Purpose
Despite the evidence supporting the benefits of adopting enhanced recovery after surgery (ERAS) protocols in orthopedic procedures, numerous barriers exist to successful implementation. This evidence-based practice project's overall objective was to improve CRNA adherence with ERAS protocols through the implementation of a comprehensive, sustainable education program by addressing the knowledge-to-practice gap.
Methodology
A comprehensive review of the evidence identified strategies for implementation and adherence to ERAS protocols with educational interventions identified a key factor. Department-specific barriers were identified via a survey of the staff CRNAs, followed by the development of three educational modules based on the ACE-Star Model and Knowles’ Theory of Adult Learning. A pre-test/post-test format was used to assess the participants' knowledge transformation, and scores were analyzed using a paired t-test. Retrospective data collected from the electronic medical record were compiled on all patients receiving a primary total hip or knee arthroplasty and analyzed to CRNA protocol adherence based on four outcome measures: average fentanyl administration, average midazolam administration, average ketamine administration, and PACU length of stay.
Results
The results from the pre-test (M=62.04, SD=10.02) and post-test score (M=80.08, SD=11.69), t(11) = -4.275, p < 0.001, reflected a significant improvement in scores based on participation in the educational interventions. Paired sample T-tests performed on the hip data set demonstrated a statistically significant decrease in fentanyl use over the course of the project from August 2018 (M = 81.93, SD = 44.90) to August 2019 (M = 48.61, SD = 28.39), t(11) = 2.12, p < 0.05. Mean midazolam use decreased throughout the evaluation period but did not demonstrate statistical significance. Mean ketamine use increased, but without evidence of clinical or statistical significance. PACU length-of-stay remained constant.
Implications
Successful implementation of an ERAS protocol requires multidisciplinary collaboration, designated oversight, identification of barriers, continuous education, and ongoing evaluation of outcomes. Clinician adherence to a standardized change in practice is determined by the organizational support, addressing barriers, and structured education. Educational modules and awareness campaigns on the advantages of facility-specific ERAS programs should be accessible and ongoing. Protocol adherence is directly impacted by clinician education, and adherence has the most significant impact on the achievement of desired patient outcomes.
