Implementing enhanced recovery pathways: a literature review with realist synthesis

Abstract

Background: Enhanced Recovery Pathways (ERPs) are increasingly popular across a broad range of surgeries within NHS hospitals. Existing research shows that when properly implemented, ERPs improve patient outcomes and reduce length of hospital stay. However, ERP implementation can require significant changes in ward procedures, and staff adherence to ERP protocols is often low. This review explored which ERP implementation strategies are most effective in which circumstances. Methods: Realist synthesis methodology was adopted to explore the interaction between hospital context, implementation mechanism and protocol adherence. The scope of the review was defined, and a search of the literature (including grey literature) conducted. Evidence was appraised, data extracted and findings synthesised. Findings: Literature related to UK ERP implementation is limited, with little detail given about context or implementation strategies. Three a priori propositions were identified: (1) The use of an “ERP champion†or change agent improves fidelity and long-term sustainability of the ERP protocol, (2) ERP protocols which are tailored to the local ward context (taking into account existing practices) are more likely to be adhered to, (3) Consultation with all stakeholders in the design and implementation of ERP protocols reduces resistance to change and ultimately improves fidelity and sustainability. Discussion: ERP literature lacks sufficient detail regarding implementation strategies. However, comparing the available data with existing implementation theory from other research areas suggests that ERP implementation is more successful (with regards to protocol adherence and sustainability) when tailored to local contexts, and when the design and implementation are guided by stakeholder input.