Enhanced Recovery in Medicine: A Realist Evaluation

Abstract Background: Enhanced recovery programmes (ERPs) are a multicomponent approach to managing and delivering care with the aim of improving care quality and speed of recovery. Originally introduced in elective colorectal surgery, they are now widespread in many surgical disciplines. Growing interest in the potential of ERPs to deliver similar benefits in acute internal medicine (AIM), has led to their introduction into this specialism. Although ERPs represent a promising model of care in this context, little is known about how they are applied and their impact on recovery. Aim: The aim of this research was to understand how, why and under what circumstances ERPs work, or do not work, for people admitted to hospital with acute medical illness. Methods: Realist methodology was used to build, refine, and test theoretical explanations in the form of ‘programme theories’, that explain how underlying casual mechanisms of change and associated contextual factors lead to outcomes. The study was conducted in a National Health Service (NHS) hospital in England. Initial theories were developed through reviewing literature and interviewing practitioners. A card-sorting exercise with practitioners was used to prioritise these theories, which were then refined and tested using observational and interview data, gathered in an acute medical unit (AMU) and a specialist medical ward. Findings: The findings show that ERPs in medicine comprise multiple interacting interventions bundled together and delivered in a flexible and adaptive manner. Biological, psychological, and social mechanisms were identified operating conjointly, at multiple levels, reflecting a broad conceptualisation of recovery. Enhancements in recovery were explained by key mechanisms of (1) proactive discharge planning, (2) involving patients and carers in shared decision making and the care process, (3) encouraging an active role and sharing responsibility for recovery, (4) individualising care, (5) communicating and sharing information. Contextual factors influencing specific mechanisms included multidisciplinary collaboration, congruence with organisational priorities, patient characteristics, practice norms, access to information systems, leadership support, availability of resources, workload pressures, the ward environment, the unpredictability of acute illness trajectory. Conclusion: This research contributes knowledge to the field of enhanced recovery by providing explanatory programme theory of how and why ERPs work in a medical setting. The findings can be used to support further research and inform practitioners and decision makers developing and evaluating ERPs at other NHS hospitals.