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March 2018

Barriers to and Facilitators of Implementing Enhanced Recovery Pathways Using an Implementation Framework: A Systematic Review

Author Affiliations
  • 1Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
  • 2Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland
  • 3Department of Surgery, UCLA (University of California Los Angeles) Medical Center
  • 4Department of Surgery, University of California, San Francisco
JAMA Surg. 2018;153(3):270-279. doi:10.1001/jamasurg.2017.5565
Key Points

Question  What are the barriers and facilitators to implementation of enhanced recovery pathways?

Findings  In this systematic review of 53 studies, the Consolidated Framework for Implementation Research framework was used to extract insights about creating enhanced recovery pathways. Common facilitators included adapting the pathway to the local context, using a formal implementation framework, and hiring full-time enhanced recovery coordinators. Common barriers included a lack of resources and not gaining buy-in from health care professionals.

Meaning  Having adaptable pathways that are well supported with a deliberate and predetermined implementation strategy are keys to successful and durable enhanced recovery programs; however, more in-depth descriptions of the implementation process are needed.


Importance  Enhanced recovery pathways (ERPs) have the potential to reduce length of hospital stay, costs, and complications following surgery but can be challenging to implement.

Objective  To examine the body of literature on ERPs to assess how authors describe barriers and facilitators of ERP implementation and identify, in aggregate, the best practices that should be considered utilizing the Consolidated Framework for Implementation Research (CFIR) to extract these elements and summarize common barriers and facilitators according to its 5 major domains: (1) intervention characteristics, (2) inner setting, (3) outer setting, (4) characteristics of the individuals, and (5) the process of implementation.

Evidence Review  A systematic review was conducted in accordance with the PRISMA statement. An ERP was defined as a bundle of multiple perioperative interventions that involve a multidisciplinary team, had a label different than traditional care, and had a formal way of measuring outcomes. Six databases (PubMed, MEDLINE, Cumulative Index to Nursing and Allied Health Literature Complete, Web of Science, PsychINFO, and Cochrane Central Register of Controlled Trials) of articles published from 1990 to November 30, 2016, were searched. Articles that were included had to address barriers and facilitators of ERP implementation and provide sufficient detail that the CFIR domain could be identified. Data were abstracted by 2 independent researchers using a standardized extraction form.

Findings  The initial search strategy returned 4563 results; 3883 studies were eliminated by screening titles and abstracts, leaving 680 articles for full-text screening. Of these, 53 studies were included in the review. The key facilitating factors were (1) adapting the program to fit local contexts, (2) achieving and demonstrating early “wins,” (3) gaining buy-in from both frontline clinicians and hospital leadership, (4) having a strong ERP team that met regularly, and (5) leveraging supporters and full-time ERP staff. The major barriers identified were (1) meeting with resistance to change from frontline clinicians, (2) not having enough resources for implementation, and (3) external factors, such as patient complexity or rural hospital location.

Conclusions and Relevance  Most ERP literature focuses on the efficacy, safety, or cost-effectiveness of these protocols. To promote the spread of ERP programs, more high-quality studies on the implementation process are needed.

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