Abstract
This systematic review identifies and assesses national guidelines that are used to improve clinical practice and patient safety in perioperative care. The authors searched, MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL Plus) and Health Management Information Consortium (HMIC) to identify relevant studies published from January 2014 until May 2024. Two researchers screened a total of 727 studies (which yielded 37 eligible studies), extracted data and rated study quality using the Mixed Methods Appraisal Tool (MMAT). The most common national guidelines identified were the Enhanced Recovery After Surgery (ERAS) and the WHO Surgical Safety Checklist (WHO SSC). 13 studies identified improvements in morbidity, 10 a decrease in length of stay and 1 a decrease in readmission. Strength of evidence was high (18 studies rated as high), with most studies being pre-post evaluations. The evidence leans to suggest that the implementation of national guidelines can improve patient outcomes, however, this conclusion should be considered in light of all the available evidence.
1
Introduction
The perioperative period encompasses the surgical care pathway from pre-surgery, during surgery and post-surgery . Patient safety is an area of focus in perioperative care due to the risk of complications, which may lead to mortality, further morbidity, or increased length of stay in hospital , . Guidelines are often developed to standardise care and share best practice on improving patient safety during the perioperative period . Guidelines are commonly developed based on the best available evidence; based on an assessment of their potential benefits and harms; and through multi-disciplinary consensus processes . Organisational bodies are often responsible for producing guidelines at the local, regional, national, and international level. Developing guidelines can be a time and resource intensive process .
Despite the extensive resources that go into developing guidelines with the hope that they will be implemented to improve patient safety, research has found that failures in guideline implementation are common across many clinical specialties . Some of the key barriers to implementing clinical practice guidelines more broadly are lack of awareness and agreement with the recommendations themselves. Other studies have reported that more time should be invested into providing support on how best to implement the existing guidelines or evaluating the impact of the existing guidelines, rather than producing more guidelines in an already saturated environment , .
Previous reviews have assessed the quality of guidelines used within perioperative care and have assessed the impact of clinical practice guidelines in perioperative care over 10 years ago . To our knowledge, there has not been a more recent systematic literature review evaluating the impact or factors acting as barriers and facilitators of implementing national level recommendations in perioperative care to improve patient safety. The purpose of this systematic review was to map national guidelines implemented in perioperative care, the factors acting as barriers or facilitators in implementation, and the impact of the guidelines on patient safety. The research questions guiding the study were as follows:
- 1)
Are national guidelines within perioperative care being implemented?
- 2)
Is the impact of national guidelines on patient safety in perioperative care being measured?
- 3)
What is the impact of national guidelines on patient safety within the perioperative care context?
2
Methods
The systematic review was informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (M. J. ) guidelines and a protocol was prospectively registered on PROSPERO: CRD42024548121.
2.1
Search strategy
Search terms were developed based on previous reviews , and informed by PICOS. We used a combination of relevant key words and subject heading searches based on the search words ’patient safety,’ ’recommendation,’ ’guideline,’ and ’perioperative care.’ The full search strategy can be found in Appendix A.
Searching was conducted on four scientific databases, MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL Plus) and Health Management Information Consortium (HMIC), all of which were searched for articles published between 1st January 2014 to 30th May 2024.
2.2
Selection criteria
This review focused on articles which had been published in peer-reviewed journals. We included all types of study design: qualitative, quantitative and mixed methods. We limited the search to humans and the past 10 years. We defined ‘guideline’ as clinical guidelines that are designed or developed to aid healthcare professionals to deliver care for patients in a clinical setting and, ‘national guidelines’ was defined as guidelines that had been recommended for use nationally across a country. Perioperative care was defined as the care of patients prior, during and after completion of surgery and, finally, patient safety was defined as reducing or preventing the risk of harm to patients whilst they receive healthcare. No limits were placed in terms of language and international publications (outside of the United Kingdom) of national guidelines were also included. Included studies also had to meet the following eligibility criteria:
- •
Participants: Participants were patients who have experienced perioperative care within a hospital. In terms of staff perspectives and experiences, any type of Healthcare Professional (HCP) was included (e.g. nurses, midwives, healthcare assistants, doctors, surgeons, anaesthetists).
- •
Interventions : The implementation of national guidelines within the field of perioperative care to improve patient safety, such as reducing mortality, length of stay, postoperative complications.
- •
Comparator: Comparison groups will include usual or routine care prior to implementation of guidelines, or in groups where guidelines were not implemented.
- •
Outcomes : Whether or not national guidelines were being implemented in the perioperative healthcare setting (research question 1). Whether the impact of national guidelines were measured across perioperative healthcare systems (research question 2). The impact national guidelines had on patient safety in the perioperative healthcare setting, such as reduced patient complications, adverse outcomes or routine complications that have adverse effects (research question 3).
2.3
Study selection
The search results were imported into the software Rayyan for de-duplication . The software was then used for the first stage of screening all titles and abstracts, this was done by two researchers, and they cross-checked 25 % of each other’s decisions, and discussed disagreements until consensus was reached. Any publication that did not meet the inclusion criteria was excluded. Full text screening was then completed using Microsoft Excel, again by two researchers who cross-checked 25 % of each other’s decisions, and discussed any disagreements amongst themselves and the senior author until consensus was reached.
2.4
Data extraction
One researcher extracted data from all included studies into an excel document, which was then cross-checked by a second researcher. The following data were extracted: article characteristics (type of study and country of study), demographic data (patient population, perioperative procedure, HCP population), type of guideline being implemented, and outcome measures from implementing guidelines. Further information on the data extraction fields can be found in Table 1 . Intervention details were extracted following the TIDieR checklist , which is a 12-item checklist that is used to improve the quality of reporting in intervention studies.
| Author, publication year, country, MMAT score | Surgical procedure/patient compliant | Study design Comparator group | Implemented guideline | Sample and sample size | Outcome of implemented guideline | Compliance with guideline |
|---|---|---|---|---|---|---|
USA 4/5 | Pancreatic adenocarcinoma/ Pancreatic duodenectomy | Cohort study Yes – pre- vs post- guideline implementation | Enhanced recovery after surgery (ERAS) guidelines | Patients Pre-ERAS = 140 Post-ERAS = 40 | Hospital Length of stay (LOS): Pre-ERAS = (m=9.5 days) Post-ERAS: (m=9 days) Not statistically significant. Death within 30 days: Pre-ERAS = 4 (3%) Post-ERAS = 2 (5%) Not statistically significant Readmission within 30 days: Pre-ERAS = 39 (28%) Post-ERAS = 11 (28%) Not statistically significant | 59.7% compliance with the ERAS guidelines among clinicians. |
Australia 4/5 | Left and right colorectal resections | Cohort study Yes -pre- vs post- protocol implementation | ERAS protocol | Patients Pre-ERAS = 42 Post-ERAS = 88 | LOS Pre-ERAS protocol = 6.5 days Post-ERAS protocol = 5 days in the subgroup that adhered ≥70% of preoperative ERAS guidelines Statistically significant. Ileus: Pre-ERAS = 6 (14.3%) Post-ERAS = 11 (12.5%) Not statistically significant. Bowel obstruction: Pre-ERAS = 0 (0%) Post-ERAS = 0 (0%) Statistical significance not assessed. Nausea: Pre-ERAS = 33 (84.6%) Post-ERAS = 5 (5.8%) Statistically significant. Patients that vomited: Pre-ERAS = 15 (35.7%) Post-ERAS = 41 (46.6%) Not statistically significant. | Increase from 0% to 43% of patients adhering to ≥70% of preoperative ERAS guidelines post ERAS protocol implementation. Statistically significant. |
Israel 5/5 | Orthopaedic procedures | Cross-sectional study Yes – pre- vs post- checklist | Modified WHO-based surgical safety checklist | Patients Pre-checklist = 380 Post-checklist = 380 | Antibiotics administered only post-operatively: Pre-ERAS = 3.2% Post-ERAS = 0% Statistically significant. Post-operative fever: Pre-ERAS = 10.6% Post-ERAS = 5.3% Statistically significant even after controlling for confounding. Surgical wound infection: Pre-ERAS = 3.2% Post-ERAS = 2.1% Not statistically significant. Composite postoperative complications: Pre-ERAS = 25.9% Post-ERAS = 18.9% Statistically significant, but not after controlling for confounding. Mortality: Pre-ERAS = 0.8% Post-ERAS = 2.7% Statistically significant. | Not reported |
| Italy 4/5 | Resection with anastomosis, lysis of adhesion, resection without anastomosis, perforated peptic ulcer repair, by-pass and hollow viscus perforation repair | Cohort study Yes – comparison in outcomes based on different levels of compliance of protocol | ERAS protocol | Patients Total = 589 | Linear correlation between postoperative item compliance of ERAS and reduction in LOS. Statistically significant. Laparoscopy was associated with adherence to postoperative protocol. Statistically significant. Laparoscopy was associated with an earlier recovery. Statistical significance not assessed. | Patients’ compliance to postoperative items was satisfactory with all targets reached one-day later in comparison with what has been reported following elective colorectal surgery. The highest adherence was obtained for operative warming and postoperative nausea and vomiting prophylaxis. |
USA 3/5 | Otolaryngologic surgery (ear, nose, and throat) | Cohort study Yes – pre- vs post- protocol implementation | Perioperative pain management protocol based on American Academy of Otolaryngology-Head and Neck Surgery | Patients Pre-protocol = 105 Post-protocol = 105 | Prescribed morphine milligram equivalent (mean): Pre-protocol = 132.5 Post-protocol = 53.6 Statistically significant. | Not reported |
Australia 2/5 | Adult patients with type 1 or type diabetes whose length of stay was greater than 24 hours on the surgical short stay unit, neurosurgery, and specialty surgery wards | Mixed methods study Yes – pre- vs post- recommendation implementation | The Joanna Briggs Institute (JBI) best practice recommendations for perioperative diabetic management (hospital patients) | Retrospective audit data from 30 patient records and a survey with a convenience sample of 40 nursing staff from the relevant wards. Focus group data with nursing staff and an endocrinologist. | Not reported | 7/9 best practice criteria achieved 100% compliance. Overall, there were two out of nine criteria that had less than 30% compliance. This was criterion 6 that examined the regular monitoring of a patient’s blood glucose being conducted while in hospital at an appropriate timeframe, which had 27% compliance; and criterion 9 that assessed if healthcare staff had received education and training regarding perioperative diabetes management which had 0% compliance. |
USA 3/5 | Radical cystectomy | Cohort study Yes – pre- vs post- protocol implementation | ERAS protocol | Patients Pre-intervention = 210 Post-intervention = 109 | Novel venous thromboembolism Pre = 13 (6.2%) Post = 1 (0.9%) Statistically significant. Perioperative bleeding: Pre = 73 (35%) Post = 36 (33%) Not statistically significant. 30-day all complications: Pre = 101 (48%) Post = 56 (51%) Not statistically significant. Hospital LOS (median): Pre = 7 days Post = 6 days Statistically significant Readmission: Pre = 44 (21%) Post = 36 (33%) Statistically significant 30-day mortality: Pre = 0 (0%) Post = 2 (1.8%) Not statistically significant. | Not reported |
Australia 3/5 | Endoscopic cardiac surgery | Cohort study Yes – pre- vs post- ERAS implementation strategy implementation | ERAS strategy | Surveys with Colorectal surgeon = 5 Audit data on patients undergoing endoscopic cardiac surgery = 20 | LOS (mean): Pre-implementation strategy = 10.8 days Post-implementation strategy = 8.3 days Not statistically significant. Unplanned readmission: Pre-implementation strategy = 0% Post-implementation strategy = 20% Not statistically significant. | Improvement in compliance was observed in four audit criteria: preoperative fasting is minimized (from 0% to 15%), early feeding is implemented postoperatively (from 10% to 65%), preoperative carbohydrate drinks are given (from 20% to 25%) and oral supplements are given postoperatively (from 0% to 20%). Compliance for one audit criterion remained constant: patients are screened for malnutrition risk in preadmission clinic (100% for both audits). Two audit criteria saw a drop in compliance: nutrition support is provided preoperatively to malnourished patients (from 60% to 15%) and nutrition education is provided preoperatively (from 60% to 20%). |
USA 3/5 | Paediatric surgery | Cohort study Yes – pre- vs post- guideline implementation intervention implementation | American Society of Anaesthesiology’s guidelines | Patients = 20 | Not reported | Compliance with the ASA ‘nothing by mouth’ instructions increased from 20% to 50%. However promising, the result still meant that half of the patients/parents could not follow the instructions. Compliance with educating and informing patients/ parents of fasting requirements in advance of surgery increased from 75% to 100%. |
China 4/5 | Short-level posterior lumbar fusion surgery | Cohort study Yes – comparison in patient outcomes when implementing ERAS in different aged groups | ERAS | 65 to 79 years of age = 109 80 years and above = 109 | According to the comparable physiological condition after propensity score matching, there were significant differences between the two age groups in:
| Not reported |
Netherlands 3/5 | Pre-operative radiotherapy and surgical resection for rectal cancer | Cohort study Yes – pre- vs post- guideline implementation | The revised Dutch Colorectal Cancer Guideline 2014 | Patients Pre-guideline revision group = 7364 Post guideline revision group = 12,057 | Surgery alone: Before guideline revision = 1297 (17.6%) After guideline revision = 5475 (45.7%) Statistically significant. Short course radiotherapy with immediate therapy: Before guideline revision = 2743 (37.3%) After guideline revision = 1921 (16.0%) Statistically significant. Long course chemoradiotherapy: Before guideline revision = 2799 (38.0%) After guideline revision = 13,655 (30.5%) Statistically significant. Circumferential Resection Margin positivity (tumour-free resection margin ≤1 mm): Before guideline revision = 385 (5.8%) After guideline revision = 441 (4.2%) Statistically significant. Postoperative complication (incl. mortality and impact on length of stay): Before guideline revision = 1656 (22.5%) After guideline revision = 2233 (18.5%) Statistically significant. | Not reported |
USA 4/5 | Ambulatory outpatient shoulder arthroscopy | Cohort study Yes – pre- vs post- guideline implementation | Multimodal perioperative pain management protocol based on American Society of Anaesthesiologists (ASA) Task Force on Acute Pain Management recommendations | Patients Pre-implementation group = 132 Post- implementation group = 120 | Quality of recovery in 24 hrs and 48hrs:Pre-implementation group: 13.4 and 14.0Post-implementation group: 14.9 and 15.0 Statistically significant. Minimal clinically important difference achieved. Compared to pre-implementation, post-implementation group reported:
| Not reported |
Netherlands 2/5 | Elective abdominal or vascular surgery | Randomised control trial Yes – control group that switches at different timepoints to receiving the IMPROVE intervention | IMPROVE intervention that supports applying the Dutch National Perioperative Safety Guidelines | Patients from 9 hospitals IMPROVE Intervention = 989 Control = 987 | Before-after comparisons show that outcomes improved over time almost regardless of the intervention.Mortality rate:Baseline = 1.9%Final = 1.8% Statistical significance not assessed. Complication rate:Baseline = 27.9%Final = 26% Statistical significance not assessed. Postoperative wound infection:Baseline = 13.6%Final = 2.6% Statistically significant. LOS (median, days):Baseline = 8 daysFinal = 6 days Statistically significant. The increased compliance to the one guideline ‘discharge from recovery room’ was however related to:
| Use of IMPROVE intervention did not significantly improve guideline adherence – mixed results could be found. Intervention was related to increased compliance with the recommendation ‘discharge from recovery room’. Statistically significant. Intervention was related to decreased compliance with the recommendation ‘hospital discharge.’ Statistically significant. |
Iran 3/5 | General surgery. | Cohort study. Yes – pre- vs post- guideline implementation | Center for Disease Control (CDC) guidelines – Protocol of perioperative narrow-spectrum antibiotics prophylaxis | Patients Pre- guideline implementation: 4380 Post- guideline implementation = 3650 | Prevalence of surgical infection: Pre-implementation: 0.7% Post-implementation: 0.6% Not statistically significant. | Not reported |
Germany 4/5 | Surgery | Prevalence study No comparison. | German S3 guideline for the prevention of inadvertent perioperative hypothermia | Patients in 26 hospitals 431 patients overall. | No patient experienced postoperative hypothermia. 13% of patients experienced intraoperative hypothermia. | Recommendation for preoperative active warming of patients only adhered to in 20% of patients. Recommendation for sublingual temperature measurement of patients only adhered to in 7% of patients. |
Italy 4/5 | Prostate cancer patients treated with robot assisted radical prostatectomy extended pelvic lymph node dissection | Cohort study Yes – pre- vs post- guideline implementation for reporting morbidity. | European Association of Urology guidelines on reporting and grading complications. | Patients Pre-implementation group: 316 Post implementation group: 167 | Complication rate: Pre-implementation = 10% Post-implementation= 29% Statistically significant. Detection of grade 1 and 2 complications: Pre-implementation = 4.7% and 2.8% Post-implementation = 8.4% and 14% | Not reported |
Norway 3/5 | All types of surgery except transplantations, cardiothoracic, neuro, ear-nose-throat and maxillofacial, orthopaedic, upper and lower gastrointestinal, urology, vascular, breast and endocrinology, gynaecology, and obstetrics, ophthalmic and plastic and burn surgery | Cross-sectional study. Yes – pre- vs post- implementation programme | WHO Surgical Safety Checklist as part of the Norwegian National Patient Safety Program | Staff: Pre-program implementation = 349 (2009) and 292 (2010) Post-program implementation = 279 (2017) | From pre-programme implementation to post-programme implementation there was a significant improvement for the following dimensions from the Hospital Survey on Patient Safety Culture (as reported by HCPs):
| Compliance was 75% (1767/2367) in orthopaedic, thoracic and neurosurgery in the pre-program implementation group. In the post-program implementation group, overall and for all types of surgery the SSC compliance averaged 88% of the operations. |
Spain 3/5 | Hip fracture | Cohort study Yes – Pre- vs post- protocol implementation | Protocol on the perioperative management of hip fractures treated with antithrombotic based on American College of Chest Physicians recommendations | Patients Pre-protocol implementation group = 113 Post- protocol implementation group = 101 | Bleeding events: Pre-protocol implementation = 68.1% Post-protocol implementation = 68.3% Statistical significance not assessed. Thrombotic events: Pre-protocol implementation = 11.5% Post-protocol implementation = 13% Statistical significance not assessed. | Moderate to high thromboembolic risk patients, bridging therapy with full doses of enoxaparin (in line with protocol): Pre-protocol implementation = 18.5% Post-protocol implementation = 50% Statistically significant. |
South Korea 2/5 | Gastric cancer surgery | Survey study No | ERAS protocol | Staff Gastric surgeons = 89 | Not reported. | Among the ERAS protocols, preoperative education, avoidance of preoperative fasting, maintenance of intraoperative normothermia, thromboprophylaxis, early active ambulation, and early removal of urinary catheter were relatively well adopted in perioperative care. Other practices, such as avoidance of preoperative bowel preparation, provision of preoperative carbohydrate-rich drink, avoidance of routine abdominal drainage, epidural anaesthesia, prophylactic antibiotics, postoperative high-oxygen therapy, early postoperative diet, restricted intravenous fluid administration, and application of discharge criteria were less well adopted. |
USA 4/5 | Laparoscopic colorectal surgery | Cohort study Yes – pre- vs post- ERP implementation groups | Enhanced recovery protocol (ERP) for colorectal surgery based on ERAS (anaesthesia section) | Patients Pre-ERP implementation group = 36 Post-ERP implementation group = 36 | Post-ERP group was associated with a substantial decrease in perioperative opiate usage compared to pre-ERP group. Without sacrificing postoperative analgesia (subsequent increase in pain score) in the post-ERP group compared to the pre-ERP group. Return to bowel function (hours): Pre-ERP = 33.5 Post-ERP = 13.8 Statistically significant. LOS (median days): Pre-ERP = 4 days Post-ERP = 3 days Statistically significant. 30-day readmission: Pre-ERP = 27.8% Post-ERP = 2.8% Statistically significant. Complications: Pre-ERP = 13.9% Post-ERP = 5.6% Not statistically significant. | 82% (41/50) compliance with the ERP anaesthesia section after the implementation date. |
South Korea 4/5 | Upper arm surgery | Randomised control trial Yes – experimental group (receiving guideline recommender care) vs control group | American Society of PeriAnesthesia Nurses (ASPAN) hypothermia guideline | Patients Experimental group receiving care according to guidelines = 26 Control group receiving regular hospital care = 25 | Maintenance of normal body temperature (36°C) in the intraoperative and postoperative period: Experimental group: yes Control group: no (perioperative hypothermia) Statistically significant. | Not reported |
Russia 3/5 | Elective craniotomy | Cohort study Yes – Pre- vs post- implementation of protocol | Perioperative blood glucose monitoring and insulin infusion protocol based on the Peri-operative management of the surgical patient with diabetes 2015 guidelines by the Association of Anaesthetists | Patients Pre-protocol implementation group = 26 Post-protocol implementation group = 42 | Comparison of the risk of postoperative infection: Decrease in risk for post-implementation group compared to pre-implementation group. Statistically significant. | Not reported |
Chile 4/5 | General surgery | Cohort study Yes – pre-vs post- checklist implementation | WHO surgical safety checklist | Patients Pre-checklist implementation group= 29,250 Post-checklist implementation group = 29,250 | Mortality: Pre–checklist implementation group = 0.79% Post-checklist implementation group = 0.61% Statistically significant. LOS (mean, days): Pre-checklist implementation group = 3 days Post–checklist implementation group = 2 days Statistically significant | Not reported |
Netherlands 3/5 | Administering low molecular weight heparin bridging during unilateral total hip or knee arthroplasty | Cross sectional study Yes – guideline implemented care group vs non-guideline implemented care group (control) | 2012 American College of Chest Physicians (ACCP) guideline – to bridge high risk patients. | Patients Control group = 98 Guideline implemented care group= 13 | Complications/ blood transfusion: Control group = 8.3% Guideline implemented care group = 54% Statistically significant. LOS (mean, days): Control group = 5.3 Guideline implemented care group = 14.2 Statistically significant. | Not reported |
USA 5/5 | Perioperative chemotherapy | Cohort study Yes – intervention group receiving guideline recommender care vs control group | National Comprehensive Cancer Network, European Association of Urology and European Society for Medical Oncology guidelines that recommend perioperative chemotherapy in all pN2–3 M0 patients with squamous cell carcinoma of the penis (SCCP) | Patients PN2–3 M0 Patients with SCCP with chemotherapy administered = 140 PN2–3 M0 Patients with SCCP without chemotherapy administered (control) = 171 | Administration of chemotherapy (CHT) was not associated with improved cancer specific mortality (CSM) outcomes in the overall cohort. No statistically significant differences were identified between CHT and no-CHT subgroups in the overall cohort. | 45% of patients received chemotherapy (aligning to the guideline). |
USA 3/5 | General surgery | Cohort study Yes – pre- vs. post- checklist implementation. | WHO – Surgical safety checklist | Staff Pre-implementation = 929 Post-implementation = 815 | Staff agreed that they would feel safe as a patient in their operating room: Pre-implementation = 41.7% Post-implementation = 49.0% Statistically significant. 73.6% reported that checklists had averted problems or complications. | 54.1% participants reported that their surgical teams always used checklists effectively. Strongly agree that team discussions (e.g., briefings or debriefings) are common: Pre-implementation = 20.11% Post-implementation = 29.64% Statistically significant. Physicians are open to suggestions: Pre-implementation = 17.80% Post-implementation = 23.94% Statistically significant. Potential errors or mistakes are pointed out without raised voices or condescending remarks: Pre-implementation = 15.86% Post-implementation = 22.89% Statistically significant. |
Australia 5/5 | Prevention of hypothermia in surgery patients | Qualitative study (semi-structured interviews) No comparison | Australian College of Perioperative Nurses (ACORN) guidance on prevention of perioperative hypothermia | Staff 12 participants | Not reported | Not reported |
Ireland 5/5 | General surgery | Qualitative study (semi-structured interviews) No comparison | WHO surgical safety checklist | Staff Nurses = 10 | Not reported | Not reported |
Denmark 4/5 | Elective open-heart surgery | Cohort study Yes – pre- vs post- guideline implementation group | Danish Clinical Guideline on oral hygiene | Patients Control (Pre-guideline implementation) = 506 Post- guideline implementation group = 466 | Antibiotic prescription on the 5th postoperative day: Control group = 12.6% Post- guideline implementation group = 7.7% Statistically significant. | The clinical guideline was considered to have been fully implemented as all patients referred for elective open-heart surgery were informed about the importance of systematic oral hygiene before admission to hospital. Of the patients in the intervention group, 405 (86.9%) reported that they had adhered to the oral hygiene recommendation. |
Canada 3/5 | Gynaecologic oncology procedure | Cohort study Yes – pre- vs post- guideline recommended pathway implementation | Perioperative glycaemic management pathways based on ERAS and Diabetes Canada guidelines | Patients 878 patients whose outcomes were compared pre- vs post- pathway implementation | Screening for risk of postoperative hyperglycaemia: Pre-implementation = 78% Post-implementation = 90% Statistically significant. Cases of postoperative hyperglycaemia: Pre-implementation = 54% (at 24 hours) 37% (at 72 hours) Post-implementation = 42% (at 24 hours) 28% (at 72 hours) Not statistically significant. LOS (median, days): Pre-implementation = 3.0 Post-implementation = 2.5 Statistically significant. | Not reported |
India 1/5 | General surgery | Mixed methods study No comparison | WHO Surgical Safety Checklist | Patients Total surgeries = 1778 | Total of complications = 74 (4.1%)
| The proportion of patients who received prophylactic antibiotics was 100%. |
England 4/5 | Open or laparoscopic colorectal surgery | Mixed methods study No comparison | Surgical warming care bundle based on the National Institute for Health and Care Excellence (NICE) Inadvertent perioperative hypothermia guideline | Patients = 124 HCPs = 21 | At least 30% of patients were hypothermic on admission to the recovery unit. | Not reported Compliance with active warming in the operating room: 96% of hypothermic patients given a forced air warming blanket. Compliance with active warming in the recovery room: 47% of hypothermic patients given a forced air warming blanket. |
Japan 3/5 | General surgery | Cross-sectional retrospective study Comparison between compliance to guidelines and level of organisational culture | Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices The Japanese Association for Infectious Diseases. Guideline for Antibiotic Use | Staff from 83 hospitals Total = 4856 | Not reported | Hospitals with high organizational culture scores were associated with higher adherence to both the CDC and Japanese guidelines. |
Turkey 3/5 | Colorectal surgery | Cross-sectional study No comparison | ERAS protocol in colorectal surgery | HCPs Total = 110 Physician = 54 Nurse = 56 | Not reported | HCPs who witnessed/performed ERAS during their training = 35.5% Not heard of ERAS = 26.4% Do not know how to use in practice = 16.4% The evidence does not convince me to change practice = 22.7% I want to use ERAS but do not have the MDT support = 6.4% Would use ERAS if given adequate education and data = 68.2% Would use ERAS if had MDT support =70% |
USA 3/5 | Open liver resection | Cohort study Yes – pre-vs post- ERAS implementation | ERAS | Patients Pre-ERAS = 42 Post-ERAS = 75 | Pain: No significant difference in pain score between pre- and post- ERAS implementation groups. Morphine administered: Significantly less morphine administered on post-operative day 1,2 and 3 in the post-ERAS implementation group compared to pre-ERAS implementation group. Post-operative complications: Pre-ERAS = 10% Post-ERAS = 1% Statistically significant. LOS (median, days) Pre-ERAS = 6 Post-ERAS = 5 Statistically significant. | There was 70% compliance with all aspects of the ERAS pathway |
China 5/5 | Colorectal surgery | Randomised controlled trial Yes – standard ERAS guidance care vs ERAS guidance with pre-operative rehabilitation considered too | Peri-operative rehabilitation recovery protocol based on and updated from ERAS guidance | Patients Standard-ERAS care group = 104 ERAS with pre-operative rehabilitation group = 109 | Patients with normal recovery of GI function: Standard ERAS care group = 64.4% ERAS with pre-operative rehabilitation group = 78.9% Statistically significant. | The compliance rate for every element of the peri-operative rehabilitation recovery protocol in both groups ranged from 92% to 100%. |
France 4/5 | Mini-invasive aortic valve replacement | Cohort study Yes – pre- vs post- ERAS program implementation | ERAS program | Patients Pre-ERAS group = 23 Post-ERAS group = 23 | Average ICU pain scores: Pre-ERAS group = 2 Post-ERAS group = 1.4 Statistically significant. LOS (median, days): Pre-ERAS group = 10 Post-ERAS group = 7 Statistically significant. | Overall, adherence to the ERAS elements of the pathway was statistically more common in the MIAVR-ERAS group. |
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