Table 5 Barriers and facilitators to ERAS implementation

Lack of knowledge and seniority support

 • Poor understanding / experience / interest in ERAS among senior clinicians and leaders

 • Resistance to change/moving away from historical models

 • Lack of understanding of long-term benefits versus up-front investment

 • High nursing turnover on wards and required education for staff rotations

 • Limited and non-compulsory implementation at a department/hospital level and institutional ‘hurdles’

Resource requirements

 • Required significant investment in effort/resources pre-operatively and post-operatively

 • Requirement for multiple stakeholder engagement; lack of multidisciplinary team involvement particularly in low resource hospitals

 • Poor quality food choices in hospitals

Lack of ability to individualise content

 • Lack of ability to ‘tailor’ to individual patients if needed

Other

 • Limited compliance, monitoring and feedback

 • Length of documented local ERAS protocols

 • Difficulties with representation / readmission if required (e.g., emergency length of stay, patients living further away, accommodation costs)

 • Departmental/hospital-level implementation and standardisation, compliance monitoring and improvement feedback

 • Cross-departmental teams for implementation and education

 • Inclusion of a dedicated ERAS® manager or nurse for implementation and monitoring

 • Patient and family engagement

 • ‘Rebranding’ or naming of ERAS principles to part of standard care rather than a separate protocol

 • Include as a ‘foundation’ of informed consent