- Downloadable PDF of the bundle
- Complete resource listing – Coming Soon!
- Safety Action Series presentation
NOTE: Bulleted Bundle elements denoted in BOLD are considered the most vital for success of an ERAS Program.
- Ensure that appropriate organizational commitment to people, resources, and time is available.
- Assess current practices and readiness for organizational change. Devise and implement a plan to promote the climate necessary for change.
- Create a multidisciplinary team with representatives important to all phases of perioperative care. This team may include representatives from anesthesiology, nursing, pharmacy, surgery, and social work.
- Provide education to all members of the multidisciplinary care team on the importance and content of an evidence-based enhanced recovery program. Assure ongoing education of staff.
- Identify champions (hospital executive leadership, administrators, frontline staff, patient representatives, etc.).
- Create and/or integrate standardized enhanced recovery content into care pathways, order sets, and patient education materials.
- Complete appropriate committee review and approval processes (electronic health record order set councils, perioperative governance, nursing practice, pharmacy, and therapeutics, etc.).
- Create a project timeline.
- Committee Opinion 750: Perioperative Pathways: Enhanced Recovery After Surgery (ACOG)
- Enhanced Recovery after Surgery: Considerations for Pathway Development and Implementation (AANA)
- Enhanced Recovery Implementation in Major Gynecologic Surgeries: Effect of Care Standardization
- Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations—2019 update
- Discuss patient goals and expectations and provide a patient-centered informed consent process.
- Provide education and counseling on relevant aspects of the enhanced recovery program.
- Work collaboratively with patients, families, caregivers, social workers and pertinent support personnel to assess and plan for potential needs after discharge. Consider implications unique to special populations (e.g., adolescent, geriatric, immunosuppressed, and patients with increased Body Mass Index (BMI)).
- Conduct preoperative assessment and provide optimization of comorbidities and lifestyle choices including, but not limited to, diabetes management, blood pressure control, smoking cessation, and alcohol consumption reduction.
- Offer and utilize minimally invasive surgical approaches, as appropriate.
- Assess and selectively determine appropriateness of mechanical or oral antibiotic bowel preparation.
- Use multimodal stepwise approach for pain prevention and management. Consider preemptive and preventive strategies.
- Utilize reduced preoperative fasting intervals.
- Offer carbohydrate loading two to four hours prior to surgery.
- Provide preoperative assessment and appropriate interventions to reduce risk of pulmonary aspiration, nausea, and vomiting and to neutralize gastric acidity.
- Provide mechanical and chemical venous thromboembolism (VTE) prophylaxis, as indicated.
- Provide surgical site infection prevention, as indicated.
- Enhanced Recovery After Surgery (ERAS) Patient Education (Penn Medicine)
- Enhanced Recovery After Surgery – A guide to your gynecology surgery experience (University of Virginia Health System)
- ERAS GYN Nutrition Guidelines (University of Texas MD Anderson Cancer Center)
- Multimodal Pain Strategies Guide for Postoperative Pain Management (Society for Hospital Medicine)
- Preemptive analgesia for postoperative hysterectomy pain control: systematic review and clinical practice guidelines
- Prevention of Surgical Site Infections After Gynecologic Surgery Patient Safety Bundle (Council on Patient Safety in Women’s Health Care)
- Strong for Surgery Toolkit (America College of Surgeons)
- Your Guide to Gynecologic Surgery – Booklet (Johns Hopkins Medicine)
- Conduct a time out in alignment with The Joint Commission’s Universal Protocol.
- Consider use of a field block and/or regional anesthesia and analgesia.
- Consider the use of an anesthetic technique to promote rapid awakening, which will allow for early recovery and ambulation.
- Consider the intraoperative use of anesthetic adjuncts to minimize anesthetic requirements and support a multimodal approach to pain prevention and management.
- Monitor body temperature, if indicated by the type of surgery (e.g., significant changes in body temperature are anticipated) and maintain normothermia.
- Maintain euvolemia and avoid both hypovolemia and hypervolemia.
- Provide prophylactic interventions for nausea and vomiting.
- Minimize use of nonindicated catheters, drains, and nasogastric (NG) tubes.
- Provide appropriate redosing of prophylactic antibiotics.
- Continue interventions to reduce postoperative nausea and vomiting.
- Provide interventions to reduce postoperative ileus.
- Encourage early feeding, as indicated.
- Encourage early ambulation, as indicated.
- Continue mechanical and chemical venous thromboembolism (VTE) prophylaxis, as indicated.
- Use multimodal stepwise approach for pain prevention and management.
- Encourage early removal of catheters and drains, when possible.
- Closely monitor clinical status, vital signs, urine output, and readiness for discharge, with goal of maximizing patient safety and optimizing timing of discharge.
- Provide appropriate wound management.
- Employ a strategy to promote smooth transitions, including providing aftercare education for patients, staff, and caregivers and follow-up planning to prevent readmission.
- Establish an audit system and database to review protocol compliance and clinical outcome data.
- Collect and monitor patient-reported outcome (PRO) metrics.
- Gather and provide feedback to surgeons, appropriate staff, leaders, and patients.
- Review and modify patient engagement materials, as necessary.
- Regularly review and refine pathways to maintain continuous quality improvement.
© 2019 American College of Obstetricians and Gynecologists. Permission is hereby granted for duplication and distribution of the bundle document, in its entirety and without modification, for solely non-commercial activities that are for educational, quality improvement, and patient safety purposes. All other uses require written permission from ACOG.
Standardization of health care processes and reduced variation has been shown to improve outcomes and quality of care. The Council on Patient Safety in Women’s Health Care disseminates patient safety bundles to help facilitate the standardization process. This bundle reflects emerging clinical, scientific, and patient safety advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Although the components of a particular bundle may be adapted to local resources, standardization within an institution is strongly encouraged.
The Council on Patient Safety in Women’s Health Care is a broad consortium of organizations across the spectrum of women’s health for the promotion of safe health care for every woman.