adequate hydration. Antithrombotic prophylactic treatment and early mobilization prevent thromboembolism, pulmonary complications, and muscle atrophy. Discharge planning should focus on releasing the client directly to their home. 

The Nurse’s Role in ERAS 

Nurses play a key role in providing client education, perioperative and postoperative evaluation, and effective cost containment in the ERAS pathway [1]. ERAS requires nurses to shoulder additional responsibilities, such as setting client expectations, coaching clients, and thoroughly documenting the recovery process. Even though these may be viewed as time-consuming for nurses, systematic implementation of ERAS is associated with overall decreased workload and higher compliance [1]. 

It is important that the preoperative, intraoperative, and postoperative periods be executed without errors or oversights for ERAS to be effective. The nurses in each of these periods are paramount in ensuring the overall success of ERAS. The preoperative nurse should ensure that the client’s medical conditions are identified and documented, the client has not engaged in prolonged fasting, and that the client has received appropriate education and emotional support regarding the surgical procedure [3]. During the perioperative period, the surgical nurse assists in maintaining anesthetic protocols and antimicrobial prophylaxis, as well as client blood conservation, fluid management, urinary catheterization, and prevention of hypothermia. The postoperative nurse’s main goals are to assist the client in recovering from anesthesia, maintaining biological functioning (such as urination), and resting in a comfortable state [7]. 

The nursing considerations for implementing ERAS can be categorized as [1]: 

1. Preoperative: Information, education, counseling, nutrition 
2. Intraoperative: Surgical safety checklist, antibiotic prophylaxis, normothermic maintenance 
3. Postoperative: Airway management, pain management, nutritional needs, surgical site assessment, early mobilization, tracheostomy care, family participation, discharge planning 
4. Discharge and home care: Diet, exercise, lifestyle modifications, medications, follow-up care 

Nurses can serve as ERAS Coordinators and ERAS Nurse Navigators to help guide the successful implementation of the ERAS protocol [14]. Nurses should stay updated on evidence-based practice supporting surgical procedures and ERAS, implement clear communication during interdisciplinary collaboration, and tailor the client’s care plan to the individual [14]. 

The nurse’s role in each of the four stages of ERAS are detailed in the following sections. 

Nurse’s Role: Preadmission Counseling 

Nurses play a key role in the effectiveness of ERAS since they are the professionals that have the most interaction with clients prior to and after orthopedic surgery. Key nursing interventions include client education, medication administration, multidisciplinary team collaboration, and execution of the client’s care plan. Preadmission counseling that includes thorough preoperative education helps reduce client anxiety and emotional distress, which in turn can decrease pain and fatigue, reduce postoperative complications, and curtail the client’s hospital stay [1,7,14,17]. 

During preadmission counseling, the nurse provides copious education and coaching. It is important that the nurse be aware of the client’s language barriers, cultural and religious beliefs, and health literacy [1]. Nurses should use therapeutic communication, permit the client to ask questions, and utilize a language interpreter, if the client’s language differs from that of the nurse. The nurse’s coaching can be delivered via in-person class, multimedia content, virtual meeting, or telephone interview [2]. The nurse should be aware of their own attitudes, biases, behaviors, and competencies that can impact the delivery of ERAS. 

Counseling helps minimize client anxiety and this includes the fear clients have about pain during the recovery period. It is important that nurses explain to clients that postoperative pain is a normal occurrence that is to be expected, but that adhering to the pain medication regimen, as opposed to trying to white-knuckle through the pain, promotes tissue healing. The nurse should also address other medications that will be used before, during, and after the procedure and ensure that the client is able to fill prescriptions once discharged after the surgery. 

It is important that the nurse assist the client in reaching optimal health prior to the surgical procedure to promote optimal outcomes. This includes assessing the client’s general health. 

A helpful checklist for evaluating the client’s general health includes [2,7,14,17]: 

• Taking a thorough health history, including review of systems, nutritional status, and social history 

• Assessing for underlying conditions, such as hypertension, diabetes mellitus, respiratory disease, heart failure, chronic kidney disease, infectious disease 

• Reviewing the client’s medical record for blood test and imaging results 

• Determining the client’s activity level and ability to conduct deep breathing exercises 

Preoperative anemia was found in 24% to 44% of THA and TKA clients in one study, with 42% of clients with hip fractures presenting with anemia on admission [7]. Preoperative anemia is associated with infection, risk of transfusion, longer length of stay, increased readmission rates, and mortality in 15% to 39% of THA and TKA clients [17].  Correcting preoperative anemia decreases the need for postoperative blood transfusion [7]. 

Nurses should counsel clients to stop smoking at least four weeks before the orthopedic procedure. Research indicates that smoking cessation at least four weeks prior to surgical procedure can reduce respiratory complications by 25% [7,17]. Nurses should also teach clients to abstain from alcohol prior to orthopedic surgery. Alcohol consumption is associated with infection, respiratory complications, and increased hospital stays [7,17]. Wound complications and preoperative anemia associated with preoperative alcohol use are associated with postoperative infections, decreased physical function, increased hospital stays, and mortality [7,17].  

Preoperative activity can improve postoperative pain and function, and thus expedite discharge [14]. Prehabilitation programs that focus on nutritional therapy, exercise regimens, and psychological preparation have been shown to improve client outcomes in general surgeries [17]. 

Nurse’s Role: Preoperative Stage 

The nurse’s role in the preoperative stage is to prepare the client for surgery. In the past, the gold standard for presurgical clients was nothing per oral (NPO) after midnight the night prior to surgery. Today, clients are permitted solid foods up to six hours prior to surgery and clear liquids are permitted up to two hours prior to anesthesia induction. Intake of clear fluids two hours prior to surgery has not been shown to increase gastric content, reduce gastric fluid pH, or increase complications [17]. Prolonged fasting is associated with catabolic stress that can cause hyperglycemia and insulin resistance that can prolong recovery [7]. Carbohydrate loading prior to surgery is not recommended since it has not been shown to be effective in orthopedic surgeries [7,17]. The nurse should obtain the client’s weight and blood glucose level prior to the procedure to establish a baseline [2]. 

The use of pain medications in the preoperative stage involves administering various medications with different mechanisms via multiple routes to simultaneously target different points in the pain pathway [7,17]. NSAIDs are very effective in NKA and THA, but the nurse should assess clients for renal dysfunction and gastrointestinal upset. Acetaminophen (Tylenol) is effective in blocking pain and reducing fever, but it does not counteract inflammation or swelling. The nurse should not anticipate administering gabapentinoids or opioids in the ERAS protocol, as they are not recommended. Research indicates that corticosteroids in combination with NSAIDs and pregabalin (Lyrica) are effective in controlling TKA pain without postoperative wound complications, so the nurse can anticipate preemptive analgesia with these substances [7]. Anxiolytics administered preoperatively have not been shown to reduce client anxiety or improve discharge criteria [17].  

Postoperative nausea and vomiting have a higher rate of incidence in females, non-smokers, postoperative opioid users, and clients with a history of motion sickness [7,17]. To preempt postoperative nausea and vomiting, the nurse can anticipate administering dexamethasone, ondansetron, and droperidol during the preoperative phase. Research indicates that dexamethasone used in conjunction with ondansetron prior to TKA versus using ondansetron alone was significantly more effective [7,17]. 

Infection after THA and TKA is of serious concern that can lead to client complications that are difficult to manage. Antimicrobial prophylaxis includes antibiotic therapy, which has been shown to reduce the relative risk of wound infection by 81% [17]. Antimicrobial prophylaxis prevents surgical site infection (SSI) and periprosthetic joint infection (PJI) in clients undergoing TKA and THA [7]. The Surgical Care Improvement Project (SCIP) guidelines for antimicrobial prophylaxis help guide surgeons in preventing SSI. 

The SCIP guidelines for antimicrobial prophylaxis are [6,7,15]: 

1. Inject prophylactic antibiotic within one hour prior to surgical incision.  
2. The type of surgery dictates the antibiotic used. 
3. Preventative antibiotics should be stopped within 24 hours of the surgery’s completion. 

SSI has been reported at a two- to six-fold increased rate in clients who received antibiotics more than two hours prior to incision [7]. Clients undergoing THA and TKA are likely to be infected with Staphylococcus aureus and streptococcal species, so cefazolin, a first-generation cephalosporin is typically administered. If methicillin-resistant Staphylococcus aureus and coagulase-negative staphylococci are identified, vancomycin should be given. If the client has an allergy to penicillin and cephalosporin, fluoroquinolone should be administered [7]. Shaving the surgical area prior to surgery increases SSI and should be avoided [7]. 

Nurse’s Role: Interoperative Stage 

The perioperative surgical factors and ERAS protocols of which nurses should be aware are the surgical technique used, use of tourniquet for knee replacement surgery, use of drains, fluid management, and urinary catheter use since these factors can affect client recovery. 

Currently, the research regarding orthopedic surgical approach is conflicting and no strong evidence advocates for one approach in favor of another. The type of approach, use of minimally invasive technique, prosthesis choice, and use of computer navigation or robot are not clarified in the ERAS protocol and no current recommendations are provided [7,17]. However, the routine use of a tourniquet in TKA for blood loss control is not advised due to an increased risk of thrombosis and wound complications [7,17]. Studies on standard care pathways (non-ERAS protocol) have found that not using a surgical tourniquet during TKA corresponds with greater client strength after surgery versus the use of a surgical tourniquet [17]. 

The nurse should not anticipate having to manage a client’s surgical drains since they are not supported in the ERAS protocol. Drains have not been shown to improve hematomas or wound infection, and they may even contribute to increased blood loss and transfusion rate [17].  

Intravenous fluids during surgery are used to combat insensible losses, maintain body fluid compartments, and promote renal excretion of waste products. The three fluid therapies include liberal fluid therapy, restricted fluid therapy, and goal-directed fluid therapy. Liberal fluid therapy includes injecting a large amount of fluid to improve tissue oxygenation and maintain urine output, and it has been shown to lead to hypercoagulability and reduced vomiting [7,17]. Nurses should monitor clients who receive liberal fluid therapy for symptoms of hypervolemia, such as tissue edema, pulmonary edema, and cardiac complications [7]. They should also monitor clients for signs and symptoms of hyponatremia, including vomiting, restlessness, muscle spasms or cramps, seizure, and coma. 

Restricted fluid therapy focuses on injecting fluid to achieve a zero balance, which avoids hypervolemia, but it can induce hypotension and decreased organ perfusion, resulting in acute kidney injury [7]. Although goal-directed fluid therapy is supported by the ERAS protocol since it monitors pulse pressure variation, delta stroke volume, central venous pressure, and urine output, it is not indicated in THA and TKA surgeries [7]. This is because client oral intake occurs soon after surgery, which helps maintain fluid balance. 

Urinary catheters are used during surgery to monitor urinary output and guide fluid resuscitation; however, research indicates that there is a low incidence of serious urological and renal complications in THA and TKA clients on the ERAS protocol [7,17]. The routine use of urinary catheters is not indicated, but if they are used, they should be removed as soon as the client is able to void, typically within 24 hours of the procedure [7,17]. To reduce the need for postoperative urinary catheterization, a catheterization threshold of 800 mL should be used [17].  

Additional perioperative factors that impact the nurse’s care of surgical clients include the type and route of anesthesia used, client hypothermia and blood loss, and infection prophylaxis. The ERAS protocol for these situations is detailed below. 

Neuraxial anesthesia is more commonly used in orthopedic lower limb surgery than general anesthesia since it reduces pulmonary complications, postoperative pain, postoperative nausea and vomiting, and ileus, all of which decrease length of hospital stay [7,17]. However, urinary bladder dysfunction is less frequently associated with general anesthesia than neuraxial anesthesia. Previous research does not define a significant difference in surgical duration, surgical site infection, thromboembolic disease, nerve palsy, blood loss, or mortality between the two surgical techniques [7]. Epidural analgesia is effective for postoperative pain, but the nurse should assess clients for hypotension and urinary retention, which can delay recovery. Because of the potential complications, epidural anesthesia is not recommended in TKA and THA [7,17].  

Local infiltration analgesia involves administering pain medication around the surgical site during surgery, primarily in TKA. The medications that can be used are local anesthetics, NSAIDs, opioids, and steroids, and they can be effective for six to 12 hours following surgery [7]. LIA does not produce motor blockade, making it preferable to other nerve blocks. However, it can cause local anesthetic toxicity, infection, and delayed wound healing [17]. Neuromuscular blockade reduces airway pressure and muscle damage in spinal surgeries that require prolonged retraction. Intrathecal opioids in addition to local anesthetic in hip and knee surgeries lower pain scores and analgesic use, but they increase urinary retention, respiratory depression, postoperative nausea and vomiting, and pruritus, so their use is not recommended [17].  

Hypothermia is common in orthopedic surgical clients and is the catalyst for stress responses, increased infection, coagulopathy, cardiovascular complications, blood transfusion rate, and need for opioid therapy [7]. Hypothermia is present in 26% of THA clients, 28% of TKA clients, and 10% of clients with hip fracture [7]. Nurse should note that hypothermia is more prevalent in older females with lower body mass index that have hip and pelvic fractures [7]. In elderly clients with hip fracture, hypothermia can account for high 30-day readmission rates and 30-day mortality rates [7]. Nurses can prevent hypothermia in surgical clients by preheating intravenous and irrigation fluids and using warming blankets and devices. Nurse anesthetists can prewarm and humidify anesthesia gases [7]. The ambient temperature should be at least 70 degrees Fahrenheit while the client is exposed, prior to active warming starting [17].  

THA and TKA are associated with pronounced blood loss, which has previously been counteracted with blood transfusion. However, the risks of transfusion reaction, coagulopathy, renal failure, infection, disease transmission, and death make it less than ideal [7]. Blood transfusion has also been associated with increased cost and hospital stay [17]. Local (intra-articular) and systemic tranexamic acid (Cyklokapron) has been shown to reduce the risk of venous thromboembolic events since the medication stops the breakdown of a fibrin clot by inhibiting the activation of plasminogen, plasmin, and tissue plasminogen activator [7,17].  

Presurgical antimicrobial prophylaxis is important for curtailing SSI. During surgery, infection rates in joint replacement can be reduced with antibiotic-loaded bone cement although the practice is more effective in hip replacement surgeries versus knee replacement surgeries [17]. The use of dilute betadine lavage before surgical wound closure in THA and TKA is an effective measure to reduce the risk of acute postoperative PJI. Skin preparation using either alcohol-based iodine or chlorhexidine solution is preferred in spine surgery [7].  

Nurse’s Role: Postoperative Stage 

The nurse’s role in the postoperative stage focuses on client comfort and restoring health to a pre-surgical condition, as much as possible. Controlling the client’s nausea and vomiting and pain are key nursing interventions. The nurse should continue to administer antiemetics as discussed previously per ERAS protocol. Non-pharmacological measures the nurse can take to control the client’s post-operative nausea and vomiting include offering aromatherapy, listening to music (as a distraction technique), and administering oral ginger [4]. 

Administering multimodal analgesics limits the use of opioids that can lead to client dependence and addiction [17]. The ERAS protocol mainstays of pain management include acetaminophen and NSAIDs. High-dose preoperative glucocorticoids added to multimodal medications have been shown to be very effective in controlling pain associated with THA and TKA [17]. The nurse should assess clients for bleeding complications, gastroduodenal ulcer, cardiovascular complications, and renal and hepatic function in clients who receive NSAIDs. Nonpharmacological nursing measures for controlling pain include cryotherapy and distraction techniques. Ice has been shown to reduce pain and swelling and improve range of motion (ROM) [7]. 

Although opioids are discouraged in the ERAS protocol, they can be prescribed and administered in the postoperative period, if necessary. Controlled-release oxycodone is better tolerated than patient-controlled analgesia (PCA) and is associated with shorter hospital length of stay [17]. Connection to a PCA pump can interfere with the client’s functional independence, which is an important discharge criterion in the ERAS protocol [17]. Nurses should monitor clients who are receiving opioids for respiratory depression, gastrointestinal upset (including constipation), pruritus, and mental confusion. 

Deep venous thrombosis (DVT) and pulmonary embolism (PE) can lead to post-thrombotic syndrome (PTS) or death in clients who undergo TKA and THA [17]. Without the use of preventative anticoagulants, VTE occurs in 40% to 60% of THA and TKA procedures [7]. Nurses should anticipate that clients will undergo DVT prophylaxis for 10 to 14 days and that assisting clients to mobilize as quickly as possible after surgery is expected. VTE prophylaxis medications include low-molecular-weight heparin, warfarin, rivaroxaban, fondaparinux, and aspirin. The nurse should anticipate the use of compression stockings and intermittent pneumatic compression devices, as well as ambulation orders for the client.  

In the postoperative period, intravenous fluids are discouraged in lieu of early oral intake [7,17]. The client is encouraged to return to a regular diet as soon as possible after surgery to reinforce normal behavior patterns. The nurse can assist the client in selecting menu items, providing fluids of choice, and explaining the importance of a healthy diet in postsurgical healing. 

Mobilization as soon as possible after surgery is a main criterion for client discharge in the ERAS orthopedic protocol [7,17]. Clients are typically discharged on the first or second postoperative day, and they should be mobilized to reduce the length of stay [17]. Prolonged bedrest is associated with muscle atrophy, reduced pulmonary function, impaired tissue oxygenation, increased risk of thromboembolism, increased insulin resistance, and anxiety and depression [7,17]. The goal is to discharge clients directly to their homes instead of a rehabilitation facility. The requirements for discharge to home include the ability to dress, transfer to and from bed, transfer to and from a toilet and chair, perform personal hygiene, and mobilize with a walker or crutches for 300 feet [17]. Each of these actions must be performed independently, and the nurse can assist clients by providing encouragement and maintaining an environment of safety. 

Barriers to the Nurse’s Role in ERAS 

Nurses are in a unique position to identify client issues since they are the professionals who assess clients on a daily basis. Even though nurses play a critical role in the successful implementation of the ERAS pathway, there are barriers that prohibit nurses from implementing an exemplary protocol. These barriers include poor nursing leadership, poor communication, lack of engagement, and lack of resources [5]. When nursing leadership is lacking, staff nurses do not feel empowered or supported. Strong nurse leaders encourage, motivate, and empower colleagues, as well as clients and their families [5]. Traditionally, nurses have been viewed as caregivers versus empowered clinicians who are autonomous. Nurses do not typically view themselves as leaders, and thus the multidisciplinary team members don’t either. Nurses can correct this by assuming more leadership roles and seeking ways to lead ERAS teams. Nurse managers and administrators should support staff nurses who seek leadership roles and encourage them to evolve from the strictly caregiver role. 

Some nurses lack knowledge about ERAS or don’t believe in its effectiveness, which can lead to inconsistencies in the protocol [5]. Some nurses feel insecure in their ability to progress clients along the ERAS pathway, particularly if the client is not compliant with early mobilization. Nurses can also doubt their autonomous role in the ERAS protocol and can find themselves seeking permission from multidisciplinary team members to advance their client along the protocol, which is not something that autonomous professionals should feel the need to do [5]. 

Communication amongst interdisciplinary team members needs improvement in the ERAS protocol. Conflicting approaches to client care among team members can lead to confusion, especially when traditional practices and beliefs are pitted against more recent evidence-based findings [5]. Nurses need to be encouraged to speak up, voice concerns, and advocate for their clients while being supported in their role. Structured meetings and nursing huddles can include daily client reviews that lead to care plan updates. Additionally, surgical nurses should be encouraged to report errors or issues to management without fear of repercussions to help promote a culture of safety in surgical environments [16]. 

Lack of client communication can lead to poorer outcomes, especially in the ERAS pathway. Nurses must communicate to the client clear expectations of the client’s behavior prior, during, and after surgery. Using appropriate language tools and taking the client’s cultural and social preferences into consideration help dispel confusion and inaccurate information, while providing individualized care that is meaningful to clients [5,16]. 

Even though research indicates that ERAS reduces the nurse’s workload, bedside nurses do not readily accept this [1,5]. Nurses may feel frustrated by the lack of time they have to follow the ERAS protocol. In recent years, nurses have left the profession due to stress and burnout, and the Covid-19 pandemic has escalated this, which is another factor that negatively impact the success of ERAS [5].  

Solutions to these challenges include ensuring nurses in the surgical setting receive ongoing education regarding new technologies and pathways to ensure their safe implementation [16]. Implementing an ERAS nurse specialist, or coordinator, can help advocate for staff education, data management, and care pathway development. The coordinator can implement real-time auditing that keeps the team informed and helps team members bridge knowledge gaps. Real-time auditing can also pinpoint successes, so that nurses can understand that their efforts are making a positive difference. 

Continuous Audit and Improvement 

ERAS protocol includes several medical departments, such as surgery, anesthesia, physical therapy, pharmacy, and nursing. The ERAS team can be comprised of pre-admission staff, dieticians, nurses, physiotherapists, social workers, occupational therapists, anesthesiologists, and surgeons [1,13]. For ERAS to be successful, the team members must be familiar with ERAS principles and be motivated to execute the pathway. This often includes looking beyond traditional concepts, attitudes, and teachings regarding perioperative care. Sharing client information among disciplines is vital to successful multidisciplinary collaboration. Consistent ERAS team meetings can help foster collaboration [7]. 

Auditing and improving protocols lead to exemplary healthcare outcomes; however, no protocol is effective if it isn’t adhered to. ERAS protocol has experienced low compliance in some procedures, such as colorectal surgery where the compliance rate is 60% [17]. Continuous auditing of protocols helps reinforce compliance. The role of an audit is to measure clinical (complications, readmissions) and non-clinical (economics, client satisfaction) outcomes, measure process compliance with ERAS components, and include new evidence and modify the concept when indicated [7,17].  

An audit compliance includes [2]: 

• Pre-operative data: Pre-op (real time) checklist, data entry 

• Anesthesia data: Anesthesia checklist, including multimodal analgesia 

• Surgery data: Length of procedure, type of procedure, skin prep 

• Inpatient activities: Daily huddles for compliance and outcomes; real-time chart audits versus post-discharge audits 

• Emergency medical record (EMR) data reports: Daily ERAS reports by service line, monthly ERAS reports, annual ERAS reports, manual check of EMR reports for accuracy 

• Data platforms: National Surgical Quality Improvement Program (NSQIP) ERAS platform; Agency for Healthcare Research and Quality (AHRQ) Improving Surgical Care and Recovery (ISCR) platform; ERAS Society data platform; and MDMetrics data platform 

Future focus is on pain-free and risk-free THA and TKA surgeries, but a better understanding of the pathophysiological mechanisms of recovery are needed. Properly designed randomized controlled studies performed in ERAS settings that highlight post-discharge markers of recovery will prove helpful. Understanding the postoperative inflammatory response, how to further reduce pain, and how to improve postoperative function at a faster rate are components that will improve ERAS. Delving into topics like identifying clients at high risk of complications due to psychiatric disorders, chronic renal failure, and impaired sleep can improve ERAS in orthopedic surgery [17]. 

Ongoing education, support, and empowerment of nurses in the ERAS protocol will ensure the pathway’s success. 

Conclusion

ERAS in orthopedic surgery can reduce postoperative complications and hospital stays, which can reduce costs. Clients can experience accelerated recovery times, which lead to improved client outcomes. Successful ERAS includes standardization of care, multidisciplinary communication and collaboration, staff continuing education, and ongoing audits to evaluate the effectiveness of ERAS. Implementing an effective ERAS system also entails flexibility whereby the 

multidisciplinary team is not afraid to change tactics and try new approaches when current protocols are proving ineffective. 

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