Successful Implementation of Enhanced Recovery in Elective Colorectal Surgery is Variable and Dependent on the Local Environment

Ann Surg. 2021 Oct 1;274(4):605-612. doi: 10.1097/SLA.0000000000005069.


Objective: To evaluate local hospital success with enhanced recovery implementation as measured by colorectal surgery process measure (PM) compliance and characterize local environment factors associated with success within a contemporary quality improvement collaborative.

Summary background data: Enhanced recovery programs (ERP) have proven an effective perioperative quality improvement strategy, but local variation in implementation can hinder patient outcome improvement.

Methods: Individual hospitals participating in a national colorectal ERP quality improvement program were evaluated with quantitative (patient-level process and outcome) and qualitative (survey and structured interviews with hospital teams) data between 2017 and 2020. Hospitals with implementation success were identified: high performers (80% of elective colorectal surgery patients compliant with >6/9 PMs) and high improvers (top quartile of PM adherence improvement over time). Hospital and implementation characteristics were compared with chi-square tests. Trends in average annual outcome change were estimated with logistic and linear regression.

Results: Of 207 total hospitals, 62 were characterized as High Performance and 52 as High Improvement. High Performance hospitals were larger, with more annual colorectal surgeries (128 vs 101, P = 0.039). Qualitative assessment revealed fewer barriers of staff buy-in and competing priorities, and more experience with standardized perioperative care in High Performance hospitals. High Improvement hospitals had lower baseline PM adherence (54.1% vs 69.6%, P < 0.001) and less experience with standardized perioperative care (30.8% vs 58.1%, P < 0.001) but were noted to have a positive trend in annual patient outcomes: annual morbidity (Δ-1.14% vs -0.20%, P = 0.035), readmission (Δ-1.85% vs 0.002%, P = 0.037), and prolonged length of stay (Δ-3.94 vs -1.19, P = 0.037) compared to Low Improvement hospitals.

Conclusions: When evaluating a collection of hospitals implementing ERP, only half of hospitals reached consistent High Performance or high improvement. Characteristics of the local environment need further study to understand the barriers to effective implementation in a pragmatic setting.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Colorectal Surgery*
  • Databases, Factual
  • Elective Surgical Procedures*
  • Enhanced Recovery After Surgery*
  • Female
  • Hospitalization
  • Humans
  • Male
  • Outcome and Process Assessment, Health Care
  • Quality Improvement
  • Retrospective Studies
  • Surveys and Questionnaires
  • Treatment Outcome
  • United States