Running head: QUALITY IMPROVEMENT PROJECT 1

Quality Improvement Project

Lisa Blair Holston

Nursing Servant Leadership- NUR 4144

March 21st, 2017

Barbara Ellcessor, DNP, RN, RNC-OB

QUALITY IMPROVEMENT PROJECT 2

Introduction

Enhanced recovery after surgery (ERAS) is a patient-centered system of care developed

for surgical facilities to prevent postoperative complications and increase recovery rates for

patients. ERAS protocol is a system that guides the patient through their surgery from their initial

doctor appointment, to their preoperative, intraoperative, and postoperative phases of surgery

within the hospital. ERAS protocols include optimal patient and family education prior to

admission, less pre-procedure fasting, oral hydration two hours before anesthesia, and return to

normal diet and activities the day of surgery. Anesthesia is applied using a multimodal approach

in an effort to decrease the use of opioid drugs. The use of ERAS has been found to decrease

surgical complications related to the use of opioid analgesics. Opioids have been seen as the drug

of choice for postoperative pain, but these drugs often cause side effects like respiratory

depression, nausea, and constipation, that can cause more harm in the long-term health of the

patient.

Implementation of ERAS protocols have been proven to lead to better patient outcomes,

increased patient satisfaction, and a reduction in the cost of care for postoperative patients

(Brady, Keller, & Delaney, 2015). On the Medical-Surgical Unit of St. Mary’s Hospital, ERAS

protocol is being implemented for radical cystectomy and abdominal surgery patients. ERAS

protocols are allowing intake of solid food, ambulation, and discharge to take place at a faster

rate. Postoperative pain is primarily controlled through epidurals, IV lidocaine infusions, and

oral nonsteroidal anti-inflammatory drugs (NSAIDs). If pain is still high after the application of

NSAIDs, low-dose narcotics can be given. The narcotics are not be administered routinely, only

as rescue pain management.

QUALITY IMPROVEMENT PROJECT 3

Heart

Nurse leaders bring people together and empower others to initiate action and take part in

projects. A leader has the power to influence the intentions and beliefs of others through their

own motivation. Since nursing is a field centered around caring, a good nurse leader must lead

with their heart. Some leaders are self-motivated, while others are motivated by the best interest

of the group. The caring nature of nursing requires selfless motivation. Motivation should come

from a place of honesty and confidence.

Having clear motivation makes it easier for others to see why they should follow you in

the first place. A bond of trust between a manager and their workers will ultimately lead the way

for productivity and commitment towards goals. If you lead with honesty, your words won’t be

questioned and people won’t have doubts. Having forgiveness towards others and acting in a

graceful manner is a way to empower your workers to take initiative. If you have a reputation for

losing your temper when mistakes are made, your staff will be too afraid to take initiative and get

things done on their own. As a manager it’s important to be understanding when mistakes are

made, and to discipline in an appropriate manner whenever necessary. Establishing oneself as a

disciplinarian may seem like a good idea in the short-term, but in the long-term people will be

afraid to act on their own and overall productivity of the unit will suffer.

Head

In order to get other people on board with your ideas and beliefs, a leader needs to be

someone that can be depended on. The ​head ​domain of leadership gives the leader a sense of

self. Before the leader can take action, they must be able to clearly define their purpose, vision

for the future, and values. It’s a leader’s job to keep the group on task and remind them of the
QUALITY IMPROVEMENT PROJECT 4

bigger picture. A leader is a mentor to their peers and needs to be willing to teach and

demonstrate to others what needs to be done.

A nurse manager is someone who assumes leadership over an area or unit of a hospital.

It’s the nursing manager’s job to delegate care among the nursing and supportive staff within the

unit, and provide proper supervision. The nurse manager sets goals and guidelines for their staff

to work towards. The nursing staff should feel empowered and supported by their nursing

manager. Communication within the interdisciplinary team should be encouraged, and nurses

should feel like their manager will stand up for them if need be. Nurses need to feel secure

within their workplace and know that someone will have their back when they advocate for their

patients.

Leaders need to convey that they are invested in their employees and have the workers’

best interests in mind. People want to feel nurtured and respected by their manager. Manager’s

need to introduce new ideas and change as opportunities for growth. Having a positive attitude

and encouraging others to share their ideas will prompt people to follow you. It’s important to

remind workers of the unit’s vision, and maintain following throughout a process of change.

Reminders of the vision and values will keep workers on taks and reorient them to the purpose of

their work.

Hands

Careful planning is involved when making changes to a structure. Change can be a

difficult process for everyone involved, and it’s a nurse manager’s job to be an agent of change.

When change is abrupt, it can cause confusion, fear, discord, and negative emotions. Managers

must be ready to deal with negative emotions and refocus the group towards the goal. Despite
QUALITY IMPROVEMENT PROJECT 5

having a career in a dynamic field, many nurses see change as a negative occurrence and are

inflexible. Nurses often fear that changes will bring an increase in their workload. It’s a

manager’s job to help workers see the benefits and necessity of change.

Communication ahead of time is a crucial component for initiating change. The staff need

to be properly warned and educated about an upcoming change, in order for implementation to

be successful. Months in advance, the nurse manager should hold unit meetings about the

upcoming ERAS protocols being implemented to the unit. Since pain management is often a

difficult task for nurses, the leader needs to be prepared to explain why pain management

through NSAIDs, rather than opioids, is a good thing for the patient and the nursing staff.

The nurse manager could explain that the sedating effects of opioids make it difficult for

the client to stay awake and ultimately delays ambulation time. Delayed ambulation time, as well

as the constipating effects of opioids, set patients up for bowel obstruction and abdominal pain.

While decreased opioid pain relief seems like more work on the nurses, it will ultimately

decrease the need for future interventions related to abdominal pain and constipation. Quicker

recovery rates and less postoperative complications will decrease the overall burden on the staff.

Habits

Nursing managers need to be able to take care of themselves as well as their workers.

Finding a moment of solitude within a busy workday is important for nurse managers to center

themselves. Getting away from the group is essential to maintaining good temperament and

having a balance between work and personal life. Solitude and prayer are good ways for

managers to take a timeout and evaluate how they’re doing, and what they could be doing better.
QUALITY IMPROVEMENT PROJECT 6

When leaders engage in reflection, it allows them to see the bigger picture of what they are doing

and it reorients them to their purpose, vision, and values.

Having a sense of spirituality can be a beneficial quality for a nurse leader to have.

Spirituality can be a way for individuals to reflect and self-actualize. Spiritual scripture can guide

leadership actions and give the person a sense of fulfilment. Engaging in spiritual beliefs often

leads people to look inwards and work on becoming an improved version of themselves.

Nurse managers should treat others as they would wish to be treated; it's important to

display and accept unconditional love. Unconditional love fosters the way towards development

of supportive relationships. It’s important for leaders to seek supportive relationships within the

workplace, as well as within their personal life. Having friends from other units, as well as the

unit you work on, is important to having a good head on your shoulders in a nursing career.

Model the Way

Nurse managers model the way to success and act as a role model for everyone else on

the unit. Even though the nurse manager isn’t someone who routinely cares for patients, its

important that they attend all of the education meetings along with the other staff so that they can

continue to be a resource for best practice and supervision. The nurse manager should be making

daily rounds on the surgical patients and making note of their progress to compare data and

evaluate the effectiveness of ERAS protocol. Hard work and accomplishments should be

acknowledged by the manager so that workers can be confident in their skills.

Inspire a Shared Vision

In order to maintain the progress of a project, the leader needs to keep reminding the

group of why they started in the first place. Once the hard work begins on a project, it can be
QUALITY IMPROVEMENT PROJECT 7

tempting for everyone to quit and leave things how they were before. People might even question

whether or not the change is necessary if it doesn’t seem beneficial to them. The nurse manager

should keep reminding the nurses that ERAS protocols are instilled to prevent further

complications after surgeries, and that this will ultimately mean less work for them. The nursing

staff should also be reminded that ERAS is an evidence-based practice that leads to better

outcomes for the patient. With the current opioid crisis occurring in the U.S., it would be

worthwhile for the nurse manager to emphasize the importance of decreased opioid

interventions. Reminding others of the bigger picture is a form of empowerment because it

motivates them to be involved in the change.

Challenge the Process

ERAS protocol is a new way of caring for surgical patients; it challenges past surgical

procedures and brings a better, safer management of care to the field of nursing. Leaders are

always looking for ways to improve. Even after a goal is reached, a good leader should ask “how

can we do even better next time?” Nurse managers should always be on the lookout for

opportunities for growth and success. ERAS allows patients to be discharged earlier, without an

increased readmission rate. This change in surgical protocol was brought to the unit from a

higher administrative level, therefore it’s the nurse manager’s job to ensure that this change is

carried forth. The nurse manager needs to be enthusiastic and passionate about this change for

the future, and encourage others to work towards an improved nursing unit.

Enable Others to Act

The nursing leader should also encourage others to join committees and share their ideas

for change. ERAS protocol requires that every healthcare team member knows the guidelines
QUALITY IMPROVEMENT PROJECT 8

and standards of practice throughout each step of the patient’s surgical care. It’s essential that

postoperative nurses understand the role of the preoperative and perioperative nurse as well.

ERAS protocols hold every healthcare team member accountable for the care that they provide to

patients, every step of the way.

Nurse leaders need to be encouraging their staff while they learn and apply new

knowledge on the floor. A good nurse manager highlights areas of excellence, while delicately

pointing out what could be improved. When a manager shows that they’re invested in the growth

and development of their staff, people are more likely to react positively to challenging

opportunities. A nursing manager is always encouraging their staff to continue their nursing

education.

Encourage the Heart

When success has been met, it’s important for the leader to acknowledge it. Showing

staff members personal recognition of their performance, will instill good work ethic. Pizza

parties and other celebratory events are ways to show your staff that you care and appreciate all

of the hard work that they do. Having outings outside of work are also good ways to build

interpersonal relationships and build teamwork.

The main purpose for a manager to encourage the heart, is to get everyone focused on the

results of their work. Leaders have the responsibility of bringing everyone closer together. The

biggest thing that a nurse manager can do to encourage the heart is to smile and be pleasant

everyday. The nurse manager should be eager to seek out what people are doing right, rather than

wrong.
QUALITY IMPROVEMENT PROJECT 9

Professional Practice Implications

ERAS protocols merge the pieces of preoperative, intraoperative, and postoperative care.

The nurse’s role in ERAS protocol is to educate patients and help develop equilibrium across the

interdisciplinary team. ERAS education empowers patients and their caregivers to fully

participate in the recovery process. Discharge planning begins at the earliest phase of the hospital

experience, so that discharge isn’t rushed and patients feel more prepared when it’s time to leave

the hospital; early planning allows more time for clarification.

The education of nurses and other interdisciplinary team members is also crucial for the

success of ERAS implementation. Enhanced recovery pathways help to outline and explain the

care process in detail from every level of care. Care pathway resources are available in binders at

the nurses’ station and each staff member is required to participate in continuing education

courses. Care for ERAS surgical patients is standardized. Each patient is expected to ambulate

the night of surgery, and there are set medication orders. Criteria for discharge and any

postoperative complications are outlined in specific protocols.

Preoperative protocols involve patient education and maintaining hydration before

surgery. On the Medical-Surgical unit of St. Mary’s Hospital, the majority of ERAS care is

involved with the postoperative phase. General nursing care includes postoperative vitals signs

every four hours, transitioning to every eight hours after the first 24 hours following surgery. For

patients with epidurals, vitals will be taken every two hours for the first four hours, and then

every four hours until the epidural is removed. Continuous pulse oximetry and capnography is

used for epidural patients during the first 24 hours after surgery.
QUALITY IMPROVEMENT PROJECT 10

General pain management follows two regimens. Epidural pain management and

lidocaine infusions are used for open cases, and laparoscopic cases are placed on lidocaine

infusions. Routine epidural medications include Acetaminophen, Ketorolac, and Celecoxib.

Tramadol and Oxycodone can be given via epidural as needed for pain. Nurses need to perform

dermatome checks for epidural patients, and each patient receiving a lidocaine drip must be

monitored for lidocaine toxicity.

ERAS patients do not require postoperative prophylactic antibiotics. Heparin is

administered immediately after surgery for DVT prophylaxis. It’s always given in the abdomen,

but distal to surgical sites. Entereg and Ondansetron are given to restore bowel function and

reduce nausea and vomiting after surgery. Ativan 0.5 mg is available every six hours as needed

for anxiety. Lactated Ringer’s solution is continued into the first postoperative day at 75 mL/hr.

On the first postoperative day, low fiber diets are implemented as the patients will

tolerate, and patients are out of bed for all meals and at least six hours total each day.

Ambulation is expected to be three times a day, for at least 50 feet each time. Each patient will

be consulted by a Wound Ostomy and Continence Nurse, and urostomy stents will be irrigated if

clots arise. On the second postoperative day, the lidocaine drip is to be discontinued. Surgical

dressing changes and ostomy teaching also takes place on this day. On postoperative day three

until discharge, epidural use is discontinued. Lactated Ringer’s solution is discontinued if the

patient is tolerating their diet and taking in adequate fluid hydration. Discharge is considered if

the patient is passing flatus, tolerating their diet, has a stable hemoglobin count, has pain under

control, and is free of abdominal distention.

QUALITY IMPROVEMENT PROJECT 11

Upon discharge, the patient will be instructed to schedule a follow-up appointment with

their surgeon seven days later. The patient should also plan to see their primary care provider as

needed. Nurses reinforce discharge teaching and utilize handbooks and instructional videos.

Discharge medications include oral Acetaminophen 1000 mg every six hours for the first 24

hours, Ibuprofen 200 mg, and Oxycodone 5 mg.

Outcomes Evaluation

The use of ERAS protocols has improved patient care efficacy, advanced recovery, and

reduced the length of stay for surgical patients. Reduced length of stay has not compromised

readmission rates for surgical patients, and the overall cost of care for these surgical patients has

been reduced (Brady, Keller, & Delaney, 2015). Multiple aspects of ERAS protocols have

contributed to the accelerated recovery rates of patients. High carbohydrate and protein drinks

given the day of surgery prevent complications that can arise due to dehydration and electrolyte

imbalances. After surgery, cortisol levels rise in a response to stress causing the body to fall into

a catabolic state. Carbohydrate loading before surgery helps to prevent muscle breakdown and

insulin resistance due to catabolism (Jankowski, 2017).

According to Pang, Groves, Venugopal, Noon, and Catto (2017), ERAS protocols have

also reduced the amount of blood loss and transfusion rates. Contrary to past surgical protocols,

ERAS patients do not undergo bowel preparation before their procedure. Bowel preparation has

been thought to prevent bacterial exposure during the surgical procedure. However, research

indicates that mechanical bowel preparation can increase the risk for exposure to infection during

surgery (Melnyk, Casey, Black, & Koupparis, 2011). Bowel preparation causes liquefaction of

the stool and increases the risk of intestinal contents spilling into the abdomen during an open
QUALITY IMPROVEMENT PROJECT 12

procedure. Bowel preparation can also cause electrolyte imbalances and dehydration during the

operation. The need for fluid replacement increases the use of IV fluid administration and

ultimately leads to an increased risk for fluid imbalances after surgery.

In order to measure the effectiveness of ERAS protocols, care measures are given

through specific order sets. Standardized nursing interventions make it easier to keep track of

patient outcomes and and develop auditing tools for quality improvement. Specific sets of

medications also cut down on pain management choices. Standardized pain management has

helped patient care adherence to ERAS protocols and evidence-based practice.

The success of ERAS protocols is dependent on the interdisciplinary team’s ability to

provide uniform care on all levels of surgery. Education is crucial for each person involved in the

patient’s care, including the patient and their caregivers. One of the biggest barriers to ERAS has

been patient noncompliance during the postoperative phase. It’s up to ERAS nurses to be leaders

and help empower and coach their patients throughout the recovery process. Nurses need to

encourage their patients to ambulate and push through the pain that follows a surgical procedure.

Even though ERAS pain management might seem insufficient in comparison to traditional

opioid interventions, it has been proven to show an overall improvement in patient outcomes and

recovery rates.
QUALITY IMPROVEMENT PROJECT 13

Reference

Brady, K. M., Keller, D. S., & Delaney, C. P. (2015). Successful implementation of an enhanced

recovery pathway: The nurse’s role. ​Association of Perioperative Registered Nurses,

102​(5), 469-481. doi: 10.1016/j.aorn.2015.08.015

Jankowski, C. J. (2017). Preparing the patient for enhanced recovery after surgery. ​International

Anesthesiology Clinics, 55​(4), 12-20. ​doi: 10.1097/AIA.0000000000000157

Melnyk, M., Casey, R. G., Black, P., & Koupparis, A. J. (2011). Enhanced recovery after surgery

(ERAS) protocols: Time to change practice? ​Canadian Urological Association Journal,

5​(5), 342-348. doi: 10.5489/cuaj.11002

Pang, K. H., Groves, R., Venugopal, S., Noon, A. P., & Catto, J. W. F. (2017). Prospective

implementation of enhanced recovery after surgery protocols to radical cystectomy.

European Urology, 73​(3), 363-371.