title: A protocol is not enough to implement an enhanced recovery programme for colorectal resection.
abstract: BACKGROUND
  Single-centre studies have suggested that enhanced recovery can be achieved with multimodal perioperative care protocols. This international observational study evaluated the implementation of an enhanced recovery programme in five European centres and examined the determinants affecting recovery and length of hospital stay.
  
  
  METHODS
  Four hundred and twenty-five consecutive patients undergoing elective open colorectal resection above the peritoneal reflection between January 2001 and January 2004 were enrolled in a protocol that defined multiple perioperative care elements. One centre had been developing multimodal perioperative care for 10 years, whereas the other four had previously undertaken traditional care.
  
  
  RESULTS
  The case mix was similar between centres. Protocol compliance before and during the surgical procedure was high, but it was low in the immediate postoperative phase. Patients fulfilled predetermined recovery criteria a median of 3 days after operation but were actually discharged a median of 5 days after surgery. Delay in discharge and the development of major complications prolonged length of stay. Previous experience with fast-track surgery was associated with a shorter hospital stay.
  
  
  CONCLUSIONS
  Functional recovery in 3 days after colorectal resection could be achieved in daily practice. A protocol is not enough to enable discharge of patients on the day of functional recovery; more experience and better organization of care may be required.
authors.affiliation: Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands.
authors.forename: J
authors.initials: J
authors.lastname: Maessen
authors.forename: C H C
authors.initials: CH
authors.lastname: Dejong
authors.forename: J
authors.initials: J
authors.lastname: Hausel
authors.forename: J
authors.initials: J
authors.lastname: Nygren
authors.forename: K
authors.initials: K
authors.lastname: Lassen
authors.forename: J
authors.initials: J
authors.lastname: Andersen
authors.forename: A G H
authors.initials: AG
authors.lastname: Kessels
authors.forename: A
authors.initials: A
authors.lastname: Revhaug
authors.forename: H
authors.initials: H
authors.lastname: Kehlet
authors.forename: O
authors.initials: O
authors.lastname: Ljungqvist
authors.forename: K C H
authors.initials: KC
authors.lastname: Fearon
authors.forename: M F
authors.initials: MF
authors.lastname: von Meyenfeldt
mesh_terms: D000368:Aged; D002985:Clinical Protocols / Q000592:standards*; D003108:Colonic Diseases / Q000534:rehabilitation / Q000601:surgery*; D003107:Colorectal Surgery / Q000534:rehabilitation / Q000592:standards*; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D010359:Patient Readmission / Q000706:statistics & numerical data; D019990:Perioperative Care / Q000379:methods*; D011183:Postoperative Complications / Q000209:etiology; D015397:Program Evaluation; D011446:Prospective Studies; D020127:Recovery of Function; D012002:Rectal Diseases / Q000534:rehabilitation / Q000601:surgery*; D016896:Treatment Outcome