World Journal of Surgery

, Volume 40, Issue 5, pp 1092–1103 | Cite as

Implementation of Enhanced Recovery After Surgery (ERAS) Across a Provincial Healthcare System: The ERAS Alberta Colorectal Surgery Experience

  • Gregg Nelson
  • Lawrence N. Kiyang
  • Ellen T. Crumley
  • Anderson Chuck
  • Thanh Nguyen
  • Peter Faris
  • Tracy Wasylak
  • Carlota Basualdo-Hammond
  • Susan McKay
  • Olle Ljungqvist
  • Leah M. Gramlich
Original Scientific Report



Enhanced recovery after surgery (ERAS) colorectal guideline implementation has occurred primarily in standalone institutions worldwide. We implemented the guideline in a single provincial healthcare system, and our study examined the effect of the guideline on patient outcomes [length of stay (LOS), complications, and 30-day post-discharge readmissions] across a healthcare system.


We compared pre- and post-guideline implementation in consecutive elective colorectal patients, ≥18 years, from six Alberta hospitals between February 2013 and December 2014. Participants were followed up to 30 days post discharge. We used summary statistics, to assess the LOS and complications, and multivariate regression methods to assess readmissions and to estimate cost impacts.


A total of 1333 patients (350 pre- and 983 post-ERAS) were analysed. Of this number, 55 % were males. Median overall guideline compliance was 39 % in pre- and 60 % in post-ERAS patients. Median LOS was 6 days for pre-ERAS compared to 4.5 days in post-ERAS patients with the longest implementation (p value <0.0001). Adjusted risk ratio (RR) was 1.71, 95 % CI 1.09–2.68 for 30-day readmission, comparing pre- to post-ERAS patients. The proportion of patients who developed at least one complication was significantly reduced, from pre- to post-ERAS, difference in proportions = 11.7 %, 95 % CI 2.5–21.0, p value: 0.0139. The net cost savings attributable to guideline implementation ranged between $2806 and $5898 USD per patient.


The findings in our study have shown that ERAS colorectal guideline implementation within a healthcare system resulted in patient outcome improvements, similar to those obtained in smaller standalone implementations. There was a significant beneficial impact of ERAS on scarce health system resources.


Guideline Compliance Alberta Health Service Royal Alexandra Hospital Provincial Healthcare System Single Health Care System 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Grant support

The ERAS project was funded by the Partnership for Research and Innovation in the Health System (PRIHS) research grant from Alberta Innovates: Health Solutions.

Compliance with ethical standards

Conflicts of interest

Dr. Ljungqvist is the current Chairman of the ERAS Society. He founded, serves on the Board and owns stock in Encare AB that runs the ERAS Society Interactive Audit System.


  1. 1.
    Simpson JC, Moonesinghe SR, Grocott MPW et al (2015) Enhanced recovery from surgery in the UK: an audit of the enhanced recovery partnership programme 2009–2012. Br J Anaesth 115(4):560–568CrossRefPubMedGoogle Scholar
  2. 2.
    Gustafsson UO, Scott MJ, Schwenk W et al (2013) Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg 37:259–284. doi: 10.1007/s00268-012-1772-0 CrossRefPubMedGoogle Scholar
  3. 3.
    Gustafsson UO, Scott MJ, Schwenk W et al (2012) Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 31:783–800CrossRefPubMedGoogle Scholar
  4. 4.
    Nygren J, Thacker J, Carli F et al (2013) Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg 37:285–305. doi: 10.1007/s00268-012-1787-6 CrossRefPubMedGoogle Scholar
  5. 5.
    Nygren J, Thacker J, Carli F et al (2012) Guidelines for perioperative care in elective rectal/pelvic surgery: enhanced recovery after surgery (ERAS®) Society recommendations. Clin Nutr 31:801–816CrossRefPubMedGoogle Scholar
  6. 6.
    Walter CJ, Collin J, Dumville JC et al (2009) Enhanced recovery in colorectal resections: a systematic review and meta-analysis. Int J Colorectal Dis 11:344–353CrossRefGoogle Scholar
  7. 7.
    Wind J, Polle SW, Jin PHPFK et al (2006) Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 93:800–809CrossRefPubMedGoogle Scholar
  8. 8.
    Gouvas N, Tan E, Windsor A et al (2009) Fast-track vs standard care in colorectal surgery: a meta-analysis update. Int J Colorectal Dis 24:1119–1131CrossRefPubMedGoogle Scholar
  9. 9.
    Adamina M, Kehlet H, Tomlinson GA et al (2011) Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery 149:830–840CrossRefPubMedGoogle Scholar
  10. 10.
    Varadhan KK, Neal KR, Dejong CHC et al (2010) The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 29:434–440CrossRefPubMedGoogle Scholar
  11. 11.
    Greco M, Capretti G, Beretta L et al (2014) Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg 38:1531–1541. doi: 10.1007/s00268-013-2416-8 CrossRefPubMedGoogle Scholar
  12. 12.
    Lv L, Y-f Shao, Y-b Zhou (2012) The enhanced recovery after surgery (ERAS) pathway for patients undergoing colorectal surgery: an update of meta-analysis of randomized controlled trials. Int J Colorectal Dis 27:1549–1554CrossRefPubMedGoogle Scholar
  13. 13.
    Eskicioglu C, Forbes S, Aarts M-A et al (2009) Enhanced recovery after surgery (ERAS) programs for patients having colorectal surgery: a meta-analysis of randomized trials. J Gastrointest Surg 13:2321–2329CrossRefPubMedGoogle Scholar
  14. 14.
    Roulin D, Donadini A, Gander S et al (2013) Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery. Br J Surg 100:1108–1114CrossRefPubMedGoogle Scholar
  15. 15.
    Lee L, Mata J, Ghitulescu GA et al (2014) Cost-effectiveness of enhanced recovery versus conventional perioperative management for colorectal surgery. Ann Surg 00:1–8Google Scholar
  16. 16.
    Gillissen F, Hoff C, Maessen JC et al (2013) Structured synchronous implementation of an enhanced recovery program in elective colonic surgery in 33 Hospitals in The Netherlands. World J Surg 37:1082–1093. doi: 10.1007/s00268-013-1938-4 CrossRefPubMedGoogle Scholar
  17. 17.
    Bell GV (2008) Sample size. In: Statistical rules of thumb, vol 36, 2nd edn. John Wiley & Sons Inc., Hoboken, pp 1–14CrossRefGoogle Scholar
  18. 18.
    Vittinghoff E, McCulloch CE (2007) Relaxing the rule of ten events per variable in logistic and Cox regression. Am J Epidemiol 165:710–718CrossRefPubMedGoogle Scholar
  19. 19.
    Derksen S, Keselman HJ (1992) Backward, forward and stepwise automated subset selection algorithms: frequency of obtaining authentic and noise variables. Br J Math Stat Psychol 45:265–282CrossRefGoogle Scholar
  20. 20.
    Vlug MS, Wind J, Hollmann MW et al (2011) Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg 254:868–875CrossRefPubMedGoogle Scholar
  21. 21.
    Delaney C, Zutshi M, Senagore A et al (2003) Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Dis Colon Rectum 46:851–859CrossRefPubMedGoogle Scholar
  22. 22.
    Gustafsson UO, Tiefenthal M, Thorell A et al (2012) Laparoscopic-assisted and open high anterior resection within an ERAS protocol. World J Surg 36:1154–1161. doi: 10.1007/s00268-012-1519-y CrossRefPubMedGoogle Scholar
  23. 23.
    Spanjersberg WR, Van Sambeeck JDP, Bremers A et al (2015) Systematic review and meta-analysis for laparoscopic versus open colon surgery with or without an ERAS programme. Surg Endosc 29(12):3443–3453CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Group (2015) The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry. Ann Surg 261:1153–1159Google Scholar
  25. 25.
    Van Bree S, Vlug M, Bemelman W et al (2011) Original research: faster recovery of gastrointestinal transit after laparoscopy and fast-track care in patients undergoing colonic surgery. Gastroenterology 141:872–880CrossRefPubMedGoogle Scholar
  26. 26.
    Gustafsson UO, Hausel J, Thorell A et al (2011) Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 146:571–577CrossRefPubMedGoogle Scholar
  27. 27.
    Polle SW, Wind J, Fuhring JW et al (2007) Implementation of a fast-track perioperative care program: what are the difficulties? Dig Surg 24:441–449CrossRefPubMedGoogle Scholar
  28. 28.
    Ahmed J, Khan S, Lim M et al (2012) Enhanced recovery after surgery protocols—compliance and variations in practice during routine colorectal surgery. Int J Colorectal Dis 14:1045–1051CrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2016

Authors and Affiliations

  • Gregg Nelson
    • 1
    • 6
  • Lawrence N. Kiyang
    • 2
  • Ellen T. Crumley
    • 2
  • Anderson Chuck
    • 3
  • Thanh Nguyen
    • 3
  • Peter Faris
    • 2
  • Tracy Wasylak
    • 2
  • Carlota Basualdo-Hammond
    • 2
  • Susan McKay
    • 2
  • Olle Ljungqvist
    • 4
  • Leah M. Gramlich
    • 5
  1. 1.Department of OncologyUniversity of CalgaryCalgaryCanada
  2. 2.Alberta Health ServicesAlbertaCanada
  3. 3.Institute of Health EconomicsEdmontonCanada
  4. 4.Department of Surgery, Faculty of Medicine and Health, School of Health and Medical SciencesÖrebro UniversityÖrebroSweden
  5. 5.Department of MedicineUniversity of AlbertaEdmontonCanada
  6. 6.Tom Baker Cancer CentreCalgaryCanada

Personalised recommendations