title: Adherence to enhanced recovery after surgery protocols across a high-volume gastrointestinal surgical service.
abstract: OBJECTIVE
  Enhanced recovery after surgery (ERAS) has been shown to improve outcomes for patients following gastrointestinal surgery. Data on protocol adherence and how this impacts on outcome are limited. This study examines how protocol adherence changes over time and determines how this impacts on outcome across a large-volume gastrointestinal surgical service.
  
  
  METHODS
  A prospective review of patients eligible for colorectal, liver and oesophagogastric ERAS over two 3-month periods in 2010 and 2011 was performed. End points included: length of stay (LOS), overall protocol adherence, individual modality adherence, reason for pathway deviation and patient outcomes.
  
  
  RESULTS
  172 patients (110 colorectal, 31 liver and 31 oesophagogastric) were evaluated. For each sub-speciality, the introduction of ERAS led to significant reductions in LOS that were sustained for the duration of the study. Adherence was achieved across 60% (colorectal), 75% (liver) and 88% (oesophagogastric) of individual pathway modalities. The major causes of pathway deviation were: post-operative nausea and vomiting (colorectal), pain (liver) and pulmonary complications (oesophagogastric).
  
  
  CONCLUSIONS
  Large-scale implementation of ERAS at a high-volume centre is feasible and offers many of the benefits demonstrated in controlled trials, but adherence may diminish over time.
authors.affiliation: Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre NIHR Biomedical Research Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
authors.forename: John S
authors.initials: JS
authors.lastname: Hammond
authors.forename: Sarah
authors.initials: S
authors.lastname: Humphries
authors.forename: Nick
authors.initials: N
authors.lastname: Simson
authors.forename: Helen
authors.initials: H
authors.lastname: Scrimshaw
authors.forename: James
authors.initials: J
authors.lastname: Catton
authors.forename: Christopher
authors.initials: C
authors.lastname: Gornall
authors.forename: Charles
authors.initials: C
authors.lastname: Maxwell-Armstrong
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003082:Colectomy; D013505:Digestive System Surgical Procedures; D004434:Early Ambulation; D016629:Esophagectomy; D005743:Gastrectomy; D019983:Guideline Adherence; D006498:Hepatectomy; D061847:Hospitals, High-Volume; D006801:Humans; D007902:Length of Stay; D008875:Middle Aged; D063868:Patient Outcome Assessment; D019990:Perioperative Care / Q000592:standards* / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D020127:Recovery of Function