World Journal of Surgery

, Volume 42, Issue 7, pp 1919–1928 | Cite as

Consensus on Training and Implementation of Enhanced Recovery After Surgery: A Delphi Study

  • Nader K. Francis
  • Thomas Walker
  • Fiona Carter
  • Martin Hübner
  • Angela Balfour
  • Dorthe Hjort Jakobsen
  • Jennie Burch
  • Tracy Wasylak
  • Nicolas Demartines
  • Dileep N. Lobo
  • Valerie Addor
  • Olle Ljungqvist
Original Scientific Report



Enhanced Recovery After Surgery (ERAS) is widely accepted in current surgical practice due to its positive impact on patient outcomes. The successful implementation of ERAS is challenging and compliance with protocols varies widely. Continual staff education is essential for successful ERAS programmes. Teaching modalities exist, but there remains no agreement regarding the optimal training curriculum or how its effectiveness is assessed. We aimed to draw consensus from an expert panel regarding the successful training and implementation of ERAS.


A modified Delphi technique was used; three rounds of questionnaires were sent to 58 selected international experts from 11 countries across multiple ERAS specialities and multidisciplinary teams (MDT) between January 2016 and February 2017. We interrogated opinion regarding four topics: (1) the components of a training curriculum and the structure of training courses; (2) the optimal framework for successful implementation and audit of ERAS including a guide for data collection; (3) a framework to assess the effectiveness of training; (4) criteria to define ERAS training centres of excellence.


An ERAS training course must cover the evidence-based principles of ERAS with team-oriented training. Successful implementation requires strong leadership, an ERAS facilitator and an effective MDT. Effectiveness of training can be measured by improved compliance. A training centre of excellence should show a willingness to teach and demonstrable team working.


We propose an international expert consensus providing an ERAS training curriculum, a framework for successful implementation, methods for assessing effectiveness of training and a definition of ERAS training centres of excellence.



The authors are grateful to the experts who contributed to this project.


  1. 1.
    Ren L, Zhu D, Wei Y et al (2012) Enhanced Recovery After Surgery (ERAS) program attenuates stress and accelerates recovery in patients after radical resection for colorectal cancer: a prospective randomized controlled trial. World J Surg 36(2):407–414. CrossRefPubMedGoogle Scholar
  2. 2.
    Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN (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(4):434–440CrossRefPubMedGoogle Scholar
  3. 3.
    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(5):571–577CrossRefPubMedGoogle Scholar
  4. 4.
    Group EC (2015) The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry. Ann Surg 261(6):1153–1159CrossRefGoogle Scholar
  5. 5.
    Lv L, Shao YF, Zhou YB (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(12):1549–1554CrossRefPubMedGoogle Scholar
  6. 6.
    Ljungqvist O, Scott M, Fearon KC (2017) Enhanced recovery after surgery: a review. JAMA Surg 152(3):292–298CrossRefPubMedGoogle Scholar
  7. 7.
    Maessen J, Dejong CH, Hausel J et al (2007) A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg 94(2):224–231CrossRefPubMedGoogle Scholar
  8. 8.
    Lyon A, Solomon MJ, Harrison JD (2014) A qualitative study assessing the barriers to implementation of enhanced recovery after surgery. World J Surg 38(6):1374–1380. CrossRefPubMedGoogle Scholar
  9. 9.
    Smart NJ, White P, Allison AS, Ockrim JB, Kennedy RH, Francis NK (2012) Deviation and failure of enhanced recovery after surgery following laparoscopic colorectal surgery: early prediction model. Colorectal Dis 14(10):e727–e734CrossRefPubMedGoogle Scholar
  10. 10.
    Keller DS, Delaney CP, Senagore AJ, Feldman LS, Force SST (2016) Uptake of enhanced recovery practices by SAGES members: a survey. Surg Endosc 31(9):3519–3526CrossRefPubMedGoogle Scholar
  11. 11.
    Dalkey NC (1969) The Delphi method: An experimental study group of opinion. The RAND Corporation, Santa MonicaGoogle Scholar
  12. 12.
    Williams PL, Webb C (1994) The Delphi technique: a methodological discussion. J Adv Nurs 19(1):180–186CrossRefPubMedGoogle Scholar
  13. 13.
    Alahlafi A, Burge S (2005) What should undergraduate medical students know about psoriasis? Involving patients in curriculum development: modified Delphi technique. BMJ 330(7492):633–636CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Gagliardi AR, Simunovic M, Langer B, Stern H, Brown AD (2005) Development of quality indicators for colorectal cancer surgery, using a 3-step modified Delphi approach. Can J Surg 48(6):441–452PubMedPubMedCentralGoogle Scholar
  15. 15.
    Ferri CP, Prince M, Brayne C et al (2005) Global prevalence of dementia: a Delphi consensus study. Lancet 366(9503):2112–2117CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Lassen K, Soop M, Nygren J et al (2009) Consensus review of optimal perioperative care in colorectal surgery: enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 144(10):961–969CrossRefPubMedGoogle Scholar
  17. 17.
    Feldheiser A, Aziz O, Baldini G et al (2016) Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand 60(3):289–334CrossRefPubMedGoogle Scholar
  18. 18.
    Scott MJ, Baldini G, Fearon KC et al (2015) Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations. Acta Anaesthesiol Scand 59(10):1212–1231CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Knott A, Pathak S, McGrath JS et al (2012) Consensus views on implementation and measurement of enhanced recovery after surgery in England: Delphi study. BMJ Open 2(6):e001878CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2018

Authors and Affiliations

  • Nader K. Francis
    • 1
    • 2
  • Thomas Walker
    • 1
  • Fiona Carter
    • 3
  • Martin Hübner
    • 4
  • Angela Balfour
    • 5
  • Dorthe Hjort Jakobsen
    • 6
  • Jennie Burch
    • 7
  • Tracy Wasylak
    • 8
    • 9
  • Nicolas Demartines
    • 4
  • Dileep N. Lobo
    • 10
  • Valerie Addor
    • 4
  • Olle Ljungqvist
    • 11
  1. 1.Department of Colorectal SurgeryYeovil District Hospital Foundation TrustSomersetUK
  2. 2.Faculty of ScienceUniversity of BathBathUK
  3. 3.South West Surgical Training Network, ERAS-UKSomersetUK
  4. 4.Department of Visceral SurgeryLausanne University Hospital (CHUV)LausanneSwitzerland
  5. 5.NHS Lothian Western General HospitalEdinburghScotland
  6. 6.Section of Surgical Pathophysiology 4074RigshospitaletCopenhagenDenmark
  7. 7.Head of Gastrointestinal Nurse Education, Academic InstituteSt Mark’s HospitalLondonUK
  8. 8.Strategic Clinical NetworksAlberta Health ServicesEdmontonCanada
  9. 9.Faculty of NursingUniversity of CalgaryCalgaryCanada
  10. 10.Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research CentreNottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical CentreNottinghamUK
  11. 11.Department of Surgery, Faculty of Medicine and HealthÖrebro UniversityOrebroSweden

Personalised recommendations