Anesthesia in the News
  • Improving Post-Hysterectomy ERAS Protocol Compliance

    To streamline perioperative safety and efficiency, Massachusetts General Hospital in Boston implemented an Enhanced Recovery After Surgery (ERAS) protocol for patients undergoing laparoscopic, vaginal, and open hysterectomy called “ERAS Hysterectomy” in March of 2018. In a paper published this Spring, the Mass General team of CRNAs, their colleague anesthesiology providers and surgeons measured the effectiveness of their plan over time.

    Confronting the ERAS challenge

    Massachusetts General Hospital is a sizable facility, with 76 certified nurse anesthetists (CRNAs), 164 anesthesiologists, and 35 surgeons who perform hysterectomies, which made streamlining of perioperative protocols a challenge.

    “Implementing and maintaining strict adherence to ERAS pathways is challenging, and compliance values of approximately 70% are common,” the researchers noted. Yet, published literature reveals that adherence to ERAS pathways — particularly in gynecology — is effective at decreasing complications, shortening hospital stays, and cutting costs.

    To implement ERAS Hysterectomy on March 1, 2018, the Mass General ERAS protocol (or “pathway,” as it was deemed) was divided into 2 “bundles:” surgical and anesthesia. Staff members then received 14 months of intensive training in following the pathway.

    In the 2 years following implementation, all of the providers participated in caring for patients while following the pathway.

    The ERAS records review reveal

    The researchers then retrospectively reviewed records of 2,570 patients who underwent hysterectomy between October 2016 and March 2020 to determine adherence to the anesthesia bundle of the pathway.

    The goal was to measure provider compliance in the use of preemptive analgesia, use of antiemetics, intra-op fluid management, and dosage of both short- and long-acting narcotics.

    Their review found that compliance with use of preemptive analgesia increased from 42% to 85%, compliance with intra-op fluid management increased by 58%, dosage of short-acting narcotics decreased by 14%, and dosage of long-acting narcotics decreased by 9%.

    Why it worked

    The researchers feel that their team was successful because they followed a deliberate implementation framework. They met with both large and small groups of staff members and communicated extensively via email to familiarize all of the patient-care stakeholders with the protocol. Nightly emails to anesthesia providers who would care for ERAS hysterectomy patients reminded clinicians of the different elements of the pathway. This tactic continued for 14 months following implementation and served to further reinforce adherence, the study authors wrote. Furthermore, they reported, compliance was sustained in the post-intervention period despite no additional actions.

    Read the full study, Ellis DB, Agarwala A, Cavallo E. et al. Implementing ERAS: how we achieved success within an anesthesia department. BMC Anesthesiol. 21, 36 (2021) at