title: Large-scale implementation of enhanced recovery programs after surgery. A francophone experience.
abstract: BACKGROUND
  Enhanced recovery after surgery program (ERP) has now surpassed the stage of clinical research in certain specialties and currently poses the problematic of large-scale implementation. The goal of this study was to report the experience during the first year of implementation in three French-speaking countries.
  
  
  METHODS
  This is a prospective study in which 67 healthcare centers, all registered in the Grace-Audit databank, participated. Included were patients undergoing colorectal (CRS), bariatric (BS) and orthopedic hip and knee surgery (OS), performed within an ERP. The main endpoints were duration of hospital stay, postoperative morbidity, the degree of compliance with the elements of the ERP, the relation between the extent of application of the elements and postoperative hospital stay, and finally the completeness of data inclusions in the databank.
  
  
  RESULTS
  A total of 1904 patients were included in the Grace-Audit databank between January 1, 2015 and January 31, 2016, undergoing CRS (n=490), BS (n=431), and OS (n=983). The mean implementation rate was 83.7±10.0% for CRS, 75.0±23.7% for BS, and 83.5±14.9% for OS. The duration of hospital stay was 6.5 days for CRS, 2.6 days for BS and 3.4 days for OS. Overall postoperative morbidity (onset of postoperative undesirable event), surgical morbidity (superficial or deep organ space surgical site complications such as bleeding, infection or defective healing) and readmission rates were 20.6%, 7.5%, and 5.7% for CRS; 2.5%, 1.4%, and 1.6% for BS and 2.9%, 0.2%, and 2% for OS, respectively. A statistically significant relationship was found between the degree of compliance of the elements of ERP and the duration of hospital stay for CRS and BS; hospital stay was reduced when at least 15 of the 22 elements of the program were applied (P<0.001). The patients included in the Grace-Audit databank represented less than 20% of the patients undergoing operation in the same establishments during the study period for all three specialties.
  
  
  CONCLUSIONS
  This study shows that large-scale ERPs are feasible and safe in French-speaking countries. Nonetheless, although encouraging, these preliminary results highlight that implementation must be improved in specialties such as bariatric surgery and that more complete data collection is needed.
authors.affiliation: Service de chirurgie digestive, CHU Estaing, 63003 Clermont-Ferrand, France; Groupe francophone de réhabilitation améliorée après chirurgie, 63110 Beaumont, France.
authors.forename: J
authors.initials: J
authors.lastname: Veziant
authors.affiliation: Groupe francophone de réhabilitation améliorée après chirurgie, 63110 Beaumont, France; Infirmerie protestante, 69300 Caluire, France.
authors.forename: O
authors.initials: O
authors.lastname: Raspado
authors.affiliation: Groupe francophone de réhabilitation améliorée après chirurgie, 63110 Beaumont, France.
authors.forename: A
authors.initials: A
authors.lastname: Entremont
authors.affiliation: Groupe francophone de réhabilitation améliorée après chirurgie, 63110 Beaumont, France; Service d'anesthésie et de réanimation, CHU de Liège, 4000 Liège, Belgium.
authors.forename: J
authors.initials: J
authors.lastname: Joris
authors.affiliation: Département de statistiques, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France.
authors.forename: B
authors.initials: B
authors.lastname: Pereira
authors.affiliation: Service de chirurgie digestive, CHU Estaing, 63003 Clermont-Ferrand, France; Groupe francophone de réhabilitation améliorée après chirurgie, 63110 Beaumont, France. Electronic address: kslim@chu-clermontferrand.fr.
authors.forename: K
authors.initials: K
authors.lastname: Slim
authors.affiliation: Groupe francophone de réhabilitation améliorée après chirurgie, 63110 Beaumont, France.
mesh_terms: D000328:Adult; D050110:Bariatric Surgery; D001530:Belgium; D003107:Colorectal Surgery; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D005602:France; D006615:Hip / Q000601:surgery*; D006801:Humans; D007717:Knee / Q000601:surgery*; D007802:Language; D010535:Laparoscopy / Q000379:methods; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission; D011184:Postoperative Period; D011446:Prospective Studies; D020127:Recovery of Function; D012307:Risk Factors; D059039:Standard of Care; D013997:Time Factors
keywords: Bariatric surgery; Colorectal surgery; Enhanced recovery after surgery; Orthopedic surgery