Houston Methodist Shares Smarter Blueprint for Gynecologic Surgical Recovery

Enhanced recovery after surgery (ERAS) protocols have transformed perioperative care across multiple surgical specialties over the past decade. But while the evidence supporting ERAS pathways has become increasingly difficult to ignore, implementing those protocols consistently in the real world remains far more complicated than simply publishing new guidelines.

That disconnect between evidence and execution sits at the center of new research from Houston Methodist Hospital’s Department of Obstetrics and Gynecology, where physicians and researchers have spent the past two years building and refining an institution-wide ERAS program for gynecologic surgery. Their recently published review offers something many health systems still lack: a practical blueprint for how to operationalize ERAS protocols across an entire surgical service line — including the unexpected challenges that emerge along the way.

Rather than focusing solely on outcomes, the paper takes a more pragmatic approach, detailing the logistical, cultural and documentation hurdles that often derail ERAS adoption before programs can fully mature.

“We wanted to be transparent about what implementation actually looks like in reality,” said Dr. Emily Rutledge, assistant professor of Clinical Obstetrics and Gynecology at Houston Methodist and co-author of the review. “The guidelines already exist. What people need help with is understanding where the pain points are and how to work through them.”

ERAS protocols are designed to reduce surgical stress and accelerate recovery through evidence-based interventions spanning the entire perioperative process — from preoperative nutrition and patient education to opioid-sparing pain management, early mobilization and standardized postoperative care. Studies have consistently linked ERAS pathways to shorter hospital stays, fewer complications, reduced opioid use and improved patient recovery.

Yet according to the paper, only 37% of institutions worldwide report having implemented ERAS protocols successfully.

Houston Methodist’s OB-GYN department launched its own ERAS initiative in late 2023 and quickly discovered that many of the biggest barriers had little to do with the science itself.

Instead, the challenges often involved workflow integration, electronic medical record limitations, provider habits and patient communication.

“One of the biggest lessons we learned was that compliance tracking is everything,” Dr. Rutledge said. “You can have a protocol on paper, but if you don’t have a way to monitor whether people are actually following it, you really don’t know if you’re practicing ERAS.”

That meant Houston Methodist researchers spent countless hours manually reviewing charts to identify gaps in compliance, documentation and workflow. The effort eventually helped the team identify recurring friction points that many institutions are likely encountering themselves.

Among the most common issues were inconsistent documentation of carbohydrate loading before surgery, variability in multimodal pain management practices, confusion surrounding thromboprophylaxis protocols and difficulties standardizing postoperative mobilization and nutrition tracking.

The paper walks through those problems systematically, pairing each challenge with practical recommendations other health systems can adapt within their own infrastructure.

For example, one persistent obstacle involved convincing patients that drinking carbohydrate-rich clear liquids before surgery was not only safe, but beneficial — directly contradicting decades of ingrained “nothing after midnight” surgical instructions.

“Patients are often terrified their surgery will be canceled if they do something wrong,” Dr. Rutledge said. “So a lot of this becomes about repeated education, clear instructions and making sure the message is consistent across every interaction they have with the care team.”

Other interventions focused more heavily on clinician workflow redesign.

To reduce unnecessary opioid prescribing, the team worked with anesthesiologists and surgical staff to restructure medication ordering systems so non-opioid analgesics became the default first-line options rather than secondary considerations.

The review also highlights the importance of multidisciplinary collaboration — not just among surgeons, but among nursing staff, anesthesia teams, IT specialists and operational leadership.

“A lot of quality improvement work is really about removing barriers from people’s daily workflow,” Dr. Rutledge said. “Most clinicians want to do the right thing for patients. Sometimes the system just makes it harder than it needs to be.”

Importantly, the Houston Methodist team emphasizes that ERAS implementation is not a one-time initiative, but an ongoing process requiring continuous auditing, provider engagement and adaptation.

The researchers describe the work less as a rigid protocol and more as a scalable implementation framework that other hospitals can modify based on their own institutional realities.

For hospitals still early in their ERAS journey, that candor may prove especially valuable.

“There are places that have been doing ERAS for years,” said Dr. Pedro Ramirez, chief of Obstetrics and Gynecology at Houston Methodist and senior author on the review. “But as a newer program, we thought it was important to share what those early stages actually look like — the things that surprise you, the barriers you encounter and the ways you can make implementation more successful.”

And despite the operational hurdles, the team says the broader direction of surgical care is no longer in doubt.

“This really is the future of perioperative medicine. ERAS should be the foundation for how we care for surgical patients moving forward.”

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Pedro Ramirez, MD