Introducing enhanced recovery after surgery (ERAS) program in Rwanda: a step-by-step approach from KAP study to protocol development and preliminary implementation.
Enhanced recovery after surgery; Evidence-based practices; Healthcare implementation; Laparoscopic surgery; Perioperative protocols; Resource-limited healthcare; Surgical care improvement; cholecystectomy; ERAS
Abstract :
[en] [en] BACKGROUND: Enhanced Recovery After Surgery (ERAS) programs improve postoperative outcomes through evidence-based practices. However, implementing ERAS in resource-limited settings like Rwanda remains challenging. This study aimed to introduce an ERAS program at the Centre Hospitalier Universitaire de Kigali (CHUK) by tailoring it to the local context.
METHODS: A multi-phase strategy was employed, beginning with a Knowledge, Attitudes, and Practices (KAP) study following an ERAS webinar to identify gaps in awareness and application of ERAS principles among perioperative care providers. Targeted training sessions were conducted to address these gaps, leading to the development of a locally adapted ERAS protocol.
RESULTS: The KAP study revealed limited awareness of ERAS protocols, including international Nil Per Os (NPO) guidelines, with only 45.7% of participants familiar with them and 48% unknowingly applying some ERAS elements. Early postoperative feeding was supported by 45.7%, and 92.5% agreed that preventing nausea and vomiting enhances recovery. Regarding opioid use, 88.4% supported selective use, while 81.5% disagreed with eliminating opioids entirely. Almost all respondents (97.7%) believed ERAS improved perioperative care, and 79.2% felt it reduced hospital expenses. Additionally, 85% of respondents recognized laparoscopic surgery as enhancing ERAS protocols. The insights gained informed the design of targeted training sessions and the development of a locally adapted ERAS protocol, supported by the formation of collaborative groups and ERAS champions.
CONCLUSION: The introduction of ERAS at CHUK demonstrates the feasibility of implementing evidence-based surgical protocols in resource-limited settings. Addressing knowledge gaps and adapting protocols to the local context represent a promising step toward improving surgical care in Rwanda and enhancing perioperative management.
CLINICAL TRIAL NUMBER: Not applicable.
Disciplines :
Surgery
Author, co-author :
Nyundo, Martin; Department of Surgery, University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda. nyundomartin@gmail.com
Gasakure, Miguel; Department of Surgery, University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda
Muhawenayo, Esperance; Department of Surgery, University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda
Kayondo, King; Department of Surgery, Rwanda Military Hospital, Kigali, Rwanda
Banguti, Paulin; Department of Anesthesia and Critical Care, University of Rwanda, Kigali, Rwanda
Twagirumukiza, Jean Damascene; Department of Surgery, Inkuru Nziza Orthopedic Hospital, Kigali, Rwanda
Gashegu, Julien; Department of Surgery, University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda ; Department of Human Anatomy, University of Rwanda, Butare, Rwanda
Detry, Olivier ; Université de Liège - ULiège > Département des sciences cliniques > Pathologie chirurgicale abdominale et endocrinienne
Language :
English
Title :
Introducing enhanced recovery after surgery (ERAS) program in Rwanda: a step-by-step approach from KAP study to protocol development and preliminary implementation.
O. Ljungqvist T. Young-Fadok N. Demartines The history of enhanced recovery after surgery and the ERAS society J Laparoendosc Adv Surg Tech 27 9 860 2 10.1089/lap.2017.0350
A.M. Riad A. Barry S.R. Knight C.J. Arbaugh P.D. Haque T.G. Weiser et al. Perioperative optimisation in low- and middle-income countries (LMICs): A systematic review and meta-analysis of enhanced recovery after surgery (ERAS) J Glob Health 13 04114 10.7189/jogh.13.04114 37787105 10546475
O. Ljungqvist ERAS—Enhanced recovery after surgery: moving Evidence-Based perioperative care to practice JPEN J Parenter Enter Nutr 38 5 559 66 10.1177/0148607114523451
H. Kehlet Multimodal approach to control postoperative pathophysiology and rehabilitation Br J Anaesth 78 5 606 17 1:STN:280:DyaK2szhvFSrsg%3D%3D 10.1093/bja/78.5.606 9175983
J. Joris D. Léonard K. Slim How to implement an enhanced recovery programme after colorectal surgery? Acta Chir Belg 118 2 73 7 10.1080/00015458.2018.1427841 29334849
M.J. Scott G. Baldini K.C.H. Fearon A. Feldheiser L.S. Feldman T.J. Gan et al. Enhanced recovery after surgery (ERAS) for Gastrointestinal surgery, part 1: pathophysiological considerations Acta Anaesthesiol Scand 59 10 1212 31 1:STN:280:DC%2BC287pvFajtw%3D%3D 10.1111/aas.12601 26346577 5049676
G.R. Joliat O. Ljungqvist T. Wasylak O. Peters N. Demartines Beyond surgery: clinical and economic impact of enhanced recovery after surgery programs BMC Health Serv Res 18 1 1008 10.1186/s12913-018-3824-0 30594252 6311010
K.K. Varadhan K.R. Neal C.H.C. Dejong K.C.H. Fearon O. Ljungqvist D.N. Lobo The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: A meta-analysis of randomized controlled trials Clin Nutr 29 4 434 40 10.1016/j.clnu.2010.01.004 20116145
K.B. Leissner J.L. Shanahan P.L. Bekker H. Amirfarzan Enhanced recovery after surgery in laparoscopic surgery J Laparoendosc Adv Surg Tech 27 9 883 91 10.1089/lap.2017.0239
S.F. Khuri W.G. Henderson R.G. DePalma C. Mosca N.A. Healey D.J. Kumbhani Determinants of Long-Term survival after major surgery and the adverse effect of postoperative complications: transactions of the Meeting Am Surg Association 123 NA 32 48
J.B. Dimick S.L. Chen P.A. Taheri W.G. Henderson S.F. Khuri D.A. Campbell Hospital costs associated with surgical complications: A report from the private-sector National surgical quality improvement program J Am Coll Surg 199 4 531 7 10.1016/j.jamcollsurg.2004.05.276 15454134
P. Mattei J.L. Rombeau Review of the pathophysiology and management of postoperative ileus World J Surg 30 8 1382 91 10.1007/s00268-005-0613-9 16850151
P. Saksena A.F. Antunes K. Xu L. Musango G. Carrin Mutual health insurance in Rwanda: evidence on access to care and financial risk protection Health Policy 99 3 203 9 10.1016/j.healthpol.2010.09.009 20965602
B. Chemouni The political path to universal health coverage: power, ideas and community-based health insurance in Rwanda World Dev 106 87 98 10.1016/j.worlddev.2018.01.023
J.L. Irani T.L. Hedrick T.E. Miller L. Lee E. Steinhagen B.D. Shogan et al. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American society of Colon and rectal surgeons and the society of American Gastrointestinal and endoscopic surgeons Surg Endosc 37 1 5 30 10.1007/s00464-022-09758-x 36515747
U.O. Gustafsson M.J. Scott M. Hubner J. Nygren N. Demartines N. Francis et al. Guidelines for perioperative care in elective colorectal surgery: enhanced recovery after surgery (ERAS ®) society recommendations: 2018 World J Surg 43 3 659 95 1:STN:280:DC%2BB3cvpslyktQ%3D%3D 10.1007/s00268-018-4844-y 30426190
Nyundo M, Kayondo K, Gasakure M, Twagirumukiza JD, Gashegu J, Detry O. Implementation and outcomes of an enhanced recovery after surgery pathway for laparoscopic cholecystectomy in East and Central Africa: A prospective non-randomized controlled trial in Rwanda’s Tertiary Teaching Hospital. World j surg. 2024;wjs.12371.
I.H. Wei E.P. Pappou J.J. Smith M. Widmar G.M. Nash M.R. Weiser et al. Monitoring an ongoing enhanced recovery after surgery (ERAS) program: adherence improves clinical outcomes in a comparison of three thousand colorectal cases Clin Surg 5 2909 33163851 7643765
O. Ljungqvist M. Scott K.C. Fearon Enhanced recovery after surgery: A review JAMA Surg 152 3 292 10.1001/jamasurg.2016.4952 28097305
E.M. Helander C.B. Billeaud R.J. Kline P.I. Emelife C.M. Harmon A. Prabhakar et al. Multimodal approaches to analgesia in enhanced recovery after surgery pathways Int Anesthesiol Clin 55 4 51 69 10.1097/AIA.0000000000000165 28901981
H. Kehlet D.W. Wilmore Evidence-Based surgical care and the evolution of Fast-Track surgery Ann Surg 248 2 189 98 10.1097/SLA.0b013e31817f2c1a 18650627
R. Oodit B. Biccard G. Nelson O. Ljungqvist M.E. Brindle ERAS society recommendations for improving perioperative care in Low- and Middle‐Income countries through implementation of existing tools and programs: an urgent need for the surgical safety checklist and enhanced recovery after surgery World J Surg 45 11 3246 8 10.1007/s00268-021-06279-x 34455460 8476382
J. Lovegrove G. Tobiano W. Chaboyer J. Carlini R. Liang K. Addy et al. Clinicians’ perceptions of enhanced recovery after surgery (ERAS) protocols to improve patient safety in surgery: a National survey from Australia Patient Saf Surg 18 1 18 10.1186/s13037-024-00397-w 38783341 11119013
F. Kifle P. Kenna S. Daniel S. Maswime B. Biccard A scoping review of enhanced recovery after surgery (ERAS), protocol implementation, and its impact on surgical outcomes and healthcare systems in Africa Perioper Med 13 1 86 10.1186/s13741-024-00435-2
