International Journal of Colorectal Disease

, Volume 32, Issue 10, pp 1471–1478 | Cite as

Variation in care for surgical patients with colorectal cancer: protocol adherence in 12 European hospitals

  • Ruben van ZelmEmail author
  • Ellen Coeckelberghs
  • Walter Sermeus
  • Anthony De Buck van Overstraeten
  • Arved Weimann
  • Deborah Seys
  • Massimiliano Panella
  • Kris Vanhaecht
Original Article



Surgical care for patients with colorectal cancer has become increasingly standardized. The Enhanced Recovery After Surgery (ERAS) protocol is a widely accepted structured care method to improve postoperative outcomes of patients after surgery. Despite growing evidence of effectiveness, adherence to the protocol remains challenging in practice. This study was designed to assess the adherence rate in daily practice and examine the relationship between the importance of interventions and adherence rate.


This international observational, cross-sectional multicenter study was performed in 12 hospitals in four European countries. Patients were included from January 1, 2014. Data was retrospectively collected from the patient record by the local study coordinator.


A total of 230 patients were included in the study. Protocol adherence was analyzed for both the individual interventions and on patient level. The interventions with the highest adherence were antibiotic prophylaxis (95%), thromboprophylaxis (87%), and measuring body weight at admission (87%). Interventions with the lowest adherence were early mobilization—walking and sitting (9 and 6%, respectively). The adherence ranged between 16 and 75%, with an average of 44%.


Our results show that the average protocol adherence in clinical practice is 44%. The variation on patient and hospital level is considerable. Only in one patient the adherence rate was >70%. In total, 30% of patients received 50% or more of the key interventions. A solid implementation strategy seems to be needed to improve the uptake of the ERAS pathway. The importance-performance matrix can help in prioritizing the areas for improvement.


ERAS Colorectal surgery Care pathways Protocol adherence Importance-performance analysis 



Research made possible by an unconditional educational grant by Baxter SA, Baxter Belgium, Baxter France, Baxter Germany, and Baxter The Netherlands to the European Pathway Association. Baxter had no influence on the study. We would like to thank the teams in the participating hospitals for their commitment. The participating hospitals are as follows: Belgium: AZ Groeninge, Kortrijk (Dr. D. Devriendt/Mrs. K. Vandendriessche & Mrs. D. Verhelst), Institute Bordet, Brussels (Dr. G. Liberale), University Hospital Leuven (Dr. A. De Buck van Overstraeten/Mr. D. Michiels & Mr. K. Op de Beeck); France: American Hospital of Paris/Institute Hospitalier Franco-Britannique, Paris/Clinique Hartmann – Ambroise Parre, Paris (Dr. A. Toledano/Mr. P. Ihout); Germany: Kreisklinikum Ebersberg (Dr. D. Plecity), Städtischen Klinikum Frankfurt Höechst (Dr. M. Ferschke & Dr. J. Reusch), Klinikum St. Georg, Leipzig (Prof. Dr. A. Weimann/Dr. M. Braunert/Dr. M. Wobith); The Netherlands: Groene Hart Hospital, Gouda (Dr. L. Tseng/Mrs. J. Verkerk), Onze Lieve Vrouwe Hospital, Amsterdam (Mrs. H. Hiemstra), Wilhelmina Hospital Assen (Dr. W. Bleeker/Mrs. G. Boekeloo & Mrs. H. Bouwman).

Compliance with ethical standards

Ethical approval for this study was obtained with the ethical committee of the University Hospital Leuven (S57152 (ML11311)). Based on the study protocol, all hospitals provided written agreement of the local study coordinator and approval of the local ethical committee.


This study was funded with an unconditional educational grant by Baxter SA to the European Pathway Association. Baxter SA had no influence on the study.

Conflict of interest

AW has received lecturers’ honoraria from Baxter, B.Braun, Berlin-Chemie, Fresenius Gabi, Lilly, Medtronic, Nestlé, and Nutricia, and has received research grants from Baxter and Danone. The other authors declare that they have no conflict of interest.


  1. 1.
    Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, Macfie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O (2013) Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg 37(2):259–284. doi: 10.1007/s00268-012-1772-0 CrossRefPubMedGoogle Scholar
  2. 2.
    Aarts MA, Okrainec A, Glicksman A, Pearsall E, Victor JC, McLeod RS (2012) Adoption of enhanced recovery after surgery (ERAS) strategies for colorectal surgery at academic teaching hospitals and impact on total length of hospital stay. Surg Endosc 26(2):442–450. doi: 10.1007/s00464-011-1897-5 CrossRefPubMedGoogle Scholar
  3. 3.
    Gonzalez-Ayora S, Pastor C, Guadalajara H, Ramirez JM, Royo P, Redondo E, Arroyo A, Moya P, Garcia-Olmo D (2016) Enhanced recovery care after colorectal surgery in elderly patients. Compliance and outcomes of a multicenter study from the Spanish working group on ERAS. Int J Color Dis 31(9):1625–1631. doi: 10.1007/s00384-016-2621-7 CrossRefGoogle Scholar
  4. 4.
    Gustafsson UO, Oppelstrup H, Thorell A, Nygren J, Ljungqvist O (2016) Adherence to the ERAS protocol is associated with 5-year survival after colorectal cancer surgery: a retrospective cohort study. World J Surg 40(7):1741–1747. doi: 10.1007/s00268-016-3460-y CrossRefPubMedGoogle Scholar
  5. 5.
    Pedziwiatr M, Kisialeuski M, Wierdak M, Stanek M, Natkaniec M, Matlok M, Major P, Malczak P, Budzynski A (2015) Early implementation of Enhanced Recovery After Surgery (ERAS®) protocol—compliance improves outcomes: a prospective cohort study. Int J Surg (London, England) 21:75-81. doi: 10.1016/j.ijsu.2015.06.087
  6. 6.
    Alcantara-Moral M, Serra-Aracil X, Gil-Egea MJ, Frasson M, Flor-Lorente B, Garcia-Granero E (2014) Observational cross-sectional study of compliance with the fast track protocol in elective surgery for colon cancer in Spain. Int J Color Dis 29(4):477–483. doi: 10.1007/s00384-013-1825-3 CrossRefGoogle Scholar
  7. 7.
    Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J (2011) Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Archives of surgery (Chicago, Ill : 1960) 146(5):571–577. doi: 10.1001/archsurg.2010.309 CrossRefGoogle Scholar
  8. 8.
    Polle SW, Wind J, Fuhring JW, Hofland J, Gouma DJ, Bemelman WA (2007) Implementation of a fast-track perioperative care program: what are the difficulties? Dig Surg 24(6):441–449. doi: 10.1159/000108327 CrossRefPubMedGoogle Scholar
  9. 9.
    Pisarska M, Pedziwiatr M, Malczak P, Major P, Ochenduszko S, Zub-Pokrowiecka A, Kulawik J, Budzynski A (2016) Do we really need the full compliance with ERAS protocol in laparoscopic colorectal surgery? A prospective cohort study. Int J Surg (London, England) 36 (Pt A):377-382. doi: 10.1016/j.ijsu.2016.11.088
  10. 10.
    Cwikel JG (2006) Social epidemiology: strategies for public health activism. Columbia University Press, New YorkGoogle Scholar
  11. 11.
    van Zelm R, Janssen I, Vanhaecht K, de Buck van Overstraeten A, Panella M, Sermeus W, Coeckelberghs E (2017) Development of a model care pathway for adults undergoing colorectal cancer surgery: evidence-based key interventions and indicators. J Eval Clin Pract. doi: 10.1111/jep.12700
  12. 12.
    Seys D, Bruyneel L, Decramer M, Lodewijckx C, Panella M, Sermeus W, Boto P, Vanhaecht K (2016) An international study of adherence to guidelines for patients hospitalised with a COPD exacerbation. Copd:1–8. doi: 10.1080/15412555.2016.1257599
  13. 13.
    McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA (2003) The quality of health care delivered to adults in the United States. N Engl J Med 348(26):2635–2645. doi: 10.1056/NEJMsa022615 CrossRefPubMedGoogle Scholar
  14. 14.
    Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, Moore L, O'Cathain A, Tinati T, Wight D, Baird J (2015) Process evaluation of complex interventions: Medical Research Council guidance. BMJ (Clinical research ed) 350:h1258. doi: 10.1136/bmj.h1258 Google Scholar
  15. 15.
    ICHOM (2016) ICHOM standard set for colorectal cancer. ICHOM, Cambridge MAGoogle Scholar
  16. 16.
    ICHOM (2016) Colorectal cancer reference guide. ICHOM, Cambrigde MAGoogle Scholar
  17. 17.
    Howell AM, Panesar SS, Burns EM, Donaldson LJ, Darzi A (2014) Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery. Ann Surg 259(4):630–641. doi: 10.1097/sla.0000000000000371 CrossRefPubMedGoogle Scholar
  18. 18.
    Song XP, Tian JH, Cui Q, Zhang TT, Yang KH, Ding GW (2014) Could clinical pathways improve the quality of care in patients with gastrointestinal cancer? A meta-analysis. Asian Pacific journal of cancer prevention : APJCP 15(19):8361–8366CrossRefPubMedGoogle Scholar
  19. 19.
    Vanhaecht K, Sermeus W, Peers J, Lodewijckx C, Deneckere S, Leigheb F, Decramer M, Panella M (2010) The impact of care pathways for exacerbation of chronic obstructive pulmonary disease: rationale and design of a cluster randomized controlled trial. Trials 11:111. doi: 10.1186/1745-6215-11-111 CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Vanhaecht K, Sermeus W, Peers J, Lodewijckx C, Deneckere S, Leigheb F, Boonen S, Sermon A, Boto P, Mendes RV, Panella M (2012) The impact of care pathways for patients with proximal femur fracture: rationale and design of a cluster-randomized controlled trial. BMC Health Serv Res 12:124. doi: 10.1186/1472-6963-12-124 CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Vanhaecht K, Van Gerven E, Deneckere S, Lodewijckx C, Janssen I, Van Zelm R, Boto P, Mendes R, Panella M, Biringer E, Sermeus W (2012) The 7-phase method to design, implement and evaluate care pathways. International Journal of Person Centered Care 2(3):341–351Google Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  • Ruben van Zelm
    • 1
    • 2
    • 3
    Email author
  • Ellen Coeckelberghs
    • 1
    • 2
  • Walter Sermeus
    • 1
    • 2
  • Anthony De Buck van Overstraeten
    • 4
  • Arved Weimann
    • 5
  • Deborah Seys
    • 1
  • Massimiliano Panella
    • 1
    • 2
    • 6
  • Kris Vanhaecht
    • 1
    • 2
    • 7
  1. 1.Leuven Institute for Healthcare PolicyKU LeuvenLeuvenBelgium
  2. 2.European Pathway AssociationLeuvenBelgium
  3. 3.Q-Consult zorgUtrechtThe Netherlands
  4. 4.Department of Abdominal SurgeryUniversity Hospitals LeuvenLeuvenBelgium
  5. 5.Department of General, Abdominal, and Oncological SurgeryKlinikum Skt GeorgeLeipzigGermany
  6. 6.Department of Translational MedicineUniversity of Eastern Piemonte (UPO)NovaraItaly
  7. 7.Department of Quality ManagementUniversity Hospitals LeuvenLeuvenBelgium

Personalised recommendations