title: Structured synchronous implementation of an enhanced recovery program in elective colonic surgery in 33 hospitals in The Netherlands.
abstract: BACKGROUND
  It has been clearly shown that after elective colorectal surgery patients benefit from multimodal perioperative care programs. The Dutch Institute for Health Care Improvement started a breakthrough project to implement a multimodal perioperative care program of enhanced recovery after surgery (ERAS). This pre/post noncontrolled study evaluated the success of large-scale implementation of the ERAS program for elective colonic surgery using the breakthrough series.
  
  
  METHODS
  A total of 33 hospitals participated in this breakthrough project during 2005-2009. Each hospital performed a retrospective chart review to gather information on traditionally treated patients (pre-ERAS group, n = 1,451). During the subsequent year patients were treated according to the ERAS program (ERAS group, n = 1 034). Outcomes were length of stay (LOS), functional recovery, adherence to the protocol, and determinants of reduced LOS.
  
  
  RESULTS
  Median LOS decreased significantly from 9 to 6 days (p < 0.001). In the ERAS group, functional recovery was reached within 3 days. Adherence to the protocol elements was high during the preoperative and perioperative phases but slightly lower during the postoperative phase. Younger age, female sex, American Society of Anesthesiologists grades I/II, and laparoscopic surgery were associated with decreased LOS. Care elements that positively influenced LOS were cessation of intravenous fluids and mobilization on postoperative day 1 and administration of laxatives postoperatively.
  
  
  CONCLUSIONS
  The ERAS program was successfully implemented in one-third of all Dutch hospitals using the breakthrough series. Participating hospitals reduced the LOS by a median 3 days and were able to improve their standard of care in elective colonic surgery.
authors: Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands. f.gillissen@maastrichtuniversity.nl
authors: Freek
authors: F
authors: Gillissen
authors: Christiaan
authors: C
authors: Hoff
authors: José M C
authors: JM
authors: Maessen
authors: Bjorn
authors: B
authors: Winkens
authors: Jitske H F A
authors: JH
authors: Teeuwen
authors: Maarten F
authors: MF
authors: von Meyenfeldt
authors: Cornelis H C
authors: CH
authors: Dejong
mesh_terms: D000368:Aged; D002985:Clinical Protocols; D003082:Colectomy; D004434:Early Ambulation / Q000706:statistics & numerical data; D017558:Elective Surgical Procedures; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006761:Hospitals / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D053208:Kaplan-Meier Estimate; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D009426:Netherlands; D017063:Outcome Assessment, Health Care; D019990:Perioperative Care / Q000379:methods* / Q000592:standards / Q000706:statistics & numerical data; D015397:Program Evaluation; D016016:Proportional Hazards Models; D020127:Recovery of Function; D012189:Retrospective Studies
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