Running Head: Enhanced Recovery After Surgery Guideline 1

Running head: ENHANCED RECOVERY AFTER SURGERY GUIDELINE 1
Enhanced Recovery After Surgery
Evidence-Based Practice Perioperative Guideline Implementation for Hepatectomy
Camille Petraitis
East Carolina University

ENHANCED RECOVERY AFTER SURGERY GUIDELINE 2
Abstract
Liver cancer is the 10th most common cancer in the United States and the fifth most common cause of
cancer-related deaths (American Society of Clinical Oncology [ASCO], 2016). Partial hepatectomy
continues to remain the most frequently used curative treatment for liver cancer (Ni et al., 2013). The
Enhanced Recovery After Surgery (ERAS) protocol is a standardized, interdisciplinary, coordinated
perioperative care plan that integrates evidence-based interventions to improve surgical outcomes through
minimizing the metabolic stress response (Huang, 2016; Ni et al, 2013; Melloul et al., 2016). Variation in
surgical care for hepatectomy can be reduced through ERAS guideline implementation that ultimately
leads to improvement in postoperative outcomes (Hughes, Chong, Harrison, & Wigmore, 2016). The
primary purpose of this project was to implement and evaluate compliance of the ERAS guideline for the
three phases of perioperative care in patients undergoing hepatectomy. Secondary aims were to evaluate
morbidity, hospital length of stay (HLOS), readmission within 30 days, and 30-day mortality. The ERAS
protocol was implemented and data was collected from September 14, 2017 to November 24, 2017. A
total of 20 patients were included in this project. The guideline was effectively implemented with a mean
overall compliance of 77.7%. Secondary aims showed favorable outcomes when compared with other
studies within this institution and will be further discussed within this paper.
Acknowledgments
Several people have played an important role throughout the process of completing this quality
improvement project. I would like to express gratitude to my DNP project committee and champion for
the guidance and encouragement to pursue this project. Next, a special thank you to my mother, father,
sister, grandparents, and friends for their generous support as well as motivation to finish. Last but
certainly not least, many thanks to my wonderful boyfriend for the continued support and love through
the countless hours of work necessary to complete school and this project. I appreciate the support all of
you have given me and am truly blessed to have each one of you in my life.
Table of Contents
Abstract ......................................................................................................................................................... 2
Acknowledgments......................................................................................................................................... 3
Problem Statement ........................................................................................................................................ 6
Justification of Study .................................................................................................................................... 7
Conceptual Framework ................................................................................................................................. 7
Lewin’s Change Management Theory...................................................................................................... 8
Assumptions.................................................................................................................................................. 9
Problem Question.......................................................................................................................................... 9
Summary ..................................................................................................................................................... 10
Research Based Evidence ........................................................................................................................... 10
Overview of ERAS Guidelines............................................................................................................... 10
ERAS in Hepatectomy............................................................................................................................ 11
Lewin’s Change Management Theory.................................................................................................... 18
Summary................................................................................................................................................. 20
Methodology ............................................................................................................................................... 20
Study Design .......................................................................................................................................... 20
Sample .................................................................................................................................................... 21
Setting ..................................................................................................................................................... 21
Methods .................................................................................................................................................. 21
Protection of Human Subjects ................................................................................................................ 24
Data Collection ....................................................................................................................................... 24

Data Analysis.......................................................................................................................................... 25
Limitations .............................................................................................................................................. 31
Results ......................................................................................................................................................... 25
Sample Characteristics ........................................................................................................................... 25
Major Findings ....................................................................................................................................... 26
References ................................................................................................................................................... 35
Appendix A ................................................................................................................................................. 40
Appendix B ................................................................................................................................................. 43
Appendix C ................................................................................................................................................. 44
Appendix D ................................................................................................................................................. 51
Appendix E ................................................................................................................................................. 61
Appendix F.................................................................................................................................................. 63
Appendix G ................................................................................................................................................. 65
Appendix H ................................................................................................................................................. 66
Appendix I .................................................................................................................................................. 69
Appendix J .................................................................................................................................................. 70
Appendix K ................................................................................................................................................. 71
Enhanced Recovery After Surgery
Evidence-Based Practice Perioperative Guideline Implementation for Hepatectomy
Liver cancer is the 10th most common cancer in the United States and the fifth most common
cause of cancer-related deaths (American Society of Clinical Oncology [ASCO], 2016). According to the
American Cancer Society (2017), there will be 40,710 new predicted cases of liver cancer in 2017. Liver
resection is the first-line option for patients with resectable disease (Jelic & Sotiropoulos, 2010).
Hepatectomies are challenging for surgeons and patients with morbidity rates ranging from 17% to 45%
and a mortality risk up to five percent (Hughes, Chong, Harrison, & Wigmore, 2016; Melloul et al.,
2016). In recent studies, Enhanced Recovery After Surgery (ERAS) perioperative guidelines have
decreased overall morbidity rates compared with traditional practice (Hughes, McNally, & Wigmore,
2014; Jones et al., 2013; Wu et al., 2015). ERAS is a concept that consists of a multidisciplinary team
working together throughout the three phases of perioperative care using a multimodal approach to
prevent issues that delay recovery and ultimately cause complications (Llungqvist, Scott, & Fearon,
2017). Randomized controlled trials implementing ERAS protocols for liver surgery have also been
shown to reduce morbidity rates after resection (Hughes et al., 2016; Jones et al., 2013).
Problem Statement
Partial hepatectomy continues to remain the most frequently used curative treatment for liver
cancer (Ni et al., 2013). Hepatectomy can cause a considerable stress reaction and disturbance in
metabolic function within the body and complications associated with this surgery can be fatal (Ahmed et
al., 2016). Standardization of perioperative care can help to improve the variability that can potentially
lead to the negative outcomes associated with major abdominal surgery (Hughes et al., 2016; Ahmed,
Khan, Lim, Chandrasekaran, & MacFie, 2011). Consequently, compliance is a key factor in improving
outcomes associated with the perioperative ERAS protocol implementation (Pedziwaitr et al., 2015). The
purpose of this project is to implement the ERAS protocol in hepatectomies and evaluate compliance in
the three phases of the ERAS guideline for hepatectomy to reduce variability in perioperative care.
Potential decreased patient morbidity, decreased hospital length of stay (HLOS), readmission within 30
days, and 30-day mortality may be observed.
Justification of Study
Cancer survivors are living much longer lives due to advancements in healthcare (Llungqvist et
al., 2017). Survival rate at one year for patients with a primary liver cancer is 44% and 17% at five-years
(ASCO, 2016). With improved survival, quality healthcare needs to be delivered through a
multidisciplinary approach within the oncologic population. At this large urban healthcare system located
in the southeastern United States (U.S.), approximately 180 hepatectomies were completed in 2016
without a uniform perioperative process. Improvements in current surgical and perioperative
management for liver resections at other organizations have led to mortality rates under five percent
(Hughes et al., 2014). Yet, morbidity rates remain greater than 30% (Wang et al., 2017). The site can
improve morbidity and mortality by standardization and compliance with hepatectomy perioperative care.
These numbers could be improved at this facility with standardization, completeness, and compliance in
perioperative care for hepatectomies.
Conceptual Framework
The concept of change management is a familiar term to many organizations but there is a great
amount of variability on how institutions manage change. Change is an inevitable occurrence, yet
literature has identified numerous barriers or failures associated with the transformation of an idea or plan
into action (Mitchell, 2013). It is estimated that more than two thirds of organizational change projects
fail (Mitchell, 2013). Planned change in any setting is very challenging; in healthcare, the difficulties
arise from attitudes of staff, availability of resources, and generalized resistance to change (Mitchell,
2013). Enhanced communication and purposeful planning will assist with the process of change
(Mitchell, 2013). Thus, a structured approach with implementation will help to overcome foreseeable
obstacles. Accordingly, an identified change theory for this quality improvement (QI) project was
essential in implementing, managing and evaluating the planned guideline transformation (Mitchell,
2013).
Lewin’s Change Management Theory
Lewin’s change management theory aimed to help others understand human behavior and change
as well as the patterns of resistance associated with change (Sutherland, 2013). Change in this model was
described as a dynamic force within an organization that moved in opposite directions (Butts & Rich,
2015). The two types of forces consisted of driving and restraining forces. The driving forces expedited
change by pushing employees in the preferred direction. In contrast, the restraining force hindered
change by pushing employees in the opposite direction (Mitchell, 2013). The balance of these forces
happened when the change occurred in this model (Butts & Rich, 2015). The shift of the balance needed
to be initiated in the direction of the planned change that promoted the desired outcome using three steps:
unfreezing, moving, and refreezing. These three steps provided a framework for managing organizational
change for this QI project.
Three stages. There are three steps to Lewin’s change management theory. In the first step,
unfreezing, this institution identified the problem of focus (Sutherland, 2013). Once the problem or
variability of perioperative care was established, communication about planned change to create
recognition of the updated protocol was completed (Mitchell, 2013). In the moving stage, attitudes were
developed with the planning and implementation of the QI project that allowed for the assessment of
consequences of these changes (Mitchell, 2013; Sutherland, 2013). Then, in the refreezing or final stage,
the change was consolidated and reinforced through policies and organizational norms (Manchester et al.,
2014). Additional support and encouragement of the updated guideline were encouraged from the ERAS
team in this phase as well. The unfreezing, moving, and refreezing stages helped to strengthen the
thought process throughout the application of this QI project. This theory created a solid foundation for
the implementation of ERAS guidelines in hepatectomy within this facility. The stages provided a
framework for following this conceptual model throughout the implementation of this project.
Assumptions
There has been an abundant amount of research conducted on ERAS guidelines within multiple
specialties (Hughes, McNally, & Wigmore, 2014; Ni et al., 2013; Lau & Chamberlain, 2016; Melloul et
al., 2016). While there are numerous studies with recommended ERAS items pertinent to hepatectomies,
discrepancies occur between institutions (Ni et al., 2013; Wong-Lun-Hing et al., 2014). Therefore,
assumptions were made about ERAS implementation at this institution prior to the execution. The first
hypothesis suggested that compliance was variable throughout the initial implementation of ERAS
guidelines. Variability can occur with new protocols due to medically justified circumstances or may be
related to existing attitudes and beliefs in healthcare (Roulin et al., 2017). Therefore, it is important to
document the rationale for deviations in guideline adherence (Roulin et al., 2017). Variability in
compliance may not reveal the true benefits of ERAS. The second assumption believed there would be
resistance from all staff involved with the application of the perioperative guideline that needed to be
overcome through audits. The final assumption stated the results of this QI project would unlikely
display much difference in improvements of secondary aims due to a short implementation period. Future
studies need to be implemented once compliance percentages are met and more cases were available for
comparison.
Problem Question
Liver surgery requires a multidisciplinary team specific to each perioperative phase that work
together to improve patient outcomes. Standardization of perioperative care can improve variable
mortality rates associated with hepatectomy cases (Melloul et al., 2016). Consequently, the following
statement was identified throughout the search for evidence on this topic: With the implementation of the
three phases of the perioperative ERAS guideline for hepatectomy through staff education and electronic
medical record (EMR) powerplan, will compliance of the protocol reduce variability in perioperative care
with possible decreases noted in patient morbidity, HLOS, 30-day readmission, and 30-day mortality?
Summary
The dissemination of ERAS in hepatectomy appeared advantageous with studies noting reduced
morbidity, hospital length of stay (HLOS), and cost with no change in mortality or readmission rates
(Ahmed et al., 2016; Hughes et al., 2014; Ni, Yang, Zhang, Meng, & Li, 2015; Wang et al., 2017; Wong-
Lun-Hing et al., 2014). It is important to note that documentation of compliance in each perioperative
phase with the guideline implementation for liver resections was a crucial part for future trials to complete
for benchmarking purposes (Melloul et al., 2016). Thus, more prospective studies need to augment
existing literature on the clinical use of the ERAS guidelines in liver resections (Ahmed et al., 2016;
Melloul et al., 2016; Wang et al., 2017). Admittedly, with new guidelines come many changes and
challenges for all the staff involved with the executed protocol. New protocols in healthcare are gradual
processes that require time, restructuring, and persistence to achieve optimal results (Mitchell, 2013).
Improved outcomes with ERAS will continue to depend on evidence-based projects to strategically guide
institutions to create and sustain these protocols.
Research Based Evidence
Overview of ERAS Guidelines
Perioperative care was changed worldwide for all patients with the introduction of multimodal
enhanced recovery programs (Wong-Lun-Hing et al., 2014). Several studies within the surgical
community have studied the enhanced recovery concept (Ni et al., 2013; Melloul et al., 2016; Wong-Lun-
Hing et al., 2014). This approach combined numerous evidence-based practices in perioperative
protocols and transformed them into a structured care pathway; this pathway permitted accelerated
postoperative recovery (Ansari, Gianotti, Schroder, & Anderson, 2013; Llungqvist, Scott, & Fearon,
2017; Wong-Lun-Hing et al., 2014). The coordinated perioperative approach aims to reduce several
physiological responses in the body, termed the stress response (Melloul et al., 2016). With a reduction in
the body’s stress response, a reduction in medical complications can be seen (Huang, 2016; Ni et al.,
2013; Lau & Chamberlain, 2016; Melloul et al., 2016).

A literature review was completed to review ERAS and hepatectomies. PubMed was the
database primarily used for this search. Ovid and Medline were also utilized to enhance this review.
Keywords associated with this search included: Enhanced recovery after surgery, ERAS, fast-track
surgery, perioperative care, hepatecomy, liver resection, liver surgery, primary liver cancer,
hepatocellular carcinoma, HCC, liver lesion, benign liver lesion, and liver metastases. For this literature
review, all patients undergoing hepatectomy were included in this search regardless of pathology. The
word “and” was included in all searches to encompass as much data as possible. Approximately 250
articles pertaining to the various elements of ERAS and hepatectomy were obtained. Predominantly,
articles published within the last five years were used for this paper. The oldest article out of the research
pertaining to ERAS protocol was a guideline published in 2010; there were no updated versions of this
article available. Data on non-liver surgery were generally excluded from this paper. If non-liver topics
were included, valuable data on ERAS utilization were included in articles non-specific to surgical
procedure. Ultimately, there were 27 articles used in this paper on ERAS data and hepatectomy. Other
articles and websites pertained to statistics and theory.
Adoption of ERAS programs have been slow despite documented benefits (Lau & Chamberlain,
2016; Llungqvist et al., 2017). Multiple articles revealed decreased HLOS, morbidity, and cost with
ERAS in liver resections; yet, future studies and additional research was recommended (Ahmed et al.,
2016; Hughes et al., 2014; Jones et al., 2013; Ni et al., 2013). The purpose of this QI project was to
complement existing data on compliance with the implementation of ERAS in hepatectomies through
EMR powerplan and education. In the process of execution, data has been collected to further discuss
deviations from the protocol to improve barriers and variability with compliance in ERAS
implementation.
ERAS in Hepatectomy
Since the creation of ERAS, many elements of this concept have been informally introduced to
perioperative care (Wong-Lun-Hing et al., 2014). For example, many institutions partially implement
ERAS guidelines by initiating some but not all the recommended ERAS items (Wong-Lun-Hing et al.,
2014). Without every element or documented compliance, the benefits of ERAS may not be identifiable
(see Appendix A for ERAS items) (Ahmed et al., 2011; Pedziwaitr et al., 2015). Fortunately, several
groups within the surgical community have started to properly execute and document the concept of
ERAS within different specialties (Wong-Lun-Hing et al., 2014). The positive outcomes associated with
ERAS and colorectal surgeries have created a new standard of perioperative care (Llungqvist et al., 2017;
Melloul et al., 2016; Wong-Lun-Hing et al., 2014). Accordingly, additional dissemination of ERAS in
hepatectomy appeared beneficial with studies noting reduced morbidity, HLOS, and cost with no change
in mortality or readmission rates (Ahmed et al., 2016; Hughes et al., 2014; Ni et al., 2015; Wang et al.,
2017; Wong-Lun-Hing et al., 2014).
Morbidity. Hepatectomies have been steadily associated with major morbidity due to the
complexity of these surgeries (Hughes et al., 2014). With advancements in perioperative care such as
enhanced recovery pathways, morbidity rates have declined but remain above 30% (Ni et al., 2015;
Hughes et al., 2014; Lau & Chamberlain, 2016). Common complications associated with hepatectomy
included: nausea, vomiting, wound infection, pleural effusion, intraperitoneal abscess, bile leak,
postoperative hemorrhage, and liver failure (Ahmed et al., 2016; Hughes et al., 2016; Ni et al., 2013).
Reduction of inflammatory reactions, decreased surgical stress, and maintenance of physiologic function
of vital organs are a few of the aims of ERAS in hepatectomy to reduce the complications associated with
surgery (Wu et al., 2015). Two meta-analyses were reviewed that evaluated ERAS with traditional care
for hepactomies. Wu et al. (2015) merged complication rates of 14 studies with 1,400 patients and found
the enhanced recovery group to have a total complication rate of 19% compared to a 27% complication
rate in the conventional surgery group. Hughes et al. (2014) revealed similar findings through their meta-
analysis including 522 patients with a median overall complication rate of 25% in the ERAS group versus
31% in the conventional group.

HLOS. Enhanced recovery pathways for major abdominal surgeries have resulted in shorter
HLOS by 30-50% according to a review of ERAS (Llungqvist et al., 2017). One of the main components
used to evaluate ERAS is HLOS. Decreased HLOS justified the additional benefits of ERAS such as
perceived quality of life and decreased hospital costs (Fawcett, Mythen, & Scott, 2012; Llungqvist et al.,
2017). Compliance to ERAS protocol could prevent unnecessary prolonged hospital stays (Ansari et al.,
2013; Fawcett et al., 2012).
ERAS programs in hepatectomy have been shown to significantly reduce HLOS (Jones et al.,
2013; Kailbori et al., 2017; Ni et al., 2015; Wu et al., 2015). On average, ERAS reduces HLOS by 2 days
in patients that underwent hepatectomy for any type of liver lesion (Joliat et al., 2016; Stone et al., 2016).
In contrast, a study by Liang, Jun, Xiao, Jun, & Jian, (2014) revealed a 4-day reduction in HLOS in
patients with hepatocellular carcinoma in the enhanced pathway group compared with conventional care.
The results of this specific study may have been skewed since the study took place in one facility and had
relatively small sample sizes (Liang et al., 2014). Regardless, with any reduction in HLOS, hospital costs
were reduced (Ansari et al., 2013; Lau & Chamberlain, 2016; Llungqvist et al., 2017; Wu et al., 2015).
Cost. As healthcare costs continue to rise, ERAS guidelines are becoming increasingly attractive
with their economic benefit and improved medical outcomes (Gani et al., 2016). These programs
decrease postoperative complication risk and accelerate recovery, which ultimately decreases hospital
LOS and cost per patient (Gani et al., 2016; Joliat et al., 2016). Postoperative complication from
hepatectomy in one study showed prolonged hospital stay and services which resulted in a total hospital
cost one and a half times higher than a benign postoperative course (Joliat et al., 2016). Another study by
Volanthen et al. (2011) revealed a statistically significant increase in costs associated with postoperative
complications. Costs reached up to five times more compared to a similar operation without complication
(Volanthen et al., 2011).
At this hospital located in the southeastern U.S. the total cost for partial hepatectomy was $13,740
and hepatic lobectomy totaled $16,529 (K. Tezber, personal communication, December 2016); In brief,
one can conclude that the reduction in LOS alone associated with the implementation of ERAS guidelines
could potentially decrease hospital costs on average by $3,000 per person. Although the implementation
of these guidelines has not yet shown a specific reduction in readmission rates, it should be noted that the
general cost of readmission at this facility is $6,000 per case (K. Tezber, personal communication,
December 2016). With the clinical improvements recognized through ERAS, assumptions could state
reduction in complication rates will also decrease readmission rates in the future.
It is important to recognize that the implementation of ERAS guidelines is an expensive
endeavor. Stone et al. (2016) completed a study that discussed implementation costs and compared these
with hospital savings from ERAS guidelines within one academic medical center. A total cost of
$552,783 was associated with implementation and was offset by a savings in the first year of $948,500;
making a net savings of $395,717 (Stone et al., 2016). To maximize cost-effectiveness while
simultaneously minimizing unnecessary use of hospital and financial resources, ERAS guidelines have
been steadily implemented worldwide (Stone et al., 2016).
Mortality and Readmission. The positive outcomes that are associated with the ERAS
guidelines in hepatectomy that previously were noted required further investigation to ensure that a
quicker recovery did not equal increased mortality or readmission rates. The same studies that have
demonstrated decreased morbidity, HLOS, and cost also revealed no significant difference in 30-day
readmission or mortality rates (Ahmed et al., 2016; Lau & Chamberlain, 2016; Ni et al., 2015; Wu et al.,
2015). While these guidelines do not necessarily improve mortality or readmission rates, they do improve
other aspects of patient care to improve overall evidence-based quality healthcare (Ni et al., 2015; Wu et
al., 2015). This data further supports that enhanced recovery pathways are favorable to traditional
surgical approaches (Wang et al., 2017; Wu et al., 2015). It was significant to note if compliance was
measured throughout implementation of the guideline to address the maximal benefits of ERAS with
implementation.
Compliance. Optimal outcomes are yet to be established in hepatectomies due to variation in the
components of ERAS protocols as well as compliance in everyday practice (Huang, 2016). Perioperative
care can vary substantially even with ERAS protocols in place (Wong-Lun-Hing et al., 2014). Increased
compliance to ERAS items in the perioperative phases can improve the outcomes previously discussed
(Pedziwaitr et al., 2015). ERAS teams that tracked compliance could better identify barriers and
problems with execution to increase adherence (Wong-Lun-Hing et al., 2014). In general, adherence to
preoperative and intra-operative modalities have been noted with a distinguishable decrease in adherence
within the postoperative period (Roulin et al., 2017). This may be due to appropriate medical decision
making to deviate from the guideline or previous training and resistance to postoperative guideline change
(Roulin et al., 2017).
The introduction of ERAS is a gradual process and compliance rates should increase with time
(Pedziwaitr et al., 2015). Full compliance in most studies was noted to be at least 70% or above in each
phase of the guideline (Gustafsson et al., 2011; Pedziwaitr et al., 2015). Higher compliance is congruent
with improved clinical outcomes (Gustafsson et al., 2011). In short, current discrepancies in results from
previous studies or ongoing studies may be due to issues with compliance that should eventually subside
(Ahmed et al., 2011). Protocol adherence needs to be documented as part of further trials to improve
future guideline application (Melloul et al., 2016).
Limitations in Previous Projects. Although all the literature included within this review was
high quality, there were still a few consistent limitations documented. To start, in a few of the studies
conducted, double-blinding was impractical to complete due to the nature of the intervention (Jones et al.,
2013; Kailbori et al., 2017). Bias could therefore be an issue because researchers wanted to produce
positive outcomes with ERAS groups (Jones et al., 2013). Bias was also noted in other studies due to
incomplete charts, which could create reporter bias in analysis sections (Hughes et al., 2016). If
complications were not charted, there is a possibility a complication was missed and not accurately
included in the study (Hughes et al., 2016). Additionally, comorbidities may have been omitted, which
also can skew data (Hughes et al., 2016).
Another common limitation was the baseline differences in patient characteristics noted between
groups (Jones et al., 2013; Wang et al., 2017). For example, in the study completed by Jones et al.
(2013), a significantly greater number of patients in one group had neoadjuvant chemotherapy. This
could increase morbidity or influence postoperative outcomes (Jones et al., 2013).
The final limitation noted a lack of consensus in published guidelines worldwide in ERAS items
for hepatectomy (Wang et al., 2017). Thus, compliance also varied within studies; both of which could
have reduced or enlarged the effects of ERAS within studies (Wang et al., 2017). Variability in
guidelines as well as terminology within the protocol can lead to misrepresentations. For example, some
studies use HLOS as an outcome of interest while other studies would prefer to use functional recovery
(Hughes et al., 2014). Hence, standardization is needed to decrease future limitations.
Gaps in Literature. Enhanced recovery pathways have demonstrated their value in many
different specialties including liver resections; still, a need remains for high-quality studies to enhance the
data for hepatectomy (Melloul et al., 2016). Research conducted on ERAS in hepatectomy has proven to
be feasible and safe (Jones et al., 2013; Kailbori et al., 2017; Ni et al., 2015; Wang et al., 2017).
However, there is a lack of standardization of ERAS guidelines in hepatectomy that need to be further
investigated (Melloul et al., 2016; Wang et al., 2017). The major gaps in literature noted in ERAS items
for hepatectomy included prophylactic abdominal drainage and analgesia.
Many institutions use prophylactic abdominal drains to detect early complications of surgery such
as leaks, hemorrhage, or abscess (Kailbori et al., 2017). Prophylactic abdominal drains in major
abdominal surgery were studied in a meta-analysis conducted in 2004 with the recommendation of
omission of routine prophylactic abdominal drainage; but only three of the selected RCT’s were focused
on liver resections (Melloul et al., 2016). Other studies have looked at prophylactic abdominal drainage
revealing some positives and negatives (Kailbori et al., 2017; Melloul et al., 2016). The positives of
prophylactic abdominal drainage in liver resections included reduced frequency of subphrenic abscess and
biliary fistula formation, as well as other excess fluid in the abdominal cavity decreasing the need for
paracentesis (Kailbori et al., 2017; Melloul et al., 2016). The disadvantages in another study regarding
prophylactic abdominal drains proved higher rates of infected collections and impediment to achieving
early mobilization (Kailbori et al., 2017). The existing research is inconclusive and no recommendation
could be made for or against abdominal drainage (Melloul et al., 2016).
Analgesia also lacks consistency in the ERAS guideline for hepatectomy. Thoracic epidural
analgesia (TEA), local anesthetic wound infusion catheters, and pain-controlled analgesia (PCA) have all
been used within the protocol (Melloul et al., 2016). A concern with TEA is the prolongation of
prothrombin time after hepatectomy, which may delay removal of the catheter and increase the rate of
corrective blood product usage (Melloul et al., 2016). Local anesthetics have shown a decrease in HLOS
but provide less pain control compared with epidural analgesia (Melloul et al., 2016). Pain-controlled
analgesia can always be used as an alternative but opioid usage can delay gastric motility and cause a
prolonged postoperative hospital stay (Melloul et al., 2016). Given these points, there is a push to
decrease opioid usage postoperatively. The standardization of postoperative pain control needs to be
addressed to unify the ERAS hepatectomy guidelines to better results.
Enhanced recovery pathways need to continually be conducted to confirm their benefit and justify
their use. Prolonged studies would benefit ERAS guidelines in hepatectomy to better investigate the
long-term effects of these guidelines such as quality of life, readmissions, or mortality. For example,
readmission rates were almost doubled in a study with the use of ERAS programs in upper
gastrointestinal surgeries (Lau & Chamberlain, 2016).
Future trials, including this project, have continued to develop the enhanced recovery pathways
for hepatectomy. Compliance and strategies for creating and sustaining ERAS programs need to be better
stated in studies to complete the gap of the unknown information that comes with implementation.
Theoretical frameworks can assist novice institutions with this process to ensure completion of the
different elements found within the ERAS protocol.
Lewin’s Change Management Theory
Lewin’s change management theory used a traditional approach to change within organizational
structure through driving and resisting forces (Butts & Rich, 2015). This approach alters the conventional
method to a clinical path (unfreezing), refines provider and staff behaviors (movement), and then
reinforces new organizational change (refreezing) to assist in the inevitable transformation within
healthcare settings (Manchester et al., 2014). Lewin’s change management theory will provide a
framework for managing organizational change with this QI project through three stages of change:
unfreezing, movement, and refreezing.
Unfreezing stage. The first step of this theory involved the identification of the initial problem
or change focus (Sutherland, 2013). In the case of this QI project, the variation in surgical management
for hepatectomy was the change focus. Thus, the implementation of ERAS guidelines within this
institution aimed to reduce the variation in perioperative care. In this stage, communication was key with
all stakeholders including ERAS specialists, nursing staff, operating room (OR) staff, managers, and
administration. The lines of communication needed to remain open and honest for feedback as this
creates a sense of trust and security with the proposed change (Sutherland, 2013). The inclusion of the
staff with the planning and decision making in the unfreezing stage helped key players to feel empowered
with the change.
In this phase, many discussions needed to take place with the intent to identify driving and
restraining forces to overcome barriers in the future with implementation (Manchester et al., 2014). For
this institution, the driving forces included: financial investment, support from surgeons as well as higher
management, standardization in perioperative care for staff, education to all staff involved with the
guideline implementation, and most importantly positive patient outcomes. The restraining forces that
would inhibit the acceptance of the ERAS guidelines consisted of: habits of experienced surgeons and OR
staff, nursing staff not following postoperative guidelines on the floor, lack of trust in the guideline,
inability to see the overall benefit or value of the project, and aversion to a new perioperative guideline as
it added more work initially (Manchester et al., 2014). The important point from this stage was to
promote driving forces while diminishing restraining forces that promoted successful adoption of ERAS
guidelines through active engagement for all involved.
Moving stage. The moving stage signified the period where ideas or attitudes were developed
with the planning and implementation of this QI project (Sutherland, 2013). Obtaining data, action
planning, execution, follow-up and assessment of implementation were all part of this process. Putting
the ERAS guidelines for hepatectomy into practice required active involvement and sustained effort from
staff across each phase of the perioperative recommendation set. A project this large involving so many
departments needed an effective roll out with inclusion of all stakeholders and champions as well as
assistance from key players. Considerations throughout this phase included: timelines, educational or
training needs, effects on workflow, organizational leadership, and reliability of data collectors for
compliance accuracy (Sutherland, 2013). A project leader was important to oversee and monitor progress
through all phases of the implementation. With time, the guidelines will become the new norm and
attitudes will be favorable toward these new practices as resistance declined (Manchester et al., 2014).
Refreezing stage. The final stage of Lewin’s theory was the refreezing stage. Consolidating the
change and reinforcement through support mechanisms, policies, and organizational norms were part of
this phase (Manchester et al., 2014). Praise, rewards, and encouragement were needed on the individual
level, and performance recognition was necessary on an organizational level to increase sustainability
(Manchester et al., 2014). Booster sessions were also encouraged to continue troubleshooting problems
with the guidelines (Manchester et al., 2014).
At this hospital, all the above needed to happen for effective implementation of ERAS guidelines.
Two key meetings were planned during the unfreezing phase completed within a month of
implementation; monthly meetings were completed thereafter. Based on the evidence, compliance levels
should be targeted to remain above 70% to generate notable differences in outcomes with ERAS
(Gustafsson et al., 2011; Pedziwaitr et al., 2015). At the end of this phase, a summary of problems and
challenges encountered as well as accomplishments were noted for future reference and will be further
explored in the discussion (Sutherland, 2013).
Summary
Enhanced recovery pathways for hepatectomy are systematically developed statements that
facilitate decision-making by healthcare personnel to decrease inappropriate variations in perioperative
care to promote high-quality patient care (Wu et al., 2015). The shift in perioperative care with ERAS
guidelines has verified improvements in surgical outcomes with major abdominal surgery (Ahmed et al.,
2011; Hughes et al., 2016). Outcomes in recent studies with ERAS in hepatectomies have demonstrated
reductions in HLOS, morbidity, and cost without increasing readmission or mortality rates (Huang, 2016;
Lau & Chamberlain, 2016; Melloul et al., 2016; Ni et al., 2015; Wang et al., 2017). Nevertheless,
completeness and compliance remain an issue to fully comprehend the significant effects of ERAS on
perioperative care.
The adoption of a new perioperative guideline can be a very difficult task (Sutherland, 2013).
The healthcare environment has created a complex culture for surgical care that can be resistant to
change. Successful introduction of ERAS guidelines through a shared vision of collaboration for patient-
centered care that involves a multidisciplinary approach has been completed in the past within this
institution. Dedication and motivation of the staff to continue to change daily practice and sustain this
guideline is essential. The change management theory was vital to help overcome the difficulties of
implementation and capturing compliance.
Methodology
Study Design
This QI project used a prospective design to evaluate compliance of staff to each of the
perioperative phase of the guideline during the implementation of the ERAS protocol. Clinical outcomes
after implementation of the ERAS guideline were also reviewed. Secondary outcomes that were observed
included: morbidity, HLOS, readmission after 30 days, and 30-day mortality. In the future, the results of
this QI project could be compared to historical data to evaluate potential decreases in secondary
outcomes.
Sample
The project included a purposive sample of adults with resectable liver lesions. Inclusion criteria
was comprised of men or women over 18 years of age and older diagnosed with a resectable liver lesion.
The liver lesion may be a primary liver cancer, metastatic disease, or a benign lesion. There were no
exclusion criteria for this project.
Setting
The ERAS protocol was implemented at an 875-bed surgery center in the Southeast U.S. The
surgery program performs benign and malignant surgical management of patients with liver conditions.
The ERAS guideline encompasses multiple sites within this institution. The preoperative phase of the
ERAS guideline was completed on site at the cancer institute. The intraoperative phase was implemented
in the preoperative area and the operating room. The postoperative phase took place in a specialized
surgical unit for hepatobiliary patients or the intensive care unit if needed.
Methods
Once this QI project was approved by the institution as well as East Carolina University
Institutional Review Boards, a multidisciplinary ERAS team was gathered. This ERAS team consisted
of: an ERAS program director, department head, ERAS nurse, anesthesiologists and surgeons, as well as
a data analyst. The role of this QI project leader within the ERAS team was to collaborate with the team,
gather data, create an EMR ERAS powerplan, fill out patient packets, as well as educate the staff on the
powerplan and ERAS protocol. Next, the foundational groundwork needed to be addressed.
Fundamental factors in this step included: identifying a motived leader, creating a realistic timeline, and
identification of current resources. Fortunately, this institution already had these three key concepts from
a previous implementation. Funding had already been addressed for this enhanced recovery pathway and
this project was added into the preexisting budget.
The initial phase of the implementation of the ERAS protocol started with extensive education to
the unit nursing staff, physicians, and residents currently on service that was divided into two sessions
one month prior to the formal execution of the guideline (see Appendix B). The education sessions were
conducted during work hours by this author. If a team member could not make one of these sessions, it
was expected that they would catch up through their peers for updates in ERAS. A call in option was
available as well. For those that could not call in or attend, the minutes from the meeting were emailed on
the information covered during these two sessions to all preoperative, intraoperative, and postoperative
staff that may be involved with ERAS patients. Minutes were sent to all staff members after completion
of the meeting. There was no log to track attendance of these meetings. Notable system-level changes
were designed and completed prior to formal implementation to facilitate compliance with each
perioperative stage of the ERAS guideline checklist (Appendix C). These system-level changes included:
creation of an electronic standardized powerplan for hepatectomy that was created by the Doctor of
Nursing Practice (DNP) project leader and EMR technologist as well as a weekly email of upcoming
hepatectomies from the clinic to notify the ERAS team and DNP project leader for data collection.
Since ERAS guidelines were already implemented within this institution for a different surgical
site within the same specialty, a pilot test was not indicated or completed. Once the formal
implementation began, the preoperative, intraoperative, and postoperative phases were strictly monitored
for quality data. Monthly meetings that discussed barriers, compliance rates, and additional restructuring
of the execution continued throughout this project as well as after to maintain sustainability.
Phase one. Preoperative care was completed in phase one of the ERAS guideline. Each patient
received one hour of preoperative counseling on the same day as their physical conducted by the
anesthesia department. One ERAS nurse completed all the ERAS educational sessions to ensure
consistency. These educational sessions involved discussions of preoperative learning and how to prepare
for surgery for patients and families undergoing hepatectomy. Counseling topics included: smoking
and/or alcohol cessation, preoperative nutrition, preoperative carbohydrate loading, complications of
surgery, drain and pain management concepts, immediate postoperative expectations, as well as discharge
and homecare expectations. The ERAS nurse gave the patients a tour of the postoperative surgical unit.
The point of educational teaching in the preoperative setting was to provide a procedure-specific
education course to help patients understand and familiarize themselves with details pertaining to the
surgery. Patients presented to the hospital the morning of surgery to begin phase two.
Phase two. Phase two was initiated when patients presented to the preoperative area and
continued in the operating room. Anti-thrombotic prophylaxis and methylprednisolone 30 mg/kg were
given to patients unless diabetic or other contraindications applied. Sequential compression devices were
placed. Skin preparation with chlorhexidine 2% scrub, and anti-microbial prophylaxis were completed in
the operating room prior to the start time of surgery. Patients received goal-directed therapy by utilization
of stroke volume variance technology. Glycemic control was maintained through insulin therapy.
Appropriate body temperature was maintained during surgery with a forced-air garment system. The use
of a nasogastric tube was not routinely indicated. Again, completion of items on the checklist were
documented for compliance purposes of the ERAS protocol. At the completion of surgery, phase three
was initiated.
Phase three. Postoperatively, patients were admitted to the hospital to the hepatobiliary surgical
unit or intensive care unit if appropriate. A PCA pump was started on most postoperative hepatectomy
cases depending on surgeon preference per each individual case. Anti-thrombotic prophylaxis was
continued throughout hospitalization. Normoglycemia was maintained with insulin therapy if indicated.
Nausea prophylaxis was made available on an as needed basis. Early mobilization was encouraged.
Diets were advanced as tolerated on postoperative day one. If adequately tolerating oral intake, pain
pumps were discontinued. Fluids are discontinued once a diet was started in effort to maintain a near-
zero fluid balance. Foleys were removed on postoperative day one. Once patients were tolerating a diet,
urinating, had bowel function, and pain was controlled, discharge was considered. A unique addition to
this guideline was the referral to a medical oncologist after discharge in addition to the surgeon. After all
the above was completed, audits were accomplished (see Appendix D).
Protection of Human Subjects
All patients received evidence-based standardized perioperative care. Patient privacy was
maintained throughout this project. Review by the Nursing Scientific Advisory Committee (NSAC) and
Institutional Review Board (IRB) at this institution as well at East Carolina University were completed.
Once permission was obtained and the project was deemed a QI project rather than subject research,
patients were assigned a unique QI number when their data was collected and recorded. All data
collected from this project was maintained on a single spreadsheet that was linked to the unique code
separate from the spreadsheet to any patient-identifying information. This information was stored in a
locked desk within a locked office that accessible by only the QI project leader. Primary and secondary
aims were then placed into ERAS Interactive Audit Systems (EIAS). The EIAS is an international
internet based data entry and analysis system used to monitor compliance. The EIAS permits official
ERAS institutions to gain access to this database. The key element to this system is that patient data is de-
identified with the main goal of assisting the perioperative team improve compliance to the ERAS
protocol. Once a subscription is cancelled, the subscriber has three months to download data of
preference then all the information is deleted. All the information collected throughout this study was
shredded after data collection and analysis.
Data Collection
Outcome measures were collected and managed by the DNP project leader. Data was extracted
from the EMR during the intervention period daily in real-time and was recorded with a compliance
checklist from September 14, 2017 through November 24, 2017 (see Appendix C). Real-time data
collection attempted observation of daily compliance and barriers that inhibited adherence to the protocol.
The DNP project leader then gave the data to ERAS nurse for proper entry into the EIAS. This system
ensured compliance was maintained and provided immediate feedback regarding deviation from best
practice noted within the ERAS guideline. Furthermore, the EIAS had the capability to continually
monitor audit progress and clinical outcomes to make identifiable improvements.
Data Analysis
Outcome measures were collected and managed by the DNP project leader and appropriately
entered into the EIAS by the ERAS nurse. The primary outcome of interest was the implementation of
the ERAS protocol for this QI project. This was measured by percent completion and compliance to the
preoperative, intraoperative, and postoperative phases of the guideline. A data analyst assisted the DNP
project leader with the statistical analyses of this study. Secondary outcomes were also evaluated that
included: morbidity, HLOS, readmission within 30 days, or 30-day mortality. Patient complications in
this project were graded using the Clavien Classification System. This is a system commonly used to
determine the severity of surgical complications. In brief, classification of surgical complications are as
follows: Grade one refers to any deviation from the postoperative course without a need for
pharmacological treatment outside of the usual medications to treat postoperative pain or nausea, grade
two complication requires pharmacologic treatment with drugs other than such allowed for grade one
complications and also includes blood transfusions as well as total parental nutrition, grade three
necessitates a need for surgical, endoscopic, or radiological intervention, grade four is a life-threatening
complication requiring intensive care unit management, and grade five refers to death of a patient (Dindo,
Demartines, & Clavien, 2004).
Results
Sample Characteristics
At the conclusion of this QI project, 20 patients underwent liver procedures performed by the
hepatobiliary surgical team between September 14, 2017 through November 24, 2017. There were a few
population variables that were important to note for this project sample. Out of the 20 patients, seven
were male (35%), the average age was 51.7 years old with a standard deviation (SD) of 14.5, and the
mean body mass index was 32.9 with a SD of 8.1. An additional important variable noted was the
American Society of Anesthesiologists (ASA) physical status classification system that measures patient
fitness prior to surgery. The lower the score, the healthier the patient. Four patients or 20% of patients
fell into categories one or two. The other 80% or 16 patients were rated a three or four demonstrating the
fact that most operative candidates had severe systemic disease (see Appendix E). There were 13 patients
that were excluded from the ERAS protocol as their procedures were aborted due to ablative procedures
not requiring resection or extensive disease. Procedure types for the participants included: left
hepatectomy, extended left hemihepatectomy, right hemihepatectomy, extended right hemihepatectomy,
other segmentectomies, as well as a wedge or minor resection (see Appendix E).
Major Findings
The purpose of this project was to implement the ERAS protocol in hepatectomies and evaluate
compliance in the three phases of the ERAS guideline for hepatectomy to ultimately reduce variability in
perioperative care. Preadmission and preoperative compliance are one phase of the guideline but given
the complexity of the preoperative phase due to extensive patient teaching, it was divided in the next
section to better evaluate compliance needs. Compliance was recorded for each individual ERAS item
that can be reviewed in Appendix F. To summarize, out of 31 measured items, compliance over 70% was
met in 19 areas. The four generalized areas that scored below 70% compliance pertained to mobilization,
postoperative epidural analgesia, and resection-site drainage (see Appendix F). These areas may be lower
due to appropriate variations in perioperative care or lack of documentation.
Overall, preadmission, preoperative, and intraoperative compliance were above 80 %. The mean
preadmission compliance totaled 81.3% with a SD of 21.3. Preoperative compliance had the highest
mean of 87.5 % with an 8.1 SD. Intraoperative compliance mean totaled 80% with a SD of 9.9. Lastly,
postoperative mean was the lowest compliance mean of 77.1% and a SD of 8.3. The total overall
compliance mean equaled 77.7 with a SD of 7.2 (see Appendix F). This remained above the
recommended 70% to see positive outcomes with the ERAS protocol (Gustafsson et al., 2011). The
potential secondary outcomes of continued compliance with the ERAS protocol in hepatectomy
procedures included decreased patient morbidity, HLOS, readmission within 30 days, and 30-day
mortality.
Morbidity. The Clavien Classification System was used to categorize the severity of surgical
complication. In total, out of the 20 cases, there was a single grade one complication (8.3%), four grade
two complications (33.3%), four grade three complications (33.3%), one grade four complication (8.3%),
and one grade five complication (8.3%). A breakdown of the most common complications can be
reviewed in appendix G including two intraoperative bleeds, one reoperation, two cases of ascites, and
one postoperative wound infection.
Secondary Outcome Measures. Hospital length of stay is a key measurement used to determine
efficiency of ERAS in hepatectomies. The mean HLOS for all months was 5 days with a SD of 5.6 days.
Hospital length of stay ranged from 3.2 to 6 days. Monthly means and SD can be viewed in Table 1
below.
Thirty-day readmission and survival were also evaluated for this project. There were two
readmissions recorded within the two-and-a-half-month period equating to a 10% readmission rate. The
survival rate at 30 days was 95% with one documented patient death.
Table 1
Hospital Length of Stay

Month Mean SD
September 5.3 3.1
October 6 7.3
November 3.2 2.7
Discussion
The ERAS guidelines have been well established in a few surgical specialties, but need continued
data collection and support for hepatectomies. This QI project implemented ERAS guidelines for
hepatectomy procedures within a single institution over a two-and-a-half-month period timeframe. This
project aimed to implement the three phases of ERAS in hepatectomies while monitoring compliance in
real time to reduce variability in perioperative care. Secondary outcomes including morbidity, HLOS, 30-
day readmissions and 30-day mortality were collected as well to monitor outcomes. In brief, 20 patients
were included in this QI project. Preadmission, preoperative and intraoperative mean compliance
remained above 80% while the postoperative mean compliance was documented at 77.1%. There were
12 patients that had complications (Appendix G). The mean HLOS for hepatectomies at this institution
was 5 days. There was one death as well as two noted readmissions within the 30-day time frame.
Implications of Findings
The main objective of this project was to evaluate and increase compliance in each perioperative
phase of the ERAS guideline with the goal of improving morbidity, HLOS, mortality and readmissions in
liver resection cases over time. Compliance has a central influence in the improvement of outcomes
associated with perioperative ERAS protocol implementation (Pedziwaitr et al., 2015). Full compliance
in this study as well as most other studies is noted to be at last 70 % or above in each perioperative phase
(Gustafsson et al., 2011; Pedziwaitr et al., 2015). The mean compliance in each phase of the
perioperative guideline exceeded 70% compliance in this QI project. This is somewhat atypical as
implementation and standardization is a gradual process that can take a period of about six months or 30
patients to attain such compliance rates (Gustafsson et al., 2011; Pedziwaitr et al., 2015). However, this
institution was practicing ERAS with other surgical procedures within the same unit possibly prompting
higher acceptance rates of this protocol among staff. It is important to exceed the 70% compliance rates
as this percentage has been found to correspond with improved clinical outcomes (Gustafsson et al.,
2011). While each phase of the guideline remained above 70%, another interesting similarity to prior
research is the lowest compliance rate noted within the postoperative period. Roulin et al. (2017)
revealed that this may be due to appropriate decision making or resistance to postoperative guideline
change from staff. Lower compliance rates in the postoperative phase found within this institution were
speculated to be due to difficult surgeries, medically unstable patients, and necessary medical deviations
due to postoperative complications.
Postoperative complications occurred in 12 patients accounting for 60% of patients undergoing
hepatectomies for this QI project. This is higher than the national morbidity rate of up to 45% (Hughes et
al., 2016; Melloul et al., 2016). This is important data to record and benchmark for future studies as well
as for comparison of ERAS patients within this facility undergoing hepatectomies in the future. A decline
in postoperative complications may be noted with increased compliance and usage of ERAS with
hepatectomies (Hughes et al., 2014; Wu et al., 2015).
Prolonged hospital stays could be prevented through increased compliance with ERAS guidelines
(Ansari et al., 2013; Fawcett et al., 2012). Typically, ERAS reduces HLOS by 2 days in patients
undergoing hepatectomy (Joliat et al., 2016; Stone et al., 2016). A meta-analysis of randomized control
trials of ERAS programs in liver surgery was completed to better evaluate ERAS outcomes. On average,
HLOS for hepatectomy procedures could range from 3 to 13 days (Song, Wawng, Zhang, Dai, & Zou,
2016). Song et al. (2016) found mean HLOS for ERAS groups was 6.05 days versus 8.9 days in the
conventional groups within this study. The ERAS group mean stay of 6.05 is comparable to the mean
HLOS of 5 days found within this QI project. Differences in HLOS could be due to high acuity patients,
severity of surgical procedures, and surgeon preferences on early discharge. Readmission and mortality
rates were also included within this project for benchmarking purposes but were not able to be compared
with other studies given lack of data on this topic.
Compliance as well as postoperative outcomes needs to be tracked to better identify barriers and
problems within the execution of ERAS protocols (Wong-Lun-Hing et al., 2014). Lewin’s change
management theory assisted this QI project to understand behaviors and patterns of resistance associated
with change (Sutherland, 2013). The unfreezing, moving, and refreezing stages provided a framework to
better implement the ERAS protocol and avoid or address barriers as well as improve compliance.
In the unfreezing stage, specific planned measures were accomplished to facilitate a smooth
implementation phase. For example, two educational ERAS meetings for staff prior to the QI start date
were completed to provide appropriate educational material to encourage usage of the ERAS guidelines
as well as guidance on navigation through the hepatectomy powerplan. These meetings addressed any
questions staff had about the protocol and created a new standard of perioperative care within this facility
for hepatectomy patients. All of which were intended to improve compliance within this stage.
In the moving phase, monthly meetings to address compliance issues with individual ERAS items
helped to disclose many questions and barriers to adherence. For example, urinary foley removal had a
compliance rate of 66.7% in the month of September. Therefore, charts were reviewed for rationale for
late foley removal and education was provided to the ERAS staff for poor compliance rates. If there was
question as to why a foley was not removed on time, the attending and nurse responsible for this patient
were asked to explain prolonged foley usage. Compliance rates increased to 77.8% and 80% the next two
months indicating this educational exercise was helpful to enhance appropriate perioperative care and
awareness of guidelines.
In the refreezing stage, consolidation of the change and reinforcement were required for
sustainability. Results of compliance and positive outcomes associated with ERAS and hepatectomy
procedures were reviewed with the team at the end of this project. Given that ERAS already was an
institutional desire and previously funded within this facility, the project has continued after the
termination of this QI project. Dissemination of the project via PowerPoint presentation was completed
to nursing staff as well as advanced care providers in the surgical oncology department to review the QI
project results and praise the hard work that was completed by all staff on the implementation of this
project. Additionally, monthly meetings with EIAS compliance data will continue to identify areas of
improvement with individual ERAS items and validate ERAS usage within this institution.
Successful introduction of ERAS and sustained usage in a complex health care environment can
be a challenging task. A lot of time and education are needed to successfully implement ERAS in any
setting involving a large multidisciplinary team. Recognition of an appropriate theoretical framework is
essential to implementation and evaluation of ERAS in hepatectomy.
Limitations
This QI project was limited due to the relatively short study period, which resulted in a smaller
number of patients for of data collection. The next limitation noted was the inclusion of all liver
resections in this project. This gave the project increased numbers for more meaningful results but did
not pertain exclusively to oncology patients; which primarily would be a topic of interest to this
institution. An additional limitation was the timing of the data collection. Due to time constraints, data
was collected at the end of the day resulting in shift change or difficulty finding sources of
noncompliance. Similarly, locating the staff that entered the data into the EMR within different areas of
the hospital proved to be very difficult to further discuss rationale for non-compliance. On this same
topic, residents and fellows completing their surgical oncology rotations were an unexpected limitation to
this QI project. Many different residents and fellows rotated through the hepatobiliary service that did not
have education on ERAS. In the future, rotation of new personnel on and off the service may need to be
considered to appropriately educate staff for consistency and compliance of the ERAS guideline. The last
limitation included the fact that this study was completed in a single center. Accordingly, future studies
need to be completed to replicate values and prove further significance.
Recommendations
The ERAS guideline for hepatectomy was safely and successfully implemented within this
facility throughout this QI project. Morbidity, HLOS, readmission and mortality rates would need to
continue to be monitored for a longer period and compared with other institutions utilizing ERAS to
confirm conclusions with statistical significance for recommended changes in practice. While the
implementation of this QI project was a challenging endeavor, sustaining this project in practice could be
quite difficult. In fact, less than 40 percent of health improvement initiatives or projects effectively
transition from adoption to sustained implementation (Health Quality Ontario, 2013). Therefore,
sustainability needs to be addressed at the beginning of a project through engagement of staff, open
communication, formalization as well as standardization of changes, appropriate training, as well as
formal measurements of intended change (Health Quality Ontario, 2013). Future studies need a larger
group of patients to correlate relationships between outcomes and individualized elements of the ERAS
guidelines. Additionally, studies need to be completed within multiple institutions to validate
transferability of the ERAS guideline for patients undergoing hepatectomy.
Conclusion
Doctor of Nursing Practice key essentials were used throughout the execution and dissemination
of this QI project. These essentials laid the groundwork for this specific project. Utilization of Essentials
I through VIII within this QI project will be further clarified in the following paragraphs. This project
should serve as a foundation for future scholarly practice and projects (American Association of Colleges
of Nursing, 2006).
Essential I: Scientific Underpinning for Practice was completed through extensive research to
appreciate the benefits of ERAS in surgical procedures, especially hepatectomies. This research
elaborated on and supported the need for a standardized compliant guideline for hepatectomy care across
this system. This aided to promote quality evidence-based improvements in surgical patient care
(American Association of Colleges of Nursing, 2006). Theory was applied to this project and used as a
concept to guide this QI project. Essential I continued to be utilized throughout the progression of this QI
project.
Essential II: Organizational and Systems Leadership for Quality Improvement and Systems
Thinking was a critical component of this QI project to improve patient and healthcare outcomes
(American Association of Colleges of Nursing, 2006). Projected healthcare reductions were considered
within this essential. System-wide practice initiatives were also introduced throughout this project as
ERAS is now being implemented within other specialties and institutions through advanced
communication and processes (American Association of Colleges of Nursing, 2006).

Essential III: Clinical Scholarship and Analytical methods for Evidence-Based Practice was
utilized throughout this QI project through the usage of ERAS within hepatectomies to replace traditional
practices with evidence based protocols (American Association of Colleges of Nursing, 2006). This
project focused on patient-centered care through the identification of gaps in existing literature regarding
hepatectomies and perioperative care prompting further investigation of this institutions current practice
and patient outcomes.
Essential IV: Information Systems/Technology and Patient Care Technology for the Improvement
and Transformation of Health Care guided the creation of the hepatectomy powerplan. This powerplan
was developed as a technologic improvement for staff to properly follow the ERAS protocol.
Additionally, unidentified patient data was kept in the EIAS to monitor compliance and compare our
institutions with others across the world. This will assist with monitoring patient outcomes, which is a
key part of Essential IV (American Association of Colleges of Nursing, 2006).
Essential V: Health Care Policy for Advocacy in Health Care influenced the ERAS protocol in
hepatectomies to impact policy makers to formally adopt this QI project. Education of staff and policy
makers on the positive inferences of ERAS such as decreased postoperative complications, HLOS, as well
as hospital cost were an important portion of this essential.
Essential VI: Interprofessional Collaboration for Improving Patient and Population Health
Outcomes was applied throughout the entire QI project. Multidisciplinary collaboration was executed to
implement this guideline across various teams and departments within this institution. Monthly meetings
continue to happen to monitor compliance and discuss barriers of the ERAS protocol for hepatectomies
(American Association of Colleges of Nursing, 2006).
Essential VII: Clinical Prevention and Population Health for Improving the Nation’s Health was
intertwined throughout this process as ERAS attempts to minimize unnecessary use of medications,
fluids, and prolonged hospital stays through optimization of surgical care. These concepts are applicable
to clinical prevention and improving patient health through evidence based information. This essential
was used throughout the entire QI project from brain storming about implementation to the completion of
the project.
Essential VIII: Advanced Practice Nursing was completed during the design, implementation, and
evaluation of this QI project. The project conducted an inclusive and systematic evaluation of the
complexity of surgical care (American Association of Colleges of Nursing, 2006). At the finish of this
project, all the data was synthesized and interpreted with the intention of improving perioperative patient
care (American Association of Colleges of Nursing, 2006).
In conclusion, this QI project demonstrated successful implementation of perioperative ERAS
guidelines for hepatectomy procedures within a single institution. Compliance rates above 70% are
attainable in a relatively short period of time if staff is already oriented to the concept of ERAS prior to
implementation. If ERAS is a new concept to an institution, 30 patients or a six-month period should be
expected to achieve over 70% compliance rates. A strong theoretical framework should be utilized to
help facilitate implementation and promote dissemination of ERAS projects. The project underlines the
importance of improved compliance rates for better postoperative outcomes. Future research may
conclude that morbidity, HLOS, 30-day mortality and 30-day readmission rates may be reduced with
increased compliance of the ERAS guideline over an extended period. If ERAS is effective in decreasing
surgical complications in oncology patients undergoing liver resections, time to chemotherapy may be
reduced; which, may promote prolonged survival rates within these populations. Forthcoming studies on
ERAS protocols will need be completed to augment existing data to validate its usage within oncologic
populations.
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Appendix A
Melloul et al. (2016) Summary of ERAS Recommendations for Liver Surgery
ERAS items Summary Evidence Grade of

level Recommendation
Preoperative Patients should receive routine dedicated Moderate Strong
counseling preoperative counseling and education before
liver surgery
Perioperative Patients at risk (weight loss >10-15% within 6 High Strong
nutrition months, BMI < 18.5 kg/m2 and serum albumin
<30 g/l in the absence of liver or renal
dysfunction) should receive oral nutritional
supplements for 7 days prior to surgery. For
severely malnourished patients (>10% WL),
surgery should be postponed for at least 2 weeks
to improve nutritional status and allow patients
to gain weight
Perioperative oral There is limited evidence for the use of Low Weak
immunonutrition immunonutrition in liver surgery
Preoperative Preoperative fasting does not need to exceed 6 h Moderate Strong
fasting for solids and 2 for liquids.
Preoperative Carbohydrate loading is recommended the Low Weak
carbohydrate load evening before liver surgery and 2 before
induction of anesthesia
Oral bowel Oral MBP is not indicated before liver surgery Low Weak
preparation
Pre-anesthetic Long-acting anxiolytic drugs should be avoided. Moderate Strong
medication Short-acting anxiolytics may be used to perform
regional analgesia prior to the induction of
anesthesia.
Anti-thrombotic LMWH or unfragmented heparin reduces the Moderate Strong
prophylaxis risk of thromboembolic complications and
should be started 2-12 h before surgery,
particularly in major hepatectomy.
Intermittent Intermittent pneumatic compression stockings Low Weak
pneumatic should be added to further decrease the risk.
compression
stockings
Perioperative Steroids (methylprednisolone) may be used Moderate Weak
steroid before hepatectomy in normal liver parenchyma,
administration since it decreases liver injury or intraoperative
stress, without increasing the risk of
complications. Steroids should not be given in
diabetic patients
Antimicrobial Single dose intravenous antibiotics should be Moderate Strong
prophylaxis administered before skin incision and less than 1
hour before hepatectomy. Postoperative
“prophylactic” antibiotics are not recommended.
Skin preparation Skin preparation with chlorhexidine 2% is Moderate Strong

superior to povidone-iodine solution
Incision The choice of incision is at the surgeon’s Moderate Strong
discretion. It depends on the patient’s abdominal
shape and location in the liver of the lesion to be
resected. Mercedes-type incision should be
avoided due to higher incisional hernia risk.
Minimally invasive LLR can be performed by HPB surgeons Moderate Strong
approach experienced in laparoscopic surgery, in
particular left lateral sectionectomy and
resections of lesions located in anterior
segments.
Robotic approach There is currently no proven advantage of Low Weak
robotic liver resection in ERAS. Its use should
be reserved for clinical trials
Prophylactic Prophylactic nasogastric intubation increases the High Strong
nasogastric risk of pulmonary complications after
intubation hepatectomy. Its routine use is not indicated.
Prophylactic The available evidence is non-conclusive and no Low Weak
abdominal drainage recommendation can be given for the use of
prophylactic drainage or against it after
hepatectomy.
Preventing Perioperative normothermia should be Moderate Strong
intraoperative maintained during liver resection
hypothermia
Early oral intake Most patients can eat normal food at day one or Moderate Strong
after liver surgery.
Nutritional - Moderate Weak

Supplements
Artificial nutrition Postoperative enteral or parenteral feeding High Strong
should be reserved for malnourished patients or
those with prolonged fasting due to
complications (e.g., ileus>5 days, DGE)
Postoperative Insulin therapy to maintain normoglycemia is Moderate Strong
glycemic control recommended
Prevention of An omentum flap to cover the cut surface of the High Strong
delayed gastric liver reduces the risk of DGE after left-sided
emptying (DGE) hepatectomy
Stimulation of Stimulation of bowel movement after liver High Strong
bowel movement surgery is not indicated
Early mobilization Early mobilization after hepatectomy should be Low Weak
encouraged from the morning after the operation
until hospital discharge
Analgesia Routine TEA cannot be recommended in open Moderate Strong
liver surgery for ERAS patients. Wound
infusion catheter or intrathecal opiates can be
good alternatives combined with multimodal
analgesia
Preventing Multimodal approach to PONV should be used. Moderate Strong

postoperative Patients should receive PONV prophylaxis with
nausea and 2 anti-emetic drugs
vomiting (PONV)
Fluid management The maintenance of low CVP (below 5 cmH20) Moderate Strong
with close monitoring during hepatic surgery is
advocated. Balanced crystalloid should be
preferred over 0.9% saline or colloids to
maintain intravascular volume and avoid
hyperchloremic acidosis or renal dysfunction,
respectively.
Audit Systematic audit improves compliance and Moderate Strong
clinical outcome in healthcare practice
Appendix B
Meeting Agenda
Meeting # 1 (8/3/17)
 Discussed start date with staff (8/28/17)

 Educated staff on the 23 items for the ERAS guideline for hepatectomy
o Reviewed the P.O.L.A.R.I.S (pre-operative learning and readiness in surgery)
preoperative teaching
 Provided handouts reviewing ERAS items
 Discussed compliance sheets. Reviewed completeness and compliance of each perioperative
phase
 Reviewed the importance of documentation if deviation from the guideline occurs and why
Meeting # 2 (8/17/17)
 Reviewed and educated staff on hepatectomy powerplan

o Directed staff on how to access / locate order set
o Went over each perioperative phase within powerplan and timing of initiation within each
phase
o Reviewed for questions
 Made staff aware of monthly meetings to go over compliance, concerns, and issues that arise with
implementation
Appendix C
Compliance Checklist
C1. Preoperative Checklist
Reason for
n Item Applied Practice Initiation Compliance Non-
Compliance
1 Preoperative Patient should receive pre- 30 PreOD ☐

counseling operative counseling
2 Smoking / ETOH Patient should have one-month 30 PreOD ☐

Cessation abstinence before surgery
3 Perioperative Routine nutritional screening 30 PreOD ☐

nutrition should be mandatory for all
patients undergoing major
abdominal surgery.
*Patients at risk: weight loss >

10-15% within 6 months, BMI
< 18.5 or serum albumin <30
g/l in absence of liver or renal
dysfunction should receive oral
nutrition for 7 days prior to
surgery
*Severely malnourished
patients (>10% WL) should
have surgery postponed for at
least 2 weeks to improve NS.
4 Preoperative Preoperative fasting does not Solids: 6 PreO ☐

fasting exceed 6 hours for solids and 2 Hrs
hours for liquids ☐
Liquids: 2
PreO Hrs
5 Preoperative Carbohydrate loading is 2 PreO Hrs ☐

Carbohydrate recommended the evening
Loading before liver surgery and 2 hours
before anesthesia induction
6 Oral Bowel Patient should not receive - ☐

Preparation mechanical bowel preparation
before liver surgery
C2. Intraoperative Checklist
Reason for
n Item Applied Practice Initiation Compliance Non-
Compliance
1 Pre-Anesthetic Patient should not receive - ☐

Medication long-acting sedatives as
pre-induction
2 Anti-Thrombotic Patient should receive 12 PreO ☐

prophylaxis LMWH 2 – 12 hrs before Hrs
(LMWH) surgery
*Should be administered ☐
12 hours prior to insertion
of epidural catheter
3 Anti-Thrombotic Patient should receive 1 PreO Hrs ☐

prophylaxis SCD from the time of
(SCD) surgery
4 Anti-microbial Patient should receive 1 PreO Hrs ☐

prophylaxis initial antibiotic dose < 1
hr before incision.
5 Perioperative Methylprednisolone 30 2 PreO Hrs ☐

Steroid mg/kg 30 minutes to 2 hrs
Administration prior to surgery unless
diabetic
7 Skin Preparation Chlorhexidine 2% scrub 0 Hrs ☐

AM prior to surgery
8 Incision Choice of incision is at - ☐

surgeon’s discretion
9 Preventing Perioperative - ☐
Intraoperative normothermia should be
Hypothermia maintained during liver
surgery
10 Minimally Laparoscopic Liver - ☐

Invasive Resection (LLR) can be
Approach performed by HPB
surgeons experienced in
laparoscopic surgery.
11 Prophylactic Routine use not indicated - ☐

Nasogastric
Intubation
12 Prophylactic Available evidence is non- - ☐ Did

Abdominal conclusive and no complete
Drainage recommendation can be
given for the use of
prophylactic drainage or
☐ Did not
against it.
complete
13 Prevention of Usage of omental flap to - ☐
Delayed Gastric cover the cut surface after
Emptying left-sided hepatectomy
will reduce incidence of
DGE
14 Glycemic Insulin therapy to - ☐

Control maintain normoglycemia
is recommended.
*Insulin therapy should be

initiated early during liver
surgery to maintain
normoglycemia (80-120
mg/dL). Programmed
infusion of insulin is
superior than manual
injection with sliding-
scale method.
15 Fluid Maintenance of low CVP -LR @ 75 ☐

Management (below 5 cmH20) with cc/hr in
close monitoring during orders
hepatic surgery is -250cc IVP
advocated. q8h x 3
doses
☐
Balance crystalloid should
be preferred over 0.9%
saline or colloids to
maintain intravascular
volume
C3. Postoperative Checklist
Compl Reason for Non-

n Item Applied Practice Initiation
iance Compliance
1 Early Oral CLD->Consistent 1 POD->2 POD ☐

Intake carbohydrate diet
2 Postoperative Postoperative enteral or - ☐

Nutrition parenteral feeding
should be reserved for
malnourished patients
or those with prolonged
fasting due to
complications.
3 Anti- Patient should receive 1 POD ☐

thrombotic LMWH during
prophylaxis hospitalization
(LMWH)
4 Anti- Patient should receive 1 POD ☐

thrombotic SCD until ambulating
prophylaxis without assistance
(SCD)
5 Glycemic Insulin therapy to 0 POD ☐

Control maintain
normoglycemia
6 Stimulation Not indicated - ☐

of Bowel
Movement
7 Postoperative Patients should receive 0 POD ☐

Nausea and 2 antiemetic drugs.
Vomiting
-4 mg ondansetron IVP
q6h prn
-12.5 mg promethazine
IVP once prn if
unrelieved by
ondansetron
-4 mg dexamethasone
IVP once prn if

unrelieved by above
8 Analgesia Patient-Controlled 0 POD ☐

Analgesia
9 Early Early mobilization 1 POD ☐

Mobilization should be encouraged
from the morning after
surgery until discharge
1 Fluid Patient should be 1 POD ☐

0 utilization on maintained in a near-
the floor zero fluid balance, until
bowel function returns
and tolerates diet
(KVO).
1 Urinary Patient’s urinary 1 POD ☐

1 catheter catheter should be no
duration later than POD #1,
unless otherwise
indicated.
1 Intra- Do not flush; empty 1 POD ☐

2 abdominal q4h and record.
drain
1 Dressing Should be clean and 0 POD ☐

3 dry. Change prn.
1 Medical Referral to medical - ☐
4 oncology oncologist at discharge.
appointment
1 Audit First case audit for - ☐

5 ERAS compliance and
immediate post-
operative results should
be performed at
discharge
*The gray items represent the ERAS society recommendations

*The green items represent additional recommendations from this institution
Appendix D
Applied Practices in Hepatectomy
D1. Preoperative Module
Grade
ERAS
n Item Applied Practice Of Evidence
LOE
Recommendation
1 Preoperative Patients should receive Moderate Strong Lassen, K.

Counseling routine dedicated (2012). Clin
preoperative counseling Nutr 31: 817
and education before liver
surgery.
2 Smoking / ETOH Alcohol abusers: 1-month Alcohol: Strong Tonnesen, H.

Cessation of abstinence before Low (1999).
surgery.
Br J Surg 86:
Daily Smokers: 1-month 869
abstinence before surgery Smoking:
Moderate
Lindstrom, D.
(2008)
Ann Surg 248:

739
3 Perioperative Routine nutritional High Strong Weimann, A.

Nutrition screening should be (2006).
mandatory for all patients
undergoing major Clin Nutr 25:
abdominal surgery. 224
*Patients at risk: weight Schindler, K.

loss > 10-15% within 6 (2010).
months, BMI < 18.5 or Clin Nutr 29:
serum albumin <30 g/l in 552
absence of liver or renal
dysfunction should receive
oral nutrition for 7 days Weimann, A.

prior to surgery (2014).
*Severely malnourished Chirurg 85:

patients (>10% WL) 320
should have surgery
postponed for at least 2
weeks to improve NS.
4
Perioperative Oral Limited evidence exists for Low Weak Mikagi, K.
Immunonutrition use of immunonutrition in (2011).
liver surgery.
Kurume Med
J 58: 1
Preoperative fasting does Moderate

5 Preoperative not exceed 6 hours for Strong Gustafsson,
Fasting solids and 2 hours for UO. (2013).
liquids World J Surg
37: 259
Preoperative
6 Carbohydrate Carbohydrate loading is Low Nygren, J.
recommended the evening Weak (2013).
Loading
before liver surgery and 2
hours before anesthesia World J
induction Surgery 37:
285
Beyer, T.
(2008).
Cell Cycle 7:
874
7 Oral bowel Patient should not receive Low Weak Holte, K.

preparation mechanical bowel (2004).
preparation before liver
surgery Dis Colon
Rectum
47:1397
D2. Intraoperative Module
n Item Applied Practice ERAS Grade Evidence

LOE
Of
Recommendation
1 Pre-Anesthetic Long-acting anxiolytic drugs Moderate Strong Walker, K.

Medication should be avoided. Short- (2009).
acting anxiolytics may be Cochrane
used to perform regional Database
analgesia prior to anesthesia
induction.
2 Anti-Thrombotic Patient should receive Moderate Strong Lassen, K.

prophylaxis LMWH 2 – 12 hrs before (2012). Clin
(LMWH) surgery Nutr 31: 817
*Should be administered 12
hours prior to insertion of
epidural catheter
3 Anti-Thrombotic Patient should have SCDs in Low Weak Nygren, J.

prophylaxis place in OR (2013).
(SCD)
World J
Surgery 37:
285
4 Perioperative Steroid (methylprednisolone) Moderate Weak Richardson, A.

Steroid may be used before (2014). HPB
Administration hepatectomy in normal liver 12: 12
parenchyma. Steroids should
not be given in diabetic
patients.
*Dosage 30 mg/kg 30 min to

2 hours prior to surgery
5
Antimicrobial Single dose antibiotics Moderate Strong Bratzler, D.
Prophylaxis should be administered less (2004).
than 1 hour before incision
Clin Infect Dis
*Postoperative prophylactic 38: 1706
antibiotics are not
recommended
6 Skin Preparation Skin preparation with Moderate Darouiche, R.

chlorhexidine 2% is superior Strong (2010).
to povidone-iodine solution
N Engl J Med
362: 18
7 Type of incision Choice of incision is at Moderate Strong D’ Angelica,

surgeon’s discretion. M. (2006).
World J Surg
30: 410
*Mercedes-type incision
should be avoided due to
higher incisional hernia risk
8 Minimally Laparoscopic Liver Moderate Strong Stoot, H.

Invasive Approach Resection (LLR) can be (2009).
performed by HPB surgeons
experienced in laparoscopic HPB 11: 140
surgery.
9
Prophylactic Prophylactic nasogastric High Strong Pessaux, P.
Nasogastric intubation increases the risk (2007).
Intubation of pulmonary complications Br J Surg 94:
after hepatectomy. Routine 297
use not indicated.
10
Prophylactic Available evidence is non- Low Weak Petrowsky, H.
Abdominal conclusive and no (2004).
Drainage recommendation can be Ann Surg 240:
given for the use of 1074
prophylactic drainage or
against it.
11
Preventing Perioperative normothermia Moderate Strong Wong, P.
Intraoperative should be maintained during (2007).
Hypothermia liver surgery
Br J Surg 94:
421
Prevention of
12 Delayed Gastric Usage of omental flap to High Strong Igami, T.
Emptying cover the cut surface after (2011).
left-sided hepatectomy will
reduce incidence of DGE J Hepatobiliary
Pancreat Sci
18: 176
Glycemic Control Moderate

13 Insulin therapy to maintain Strong Frisch, A.
normoglycemia is (2010).
recommended. Diabetes Care
33: 1783
*Insulin therapy should be

initiated early during liver Lipshitz, A.
surgery to maintain (2009).
normoglycemia (80-120
mg/dL). Programmed Anesthesiology
infusion of insulin is superior 110: 408
than manual injection with
sliding-scale method.
Blixt, C.
(2012).
Clin Nutr 31:
676
14 Fluid management Maintenance of low CVP Moderate Strong Dunki-Jacobs

(below 5 cmH20) with close E. (2014).
monitoring during hepatic
surgery is advocated. Ann Surg
Oncol 21: 473
Balance crystalloid should

be preferred over 0.9%
saline or colloids to maintain Shaw, A.
intravascular volume (2012).
Ann Surg 255:

821
D3. Postoperative Module
Grade
n Item ERAS LOE Evidence
Applied Practice Of
Recommendation
1 Early Oral Moderate Lassen, K.

Intake Eat normal food at day one Strong (2008).
after liver surgery.
Ann Surg 247:
721
Oral nutritional
2 Postoperative Oral nutritional supps: Weak Richter, B.
nutrition Postoperative enteral or supps: Moderate (2006).
parenteral feeding should be
reserved for malnourished Dig Surg 23: 139
patients or those with No routine
No routine postoperative
prolonged fasting due to postoperative
complications. artificial nutrition: Guenter, P.
artificial Strong
nutrition: High (2012).
JPEN 36: 399
Anti-
3 Thrombotic Should continue while in Moderate Strong Rasmussen, M.
prophylaxis hospital. Could be (2009).
(LMWH) continued for 4 weeks after Cochrane
hospital discharge; Database System
especially in oncology Review
population.
4 Anti- Compression stockings Low Weak Nygren, J.

Thrombotic should be in place until (2013).
prophylaxis mobile to further decrease
(SCD) risk. World J Surgery
37: 285
5 Glycemic Insulin therapy to maintain Moderate Strong Okabayashi, T.

Control normoglycemia is (2009). Diabetes
recommended. Care 32: 1425
*Programmed infusion of
insulin is superior than

manual injection with
sliding-scale method.
6
Stimulation Stimulation of bowel High Strong Ni, C. (2013).
of Bowel movement with laxative or
Movement chewing gum is not Eur J Surg Oncol
indicated. 39: 542
Melloul, E.
(2012).
J Hepatol 57:
1268
7
Early Early mobilization after Low Weak Brower, R.
Mobilization hepatectomy should be (2009).
encouraged from the Crit Care Med
morning after the operation 37: S422
until discharge
8 Analgesia Routine thoracic epidural Moderate Strong Roy, J. (2006).

analgesia (TEA) cannot be
recommended in open liver Anesth Analg
surgery for ERAS patients. 103: 990
*Wound infusion catheter

or intrathecal opiates can be
good alternatives when
combined with multimodal Revie, E. (2012).
analgesia.
HPB 13: 611
9
Postoperative Multimodal approach to Moderate Strong Carlisle, J.
Nausea and PONV should be used. (2006).
Vomiting Patients should receive
PONV prophylaxis with 2 Cochrane
antiemetic drugs. Database Syst
Rev
*5HT3 antagonists remain

the first-line therapy due to
their good side effect
profile. Secondary drugs:
Low-dose dexamethasone
improves liver regeneration;
use in caution with
diabetics, antihistamines,
butyrophenones and
phenothiazines.
10 Urinary Removed not later than High Zaouter, C.

Catheter POD #1 after major Strong (2009).
Duration abdominal surgery, unless
Anesth Pain Med
otherwise indicated
34: 542
Wald, H. (2008).
Arch Surg 143:

551
At discharge from the

11 Medical hospital, patient will need a - - Stein, S. (2013).
Oncology referral to medical J Clin
Referral oncologist to promote a Gastroentreology
multidisciplinary approach 47: 47
to care.
Jelic, S. (2010).
Annals of
Oncology: 21:
59
12 Audit Systematic audit improves Moderate Strong Gustafsson, U.

compliance and clinical (2011).
outcomes in healthcare
practice Arch Surg 146:
571.
*The gray items represent the ERAS society recommendations

*The green items represent additional recommendations from this institution
Appendix E
Population and Procedure Variables
E1. Population Characteristics
All Liver Procedures Performed by HPB Surgery Between 9/14/17 – 11/24/2017

n=20
Population Variables
Sex, male n (%) 7 (35)
Age, years, mean (SD) 51.7 (14.5)
BMI, mean (SD) 32.9 (8.1)
ASA Group n (%)
1-2 4 (20)
3-4 16 (80)
E2. Liver Procedures
Liver Procedures
Procedure Type n (%)
Left hepatectomy 6 (30)
Extended left hemihepatectomy 3 (15)
Right hemihepatectomy 6 (30)
Extended right hemihepatectomy 3 (15)
Other segmentectomies 2 (10)
Wedge or minor resection 1 (5)

Appendix F
Compliance Variables
F1. Compliance SD by Module
Compliance Variables
Compliance by module
Preadmission compliance, mean (SD) 81.3 (21.3)
Preoperative compliance, mean (SD) 87.5 (8.1)
Intraoperative compliance, mean (SD) 80 (9.9)
Postoperative compliance, mean (SD) 77.1 (8.3)
Total/Overall compliance, mean (SD) 77.7 (7.2)

F2. Compliance by Item and Month

Appendix G
30-Day Complications
30-Day Complications 12 (60)

Any n (%)
Intraoperative bleeding or hemorrhage n (%) 2 (10)
30-day reoperation n (%) 1 (5)
30-day ascites n (%) 2 (10)
30-day wound infection n (%) 1 (5)
30-day postoperative bleeding or hemorrhage n (%) 0

Appendix H
Project Evaluation Form
Appendix I
Letter of Support
Appendix J
East Carolina University IRB Waiver
Appendix K
Organization IRB Waiver

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Running head: ENHANCED RECOVERY AFTER SURGERY GUIDELINE 1

Enhanced Recovery After Surgery

Evidence-Based Practice Perioperative Guideline Implementation for Hepatectomy

East Carolina University

Enhanced Recovery After Surgery (ERAS) protocol is a standardized, interdisciplinary, coordinated

Problem Statement ........................................................................................................................................ 6

Justification of Study .................................................................................................................................... 7

Conceptual Framework ................................................................................................................................. 7

Lewin’s Change Management Theory...................................................................................................... 8

Research Based Evidence ........................................................................................................................... 10

Overview of ERAS Guidelines............................................................................................................... 10

Lewin’s Change Management Theory.................................................................................................... 18

Study Design .......................................................................................................................................... 20

Protection of Human Subjects ................................................................................................................ 24

Data Collection ....................................................................................................................................... 24

Sample Characteristics ........................................................................................................................... 25

Major Findings ....................................................................................................................................... 26

Enhanced Recovery After Surgery

Evidence-Based Practice Perioperative Guideline Implementation for Hepatectomy

days, and 30-day mortality may be observed.

without a uniform perioperative process. Improvements in current surgical and perioperative

perioperative care for hepatectomies.

Lewin’s Change Management Theory

change for this QI project.

institutions to create and sustain these protocols.

Research Based Evidence

Overview of ERAS Guidelines

2013; Lau & Chamberlain, 2016; Melloul et al., 2016).

articles and websites pertained to statistics and theory.

2017; Wong-Lun-Hing et al., 2014).

31% in the conventional group.

2013; Fawcett et al., 2012).

(Volanthen et al., 2011).

It is important to recognize that the implementation of ERAS guidelines is an expensive

been steadily implemented worldwide (Stone et al., 2016).

(Roulin et al., 2017).

future guideline application (Melloul et al., 2016).

also can skew data (Hughes et al., 2016).

could increase morbidity or influence postoperative outcomes (Jones et al., 2013).

(Hughes et al., 2014). Hence, standardization is needed to decrease future limitations.

for hepatectomy included prophylactic abdominal drainage and analgesia.

could be made for or against abdominal drainage (Melloul et al., 2016).

addressed to unify the ERAS hepatectomy guidelines to better results.

gastrointestinal surgeries (Lau & Chamberlain, 2016).

different elements found within the ERAS protocol.

Lewin’s Change Management Theory

unfreezing, movement, and refreezing.

with the change.

guidelines through active engagement for all involved.

with the guidelines (Manchester et al., 2014).

explored in the discussion (Sutherland, 2013).

facilitate decision-making by healthcare personnel to decrease inappropriate variations in perioperative

implementation and capturing compliance.

exclusion criteria for this project.

this project was added into the preexisting budget.

and/or alcohol cessation, preoperative nutrition, preoperative carbohydrate loading, complications of

Protection of Human Subjects

shredded after data collection and analysis.

monitor audit progress and clinical outcomes to make identifiable improvements.

Demartines, & Clavien, 2004).

hepatectomy, extended left hemihepatectomy, right hemihepatectomy, extended right hemihepatectomy,

other segmentectomies, as well as a wedge or minor resection (see Appendix E).

due to appropriate variations in perioperative care or lack of documentation.