Pre-Operative Enhanced Recovery After Surgery (ERAS) Protocol Compliance Towards Major Surgery Patients at Dr. Soetomo General Hospital, Surabaya

Article history: Received 11 May 2020 Received in revised form 28 May 2020 Accepted 02 June 2020


Introduction
Surgery is one of the most widely performed medical procedures in the world. 1 Major surgery can cause postoperative complications which can worsen the patient's condition and increase the patient's mortality rate. 2 This event can add cost and energy burdens to clinicians and patients. 3 This has a major impact especially in the era of universal healthcare, where costs, labor and time must be minimized as much as possible to reduce risks and deficits. 4 An effective way to prevent this complication is by applying ERAS protocol (Enhanced Recovery After Surgery) The ERAS protocol is a multi-modal peri-operative treatment pathway that aims to restore the physiological state of the body post-surgery as optimal as possible before surgery and reduce the impact of surgical stress by giving operative patient right amount of care before, at, and after surgery. 5 Research in China suggest that higher adherence to ERAS protocol has benefits to major surgery patients. 6 However, ERAS protocol still faces various obstacles. This is because the ERAS protocol changes the existing operating care doctrine. 7,8 The ERAS protocol component of the pre-operative period is the earliest treatment action and can determine the effect of subsequent peri-operative care. Dr. Soetomo General Hospital has many clinical practices carried out, including surgery. This study aims to determine the description of the adherence and consistency of preoperative management based on ERAS protocol. We Biomolecular  used pre-operative part of the surgery for evaluation was because pre-operative ERAS protocols can be carried out in any hospital without sophisticated equipment and invasive procedures unlike the intra-operative period which including minimally invasive surgery. 9 Thus, we can compared Dr. Soetomo General Hospital with another hospital with higher technological capabilities. The surgical procedures included in the research are digestive surgery, thoracic cardiovascular surgery, and gynecology/oncology surgery because the only available pathway in those 4 types of surgery. 10,11,12,13 Methods This was a descriptive-observational research by taking data from surgical patients consecutively for 4 weeks from 18 May 2019 to 1 June 2019 and 9 June 2019 to 22 June 2019 conducted at Dr. Soetomo General Hospital. The inclusion criteria were elective, major surgery patients with age above 18 years old and with types of surgery that has ERAS guidelines (digestive, thoracic and cardiovascular, and gynecologic). The exclusion criteria were patient underwent emergency surgery and minor surgery. Total number of surgery patients observed was 36 patients. The ethical clearance had approval from the research ethical committee of Dr. Soetomo General Hospital (110/KEPK/IV/2019).
Data from surgery patients was obtained by reading through the sheets related to the application of ERAS in the patient's medical record while the patient had still monitored inward. Data including SOAP (Subjective, Objective, Assesment, Plan) sheets, intensive care/ high-care sheets, CIE (Consultation, Information, and Education) sheets, early adult nursing assessment sheets, medical assessment sheets, anesthesia and sedation sheets, medication sheets, laboratory examination sheets, and surgery sheets. Each patient then categorized into thirteen elements as seen from table 2 based on percentage of pre-operative care adherence to the patient (> 90%, 80-89%, 70-79%, 60-69%, and <60% respectively). 14 All data analyzed by categorizing the data based on characteristics and compliances for different type of surgery, then comparing each types of surgery compliance of pre-operative ERAS protocol in Dr. Soetomo General Hospital. WPS Office 11 and SPSS 25 software was used for data collection, recording and calculation. Each type of surgeries compliance then compared with other hospital researches within the same type of surgery.

Characteristics of Major Surgery Patient
Based on the data obtained from observations in table 1, the most number of patients in types of surgery category were gynecological/ surgery patients, (n=15, 41.7%) and the least number of patients were patients with digestive surgery (n=7, 19.4%). Majority of patients was female (n=24, 66.7%) with average age was 50 ± 13,5 years.

Compliance with Pre-operative ERAS Protocol Elements in Major Surgery
In table 3, none of the patients had total adherence of less than 70% from thirteen elements listed in table 2. Almost all pre-operative ERAS elements had a percentage of> 90% except screening and treatment of anemia and pre-operative medical pre-habilitation.

Compliance with Pre-operative ERAS Protocol Elements in Thoracic and cardiovascular Surgery
Thoracic-cardiovascular surgery patient compliance at Dr. Soetomo General Hospital was higher than the two types of operations as seen in table 4 and 5. In particular, prehabilitation elements in thoracic and cardiovascular surgery was more adhered than digestive surgery and gynecological surgery. Even so, this still needs improvement as prehabilitation was only done in half of the patients.

Compliance with Pre-operative ERAS Protocol Elements in Gynecologic Surgery
Total percentage of compliance in Dr Soetomo General Hospital ERAS preoperative protocol in gynecologic surgery on  ERAS protocol is done to reduce post-operative stress and complications. There are three parts of ERAS protocol which consists of pre-operative, intra-operative, and post-operative elements. First, elements of pre-operative ERAS protocol include education, risk assessment and reduction, fasting and nutrition enhancement, and preoperative medication including PONV (Post-Operative Nausea and Vomiting). Elements of intra-operative ERAS protocol consists of standard anesthetic protocol, intraoperative fluid therapy, surgical techniques, and hypothermia reduction. Finally, postoperative therapy including thromboprophylaxis, postoperative nutrition and fluid therapy, drain management, and early mobilization.
Other criteria for peri-operative managements are not comprehensive like ERAS, for example there is only one criterion focusing on pre-operative fasting for long hours. ERAS criteria are based on comprehensive peri-operative treatment. Compared to old criteria for fasting, in ERAS, patient must be given nutrition before fasting and long hours of fasting are reduced. 10,11,12,13,20 When compared among digestive surgery, thoracic and cardiovascular surgery, and gynecological surgery in table 2 and 4, the total percentage of overall major surgery patients compliance was higher than digestive and gynecological operations combination and slightly lower than thoracic and cardiovascular operations. The least complied type of surgery in ERAS protocol was digestive surgery. This is because in digestive surgery, opioid sparing medication had not been used at all because the doctors were still inconsistent in adherence towards ERAS protocol. 12 The pre-operative ERAS protocol that had been done the least were screening and treatment of anemia and preoperative medical pre-habilitation which contribute to decrease in compliance persentage. Screening of anemia had been done in all patients, but treatment in patients with anemia generally uses blood transfusions which can increase the risk of complications. 21 Medical prehabilitation in all patients was not performed because the management system of Dr. Soetomo General Hospital is still inadequate to accommodate all major surgery patients. Medical pre-habilitation compliance was better in thoracic and cardiovascular surgery because more medical evidence supports pre-habilitation in this type of surgery compared to other operations. 22 The lack part in compliance could be improved with better medical management and education to ERAS adherence.
This study has limitation in only focused on pre-operative elements, while ERAS is multimodal and interlinked between pre-operative, intra-operative, and post-operative to bring optimal result to patients. 12 The difficulties in Dr. Soetomo General Hospital to implement ERAS are lack of medical personnel knowledge and medical management system.