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6. Department of Health. Eligible Nurse Practitioners Questions and Answers [Internet]. Canberra: Australian Government; 2018 [cited 25 August 2020]. Available from: Birks M, Davis J, Smithson J, Lindsay D. Enablers and barriers to registered nurses expanding their scope of practice in Australia: A cross-sectional study. Policy, Politics, & Nursing Practice 2019;20(3):145– 152. 8. Smith T, McNeil K, Mitchell R, Boyle B, Ries N. A study of macro-, meso- and microbarriers and enablers affecting extended scopes of practice: The case of rural nurse practitioners in Australia. BMC Nursing 2019;18(1):14. 9. Scanlon A, Cashin A, Bryce J, Kelly JG, Buckely T. The complexities of defining nurse practitioner scope of practice in the Australian context. Collegian. 2016;23(1):129– 142. 10. ACT Government Health. Nurse Practitioners [Internet]. Canberra: ACT Government; 2020 [updated 10 December 2020, cited 22 May 2021]. Available from: www.health.act.gov.au/ nursepractitioners. 11. Medicare Benefits Schedule (MBS) Online. What legislation covers the MBS [Internet]. Canberra: Australian Government; 2019 [updated 7 August 2020, cited 11 January 2021]. Available from: www.mbsonline.gov.au/internet/mbsonline/ publishing.nsf/Content/FAQ-Legislation. 12. Laurant M, van der Biezen M, Wijers N, Watananirun K, Kontopantelis E, van Vught A. Nurses as substitutes for doctors in primary care. Cochrane Database of Systematic Reviews. 2018(7). 13. Mundinger MO, Kane RL, Lenz ER, Totten AM, Tsai W-Y, Cleary PD, et al. Primary care outcomes in patients treated by nurse practitioners Enhanced recovery after surgery in Australia: A classic example of an evidence–practice gap Enhanced recovery after surgery (ERAS) pathways – often referred to as fast-track programs – are multidisciplinary, evidence-based perioperative pathways, designed to achieve early recovery for patients undergoing major surgery. ERAS has been described as a surgical revolution because of the benefits it produces. A recent systematic review found, on average, ERAS pathways reduce length of stay by 2.3 days and case costs by $639.00; without adverse impact on mortality, adverse events, or readmissions1 . Despite the clear benefits to patients and the health system, there is little evidence that ERAS pathways are routinely used in Australian hospitals. Some people claim they are using them, but usually what they mean is that individual clinicians are adhering to specific elements of a pathway. This is not ERAS. Improved outcomes demonstrated by ERAS pathways are the result of consistent application of all elements across the entire surgical period (from referral for surgery to recovery). ERAS pathways vary depending on the category of surgery, but broadly speaking they include the following: • preoperative patient education • preoperative optimisation of health • perioperative nutritional supplements • antimicrobial measures and venous thromboembolism prophylaxis • multimodal antiemetics and analgesia • avoidance of bowel preparation, nasogastric tubes and drains • early oral nutrition and mobilisation. You can see from the pathway elements above that ERAS requires the commitment of the entire surgical team, including surgeons, nurses, anaesthetists, allied health professionals, administrative staff and managers. In Australia, surgical care is extremely siloed. Care provided in the perioperative department is distinct and separate from that provided in the preadmission clinics or the surgical wards. This fragmentation of care delivery is a barrier to the uptake of ERAS and an impediment to the good governance of surgical services. Besides the patient, the one person who traverses the entire surgical period is the surgeon. This would make surgeons best placed to lead the introduction of ERAS into hospitals. Unfortunately, in Australia, there is no incentive or support for them to lead such a significant practice change. The other entity who should have an interest in implementing ERAS is government. The efficiencies and cost savings that result from the introduction of ERAS have been a major driver for the Canadian, United Kingdom (UK) and New Zealand governments.
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