Enhanced recovery after surgery in colorectal surgery: Impact of protocol adherence on patient outcomes

Study objectives: There is growing evidence internationally to support Enhanced Recovery After Surgery (ERAS) pathways. The impact of pathway compliance and the relative importance of individual components, however, remains less clear. Our institution implemented a multimodal ERAS protocol for elective colorectal surgery in November 2013. The objectives of this study were to investigate the impact of the introduction of the pathway, the relationship between pathway adherence and patient outcomes, and the relative importance of individual components. Design: This was a single-center, observational cohort study of elective colorectal surgical patients. Setting: A tertiary care and academic teaching hospital in Canada. Patients: Prospective data was collected from 495 consecutive major colorectal surgical patients following the ERAS launch. Retrospective data was also collected from a pre-ERAS cohort of 99. Measurements: Adherence to 12 ERAS components were measured, along with American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP (R)) defined patient complications and hospital length of stay (LOS). Post-ERAS patients were divided in to two groups: high compliance (>= 75% process adherence) and low compliance (< 75% adherence). Outcomes were compared between groups. Main results: There was a significant reduction in both complication rate (31.5% vs 14.6%; p <= 0.05) and hospital mean LOS (10.1 vs 6.9 days; p <=.0.05) following introduction of the ERAS pathway. The high adherence group had a shorter mean LOS (5.7 vs 8.6 days; p <= 0.01) and lower rate of complications (11.2% vs 19.6%; p = 0.02) compared with the low compliance group. Conclusions: Higher adherence to the standardized ERAS protocol was associated with improved patient outcomes, including reduced pulmonary complications. The cause-effect relationship is complex and likely influenced by confounding factors. Our data provides feedback to aid ongoing innovation of our pathway locally and adds to the growing body of evidence supporting the value of ERAS in general.