MSQC Enhanced Recovery Clinical Pathways

The following presentations and documents may be modified for customization, and reproduced for use and distribution in starting an Enhanced Recovery Program (ERP) at your site. These documents have been made available with the sole intent of assisting sites with the initiation and development of an enhanced recovery program. In the interest of improving surgical care, favorably affecting patient outcomes, and wide promotion of best practices, MSQC has made these documents accessible with minimal restriction. Please be respectful of their use, and refrain from reproducing or using these documents outside of their intended purpose.


Table of Contents

  1. Pre-Operative Instructions
  2. Intra-Operative Instructions
  3. Post-Operative Instructions
  4. Extra Resources
  5. Recent Enhanced Recovery Publications

1. Pre-Operative Instructions

Pre-Op Nursing Slide Deck

This is the first of a 3-series set of PowerPoint presentations for each phase of the operative period. This presentation covers the core principles that are integral to ERP, as well as the interventions pertinent to the preoperative phase of nursing care, beginning with the surgeon’s office and continuing through pre-admission testing. These presentations are individual components of a comprehensive educational series to include providers across the continuum of care from the surgeon’s office through inpatient discharge. While the primary intended audience is nursing, the scope of education may be relevant to providers outside of it (i.e., ancillary nursing staff, mid-level providers, nutrition, physical therapy, etc.). 

ERP Nursing Pocket Card

This synopsis of ERP nursing responsibilities for Patient education, Carbohydrate loading and Bowel prep, PONV assessment and calculator, Targeted interventions and Discharge readiness is displayed on a two-page document that can be printed two-sided for use as a pocket card resource.

Mechanical Bowel Prep with Oral Antibiotics 

This nursing education tip sheet offers a concise explanation and references in support of the importance of mechanical bowel prep in colectomies, as well as nursing notes for patient education. The tip sheets are intended to provide detailed, supplemental instruction in assisting with practical application of ERP initiatives (guidelines for nursing practice and patient education) using evidence-based rationale. These are single-paged documents that may be printed individually or as a collection for easy reference.

Carbohydrate Loading and Optimizing Hydration

This one-page tip sheet outlines the appropriate loading and pre-surgical amounts for carb loading with its effects on the body, as well as optimal hydration practices. Notes are included for nursing and patient education.    

Pre-Operative Resources Contributed by MSQC Member Hospitals

This portion of the toolkit represents a collection of resources and tools currently used in clinical practice that have been developed by MSQC member surgeons and hospitals. With permission from contributors, these documents have been made available for widespread use across the collaborative to facilitate the sharing of best practices with respect to ERP and its related initiatives.

St. Joseph Mercy Bowel Prep-This document offers a guide to Miralax bowel preparation for patients. 

St. Joseph Mercy Intake/Output Log-The I&O log is intended for patients to track and record fluid intake and output, and includes a column for BM’s. The log also includes notes on proper hydration and signs and symptoms of dehydration.

Munson Insulin (Pre/Post-Op) Protocol-This Diabetic Pre and Post-Procedural Insulin protocol describes processes for assessing blood glucose status in all phases of surgery, as well as a guide for sliding-scale insulin coverage.  

Mercy Health Hackley Day of Surgery Activity-This one-page tool is supplied to patients for tracking day-of-surgery activities, such as deep breathing exercises/spirometer use and bed exercises.

St. Joseph Mercy Patient Kit Contents– List of patient surgical care kit items  

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2. Intra-Operative Instructions

Intra-Op Nursing Instruction Slide-Deck

This second PowerPoint module repeats some ERP background and then presents the responsibilities for ERP-related nursing care from admission for surgery through immediate postoperative recovery.  

Intra-Operative Resources Contributed by MSQC Hospitals 

Munson Ventilator Orders-This sheet serves as a checklist for anesthesia to include communication with nurse, activity, radiology, ABG monitoring, ventilator settings and sedation.

Munson Peri-Op Protocol 1-An anesthesia checklist for hypo-, hyper-tension parameters, respiratory and apnea monitoring, temperature control, IV fluids and medications.

Munson Peri-Op Protocol 2-This anesthesia checklist covers IV fluids and post-op hypo-, hyper-tensive medications, and antiemetics. 

Munson Per-Op Protocol 3-This anesthesia checklist includes post-op oxygen, IV fluids, Metoprolol and Insulin administration.

St. Joseph Mercy Intra-Op Checklist– A comprehensive but easy to use checklist for providers to use to track process compliance throughout the entire surgery pathway.[Return To Table of Contents]

3. Post-Operative Instructions

Post Op Nursing Slide Deck

This final ERP PowerPoint module repeats some ERP background and then focuses on the nursing responsibilities for the postoperative recovery phase of care that begins when the patient is admitted to an inpatient unit and ends when the patient is discharged from the hospital. 

VTE Prevention 

Effective nursing tip sheet that focuses on VTE Prophylaxis nursing considerations and patient education on VTE prevention, specifically involving techniques for assessment and intervention.

Early Ambulation Tips

Early ambulation education for ERP patients is summarized here. 

PONV Risk Assessment 

This evaluation guide outlines the techniques to assess Post Operative Nausea and Vomiting (PONV) risk. 

Post-Operative Resources Contributed by MSQC Hospitals 

St. Joseph Mercy Post Op Instructions by Day-Serves a checklist for each day of the elective colorectal surgical process, beginning with day of surgery through day of discharge. St. Joseph Mercy Post-Op Protocol-A comprehensive list of surgical and care interventions to order, including code status, consults, labs, as well as when to begin applicable protocols.  St. Joseph Mercy Post Op Checklist-A log for tracking patient’s activity, diet, consults, fluid totals, length of stay, discharge date and any complications acquired.Munson Post Op Protocol-A comprehensive list of order reminders for all post-op care interventions. Munson Post Surgical Activity Log-A brief form on which to log all patient activities. Mercy Health Hackley Patient Discharge Instructions-A brief resource sheet for patients for what milestones to expect and goals for discharge. Mercy Health Hackley Patient “Next Steps to Recovery” Instructions-A one-page instruction and tracking sheet for patients to track spirometer use and ambulation. Beaumont Troy Patient Discharge Instructions– Three-page comprehensive ERAS discharge instructions for colorectal surgery patients.   [Return To Table of Contents]

4. Extra Resources

Beaumont Troy ERP Rounding Checklist-A checklist for providers to track orders for ERAS colorectal surgery throughout the surgical course to discharge. Evidence Guidelines-Munson uses this grading scale to measure the strength of research-based evidence in support of surgical clinical guidelines. Based on the AHRQ rating scale, Grade A represents good research-based evidence to support specific recommendation.

5. Recent Enhanced Recovery Publications

Liu VX, Rosas E, Hwang J, Cain E, Foss-Durant A, Clopp M, Huang M, Lee DC, Mustille A, Kipnis P, Parodi S. Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System. JAMA Surg. 2017;152(7):e171032. doi:10.1001/jamasurg.2017.1032 Wahl TS,  Goss LE, Morris MS, Gullick AA, Richman JS, Kennedy GD,  Cannon JA,  Vickers SM, Knight SJ, Simmons JW, Chu DI. Enhanced Recovery After Surgery (ERAS) Eliminates Racial Disparities in Postoperative Length of Stay After Colorectal Surgery. Annals of Surgery. Published ahead of print. Jun 2017. doi:10.1097/SLA.0000000000002307 George E, Krapohl G, Regenbogen SE. Population-based evaluation of implementation of an enhanced recovery protocol in Michigan, Surgery (2017), doi: 10.1016/j.surg.2017.08.016 Ljungqvist O, Scott M, Fearon M. Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017;152(3):292-298. doi:10.1001/jamasurg.2016.4952 Miller D, Pearsall E, Johnston D, Frecea M, McKenzie M. Executive Summary: Enhanced Recovery After Surgery: Best Practice Guideline for Care of Patients With a Fecal Diversion, Journal of Wound, Ostomy and Continence Nursing, Volume 44(1), January/February 2017, p 74–77. doi:10.1097/WON.0000000000000297 Chemali ME, Eslick GD. A Meta-Analysis: Postoperative Pain Management in Colorectal Surgical Patients and the Effects on Length of Stay in an Enhanced Recovery After Surgery (ERAS) Setting. The Clinical Journal of Pain.  January 2017, Volume 33(1), p 87–90. doi 10.1097/AJP.0000000000000370 Yeung SE, Hilkewich L, Gillis C, Heine JA, Fenton TR. Protein intakes are associated with reduced length of stay: a comparison between Enhanced Recovery After Surgery (ERAS) and conventional care after elective colorectal surgery. Am J Clin Nutr July 2017 vol. 106 no. 1 44-51. doi: 10.3945/​ajcn.116.148619 Sibbern T, Bull Sellevold V, Steindal SA., Dale C, Watt-Watson J, and Dihle A.  Patients’ experiences of enhanced recovery after surgery: a systematic review of qualitative studies.J Clin Nurs, 2017, 26: 1172–1188. doi:10.1111/jocn.13456 Slieker J, Frauche P, Jurt J. et al., Enhanced recovery ERAS for elderly: a safe and beneficial pathway in colorectal surgery. Int J Colorectal Dis (2017) 32: 215. doi: 10.1007/s00384-016-2691-6[Return To Table of Contents]