Enhanced Recovery after Cardiac Surgery: Obstacles to Implementation

Dear Editor, Enhanced Recovery After Surgery protocols have transformed perioperative care across numerous specialties, and they are increasingly being adopted in cardiac surgery. Enhanced Recovery After Cardiac Surgery (ERACS) focuses on improving patient outcomes, accelerating recovery, and reducing healthcare costs by employing evidence-based, multidisciplinary strategies throughout the surgical journey—from preoperative preparation to postoperative care and follow-up. The main obstacles to implementing ERACS protocols across cardiac centers arise from a combination of resource limitations, organizational challenges, professional resistance, communication issues, and gaps in policy and training.1 Inflexible hospital policies, lack of pathway order sets, and inability to alter established routines are also frequently cited.2 Despite compelling evidence, real-world implementation of ERACS remains inconsistent due to multiple, interdependent obstacles. There is growing support from major societies, such as the ERAS® Cardiac Society, which has championed protocols and international conferences to standardize and spread ERACS principles.3 In this issue, Gourav et al. present a study in which they observed many teams and interviewed them to determine barriers to adherence to ERACS protocols. They identified nine obstacles to adherence, with resistance to change in their practice being the most common, followed by lack of staff motivation. Resource constraints are a primary concern in the implementation of ERACS. Most centers face insufficient numbers of nurses, doctors, and allied health professionals due to heavy workloads, which directly affects implementation quality cited.4 Lack of dedicated financial resources for ERACS-specific interventions, staffing, training, and incentives is a significant barrier, especially in centers that struggle with budget constraints. Many hospitals lack the policy frameworks, administrative incentives, and leadership support needed to drive ERACS adoption cited. Without institutional drive or incentives, staff motivation can be low. Such centers often have no formal, standardized ERACS training program, which leads to inconsistent implementation and wide variation across centers. Such centers lack robust monitoring or quality improvement programs to track adherence or outcomes, making it difficult to identify problems or optimize protocols.5 Another major hindrance is professional and cultural resistance to change. Clinicians, especially those with entrenched practices, may be reluctant to adopt new ERACS guidelines, often citing patient safety concerns or skepticism about protocol efficacy.6 The members of the ERACS team have different approaches and priorities, which may hinder communication and collaboration among the surgeons, anesthesiologists, nurses, and physiotherapists. Breaking traditional norms can be challenging. Cultural resistance is evident among some professionals, who are hesitant to adopt novel ERACS strategies due to concerns over risks such as outcomes and complications. Successful ERACS implementation requires continuous education, regular team meetings, and the development of a common understanding and vocabulary among all professional groups involved. Misunderstandings and a lack of consistent, transparent communication among team members are frequent, affecting protocol adherence and patient outcomes. Some staff are unaware of the existence of ERACS guidelines or lack a detailed understanding of recommended practices.7 In the absence of ongoing education and visible leadership engagement, staff compliance remains variable. Adoption of ERACS is significantly higher in well-resourced academic centers, but lags in smaller hospitals, limiting broader population-level impact.8 There is limited formal inclusion of patient perspectives and feedback in developing and tailoring ERACS protocols, which can affect uptake and success. To overcome these obstacles, efforts are needed to improve funding, staffing, infrastructure, formal training, team communication, and to actively include both multidisciplinary perspectives and patient feedback in ERACS protocol development and rollout. To ensure the success of the ERACS, multidisciplinary teams must collaborate and contribute their discipline’s specific component. For optimized enhanced recovery outcomes: Each discipline must address its specific components—prehabilitation, anesthesia protocols, early tracheal extubation, rehabilitation, nutrition, and pain management. Teams should hold structured, frequent meetings to align strategies, track protocols, and address challenges for each patient. These discussions ensure everyone is updated on patient status and protocol adjustments, reducing miscommunication and variation in care. Ongoing feedback sessions must be there to review outcomes, modify approaches, and share lessons learned, fostering a learning health system, promoting protocol adherence, and enabling iterative improvement. Multidisciplinary collaboration is inescapable to ensure that patients’ goals, preferences, and comorbidities are considered in plan development and execution. Teams must work together to educate and engage patients and their families. This improves understanding, compliance, and satisfaction with the program. Good teamwork facilitates smooth patient handovers and transitions—from surgery to ICU, ward, and rehabilitation—minimizing disruptions and ensuring continuity across all care environments. Patient comorbidities and frailty may necessitate protocol modifications, reducing standardization and efficacy. Collaboration with external physicians and rehabilitation specialists further extends the ERACS philosophy beyond hospital discharge. Stakeholders must jointly develop, adapt, and update protocols tailored to institutional capabilities and patient needs to promote buy-in at all levels. There is a need for greater advocacy for national guidelines, funding models, and certification incentives from professional societies and payers. Some aspects of ERACS still lack consensus. ERACS protocols followed are derived from single-center studies or select patient groups, limiting generalizability. The optimal hemoglobin thresholds and techniques (e.g., cell salvage vs. autologous priming) need to be defined. There are also evidence gaps in standardizing patient blood management, goal-directed therapy, and protocols for acute kidney injury risk reduction. Although the feasibility of ERACS in the pediatric population has been demonstrated and its protocols followed by many pediatric cardiac anesthesiologists, no guidelines have yet been published. Cardiac surgical patients often have complex comorbid conditions (heart failure, diabetes, renal dysfunction), which complicate the application of standardized protocols and require individualized care. Implementation is riskier for very frail, elderly, or high-acuity patients, limiting ERACS’ applicability to all cases. Although feasibility is shown in high-risk populations, more tailored protocols and validation in these subgroups are needed.9 Multidisciplinary teams are the foundation of successful ERACS integration in cardiac surgery. Their collaboration ensures streamlined, evidence-based care, effective communication, and patient-focused outcomes. This approach not only improves clinical results and satisfaction but also fosters a culture of continuous improvement and innovation within surgical care pathways. Studies document that ERAS programs underpinned by multidisciplinary collaboration achieve shorter hospital stays, fewer complications, improved pain control, and reduced healthcare costs compared to traditional care. Well-organized multidisciplinary approaches also correlate with better survival rates and higher patient quality of life.10 ERACS is a proven, multidisciplinary paradigm that improves recovery, reduces complications, and enhances patient satisfaction. ERACS is rapidly maturing, with proven clinical and economic benefits. Yet, the path to universal implementation remains hindered by both logistical and clinical challenges.11 Ongoing international collaboration, technological integration, and systemic changes will be crucial to turning ERACS from promise to a global standard of care. Most contemporary ERACS research has focused on short-term benefits (ICU/hospital stay, pain control, complications). More high-quality data on long-term outcomes, such as quality of life, full functional recovery, and health care costs, is needed.