In this study, we prospectively collected and retrospectively analyzed bowel resection patients in a single institution both before and after implementation of an ERAS protocol. The volume of resections is relatively large for international rural standards, but this volume was attainable through the large geographic catchment area. Overall, the greatest effect of the Enhanced Recovery interventions was observed in decreased length of stay of 1.8 days on average. This resulted in a net savings of approximately $3,000 per patient at our institution. Notably, there was no statistically significant difference in the rates of any complication nor readmissions pre and post ERAS. Additionally, rates of commonly reported colorectal complications are commensurate with nationally reported rates.14,15 It is unclear why our institution did not see an improvement in complication rates as demonstrated in other meta-analyses of ERAS trials.16,17 However, we did not see an increase in readmission rates either, which is frequently reported in other studies.18
The study was not randomized, and this is a limitation. The intervention (ie/ ERAS protocol) was not blinded, and this is a source of potential bias. However, patient groups pre and post were comparable in demographics and comorbidities. It was necessary to maximize the number of patients subjected to protocol in a short period, and this required a total overhaul in the institutional practice. The compliance rates of order sets (75-93%) are better than, or commensurate with, other published rates.18,19
One of the most important components was the support of the organization, which permitted the needed devoted meetings with all representatives of pre, trans, and post operative levels of care. Every relevant party was included. The changes hoped for were discussed, and there was consensus. These interventions started in the clinic setting at the network level, and flowed through the perioperative period. The unique, complex nature of implementing these changes may also represent a limitation of generalizability to other organizations.
At the core, the sustainable endpoint of any project implementation requires shifting culture by convincing those involved of the intrinsic benefits. From a patient’s perspective, this may include convincing a patient that carbohydrate loading, early ambulation, and a clear recovery timeline will be best for them. This was accomplished through clear, lay-term pamphlets in clinic and prominent ERAS-educational whiteboards in patient rooms. From a health caregiver-provider perspective, this included in-service training providing convincing data that their patient’s would benefit from the interventions.
We believe this demonstrates that ERAS is feasible for rural hospitals, despite unique challenges in the rural setting. Lack of human labor, poor communication and collaboration, resistance to change, rotating residents, and patient factors (such as comorbidity and socioeconomic disadvantages) have all been listed as barriers in other publications.20,21 Table 3 demonstrates how a “rural-specific barrier” to implementation can be overcome, yielding a sustainable endpoint. Several of these sustainable endpoints are difficult to quantify, such as trusted relationships or lessened burden of opioid addiction on the community. There is opportunity for more research therein.