Implementation of an Educational Program for Certified Registered Nurse Anesthetists To Improve Adherence to Enhanced Recovery Protocols in the Orthopedic Surgery Patient


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.


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.


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.


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.