Structured synchronous implementation of an enhanced recovery program in elective colonic surgery in 33 hospitals in The Netherlands

World J Surg. 2013 May;37(5):1082-93. doi: 10.1007/s00268-013-1938-4.


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.

Publication types

  • Evaluation Study
  • Multicenter Study

MeSH terms

  • Aged
  • Clinical Protocols
  • Colectomy*
  • Early Ambulation / statistics & numerical data
  • Elective Surgical Procedures*
  • Female
  • Guideline Adherence / statistics & numerical data
  • Hospitals / standards
  • Hospitals / statistics & numerical data
  • Humans
  • Kaplan-Meier Estimate
  • Length of Stay / statistics & numerical data*
  • Male
  • Netherlands
  • Outcome Assessment, Health Care
  • Perioperative Care / methods*
  • Perioperative Care / standards
  • Perioperative Care / statistics & numerical data
  • Program Evaluation
  • Proportional Hazards Models
  • Recovery of Function
  • Retrospective Studies