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Enhanced Recovery After Surgery implementation in practice: an ethnographic study of services for hip and knee replacement
  1. Sarah Drew1,
  2. Andrew Judge1,
  3. Rachel Cohen2,
  4. Raymond Fitzpatrick3,
  5. Karen Barker4,
  6. Rachael Gooberman-Hill1
  1. 1 Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
  2. 2 School of Population Health Sciences, Centre for Academic Mental Health, University of Bristol, Bristol, UK
  3. 3 Nuffield Department of Population Health, University of Oxford, Oxford, UK
  4. 4 Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
  1. Correspondence to Sarah Drew; sarah.drew{at}


Objectives Enhanced Recovery After Surgery (ERAS) programmes aim to improve care quality by optimising components of the care pathway and programmes for hip and knee replacement exist across the UK. However, there is variation in delivery and outcomes. This study aims to understand processes that influence implementation using the Consolidated Framework for Implementation Research (CFIR) to inform the design and delivery of services.

Design An ethnographic study using observations and interviews with staff involved in service delivery. Data were analysed using a thematic analysis, followed by an abductive approach whereby themes were mapped onto the 31 constructs and 5 domains of the CFIR.

Setting Four hospital sites in the UK delivering ERAS services for hip and knee replacement.

Participants 38 staff participated including orthopaedic surgeons, nurses and physiotherapists.

Results Results showed 17 CFIR constructs influenced implementation in all five domains. Within ‘intervention characteristics’, participants thought ERAS afforded advantages over alternative solutions and guidance was adaptable. In the ‘outer setting’, it was felt ERAS should be tailored to patients and education used to empower them in their recovery. However, there were concerns about postdischarge support and tensions with primary care. Within the ‘inner setting’, effective multidisciplinary collaboration was achieved by transferring knowledge about patients along the care pathway and multidisciplinary working practices. ERAS was viewed as a ‘message’ that had to be communicated consistently. There were concerns about resources and high volumes of patients. Staff access to information varied. At the domain ‘characteristics of individuals’, knowledge and beliefs impacted on implementation. Within ‘process’, involving opinion leaders in development and ‘champions’ who acted as a central point of contact, helped to engage staff. Formal and informal feedback helped to develop services.

Conclusions Findings demonstrate successful implementation involves empowering patients to work towards recovery, providing postdischarge support and promoting successful multidisciplinary team working.

  • Enhanced Recovery After Surgery
  • joint replacement
  • implementation science
  • qualitative research

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  • Contributors SD, AJ, RC and RG-H contributed to study design and data analysis. SD, AJ, RC, RF, KB and RG-H contributed to the interpretation of data and preparation of the manuscript and provided final approval of this version of the manuscript.

  • Funding This project was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project name ATLAS, project number 14/46/02). Additional support was received from the Oxford NIHR Biomedical Research Centre, Nuffield Orthopaedic Centre, University of Oxford. AJ and RG-H were supported by the NIHR Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol.

  • Disclaimer The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR Programme, NIHR, NHS or the Department of Health.

  • Competing interests Yes, there are competing interests for one or more authors and I have provided a Competing Interests statement in my manuscript.

  • Ethics approval Ethical approval was provided by the South-West Exeter Research Ethics Committee (Ref: 16/SW/0214).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement At the time this study was performed, participants consented to the data of this study being used for research. Therefore, completely open access of the data would contravene consent and ethics approval. The original study team will have exclusive use of this data for 6 years from the start of the study on 1 April 2016. Data will be kept on the University of Bristol research office’s secure server and in hard copy within a secure filing cabinet at the University of Bristol’s Musculoskeletal Research Unit. After 1 April 2022, the fully anonymised interviews will be deposited at the University of Bristol Research Data Repository for a further 14 years. Controlled access to the data request must be sought by completing and submitting a request to the University of Bristol Data Access Committee. This will assess the motives of potential researchers before granting access to the dataset. RC will be custodian of the data.

  • Patient consent for publication Not required.

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