Development of an Enhanced Recovery After Surgery Surgical Safety Checklist Through a Modified Delphi Process
Authors: Pilkington Mercedes , Nelson Gregg , Cauley Christy , Holder Kari , Ljungqvist Olle , Molina George , Oodit Ravi , Brindle Mary E. ,   ERAS Checklist Collaborative, Alvarez Adrian , Cardosa-Wagner Ainsley , Lee Alan , Gregory Alexander , Cochran Allyson R , Altman Alon , Kefleyesus Amaniel , Cameron Anna , Fagotti Anna , Fabrizio Anne , Gil-Moreno Antonio , Babaier Aziz , Pultram B B , Pache Basile , Riedel Bernhard , Jim Brent , Jago Caitlin , Achtari Chahin , Jones Chris , Noss Chris , Aubrey Christa , Fotopoulou Christina , Temple-Oberle Claire , Warden Claire , Laflamme Claude , Vrochides Dionisios , Coetzee Emile , Chacon Enrique , Miralpeix Ester , Panieri Eugenio , Bhandoria Geetu , Glaser Gretchen , de Boer Hans D , Smid Henriette , Thomas Jackie , Ripolles-Melchor Javier , Huang Jeffrey , Bennett Jessica , Dort Joseph C , McGinigle Katharine , Arendt Katherine , Elias Kevin , How Kwang Yeong , Meyer Larissa , Hopkins Laura , Wijk Lena , Roberts Lesley , Helpman Limor , Mack Lloyd , Burns Mairead , Roxas Manuel , Sioson Marianna , Hubner Martin , Scott Michael , Yang Michael , Alruwaisan Mohammed , Thomakos Nikolaos , Sgarbura Olivia , Chu Pamela , Vendittoli Pascal-André , Trudeau Pat , Ramirez Pedro , Findley Rachelle , Arora Rakesh , Stone Rebecca , Ferguson Sarah , Dowdy Sean , Pin Sophia , Bisch Steven , Wallace Sumer , Rockall Timothy , Paul Timothy , Addor Valerie 
Published: February 2023

Importance

Enhanced Recovery After Surgery (ERAS) guidelines and the World Health Organization Surgical Safety Checklist (SSC) are 2 well-established tools for optimizing patient outcomes perioperatively.

Objective

To integrate the 2 tools to facilitate key perioperative decision-making.

Evidence Review

Snowball sampling recruited international ERAS users from multiple clinical specialties. A 3-round modified Delphi consensus model was used to evaluate 27 colorectal or gynecologic oncology ERAS recommendations for appropriateness to include in an ERAS SSC. Items attaining potential consensus (65%-69% agreement) or consensus (≥70% agreement) were used to develop ERAS-specific SSC prompts. These proposed prompts were evaluated in a second round by the panelists with regard to inclusion, modification, or exclusion. A final round of interactive discussion using quantitative consensus and qualitative comments was used to produce an ERAS-specific SSC. The panel of ERAS experts included surgeons, anesthesiologists, and nurses within diverse practice settings from 19 countries. Final analysis was conducted in May 2022.

Findings

Round 1 was completed by 105 experts from 18 countries. Eleven ERAS components met criteria for development into an SSC prompt. Round 2 was completed by 88 experts. There was universal consensus (≥70% agreement) to include all 37 proposed prompts within the 3-part ERAS-specific SSC (used prior to induction of anesthesia, skin incision, and leaving the operating theater). A third round of qualitative comment review and expert discussion was used to produce a final ERAS-specific SSC that expands on the current WHO SSC to include discussion of analgesia strategies, nausea prevention, appropriate fasting, fluid management, anesthetic protocols, appropriate skin preparation, deep vein thrombosis prophylaxis, hypothermia prevention, use of foley catheters, and surgical access. The final products of this work included an ERAS-specific SSC ready for implementation and a set of recommendations to integrate ERAS elements into existing SSCs.

Conclusions and Relevance

The SSC could be modified to align with ERAS recommendations for patients undergoing major surgery within an ERAS protocol. The stakeholder- and expert-generated ERAS SSC could be adopted directly, or the recommendations for modification could be applied to an existing institutional SSC to facilitate implementation.