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Structured Synchronous Implementation of an Enhanced Recovery Program in Elective Colonic Surgery in 33 Hospitals in The Netherlands

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Abstract

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.

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Acknowledgments

The authors thank the Perioperative Care Breakthrough Project Group for collection of data: C.L.H. van Berlo, VieCurie Medisch Centrum, Venlo; A.J.A. Bremers, Universitair Medisch Centrum St. Radboud, Nijmegen; M.A.M. Brouwers, Haga Ziekenhuis, Den Haag; D. Cobben, Medisch Centrum Leeuwarden; P.P.L.O. Coene, Medisch Centrum Rijnmond Zuid, Rotterdam; K.C.A. van Engelenburg, Slingeland Ziekenhuis, Doetinchem; S.J. van der Hagen, Refaja Ziekenhuis, Stadskanaal; K.Havenga, Universitair Medisch Centrum Groningen; E.J. Hesselink, Gelre Ziekenhuizen, Apeldoorn; I.H.J.T. de Hingh, Catharina Ziekenhuis, Eindhoven; A.P.J. Houdijk, Medisch Centrum Alkmaar; J.M. Klaase, Medisch Spectrum Twente, Enschede; E.A.G.L. Lagae, Ziekenhuis Zeeuws Vlaanderen; F. Logeman, Beatrix Ziekenhuis, Winterswijk; E.J. Mulder, Antonius Ziekenhuis Sneek; K.H. Ong, Rivierenland Ziekenhuis, Tiel; R.J. Oostenbroek, Albert Schweitzer Ziekenhuis, Dordrecht; J.W.A. Oosterhuis, Isala Klinieken, Zwolle; R.T. Ottow, Groene Hart Ziekenhuis, Gouda; A.J. den Outer †, Rijnland Ziekenhuis, Leiderdorp; B. van Ramshort, St Antonius Ziekenhuis, Nieuwegein; P.H.M. Reemst, Maxima Medisch Centrum, Eindhoven; C. Rosman, Canisius Wilhelmina Ziekenhuis, Nijmegen; G.A. Vos, Waterland Ziekenhuis, Purmerend; F. Wit, Ziekenhuis de Tjongerschans, Heereveen; R.J. Zijlstra, Ziekenhuis Nij Smellinghe, Drachten; J.F.M. Reinders, Ijsselmeerziekenhuizen, Lelystad; R.A. Schasfoort, Scheper Ziekenhuis, Emmen; R. van Hillegersberg, Universitair Medisch Centrum, Utrecht; H.E. Lont, Vlietland Ziekenhuis, Vlaardingen; J. Jansen, Ziekenhuis Walcheren.

Author information

Author notes

  1. Freek Gillissen

    Present address: , PO Box 5800 6202 AZ, Maastricht, The Netherlands

Authors and Affiliations

  1. Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands

    Freek Gillissen, Maarten F. von Meyenfeldt & Cornelis H. C. Dejong

  2. Department of Surgery, Leeuwarden Medical Centre, Leeuwarden, The Netherlands

    Christiaan Hoff

  3. Department of Oncology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands

    Freek Gillissen & Maarten F. von Meyenfeldt

  4. Department of Patient and Care, Maastricht University Medical Centre, Maastricht, The Netherlands

    José M. C. Maessen

  5. Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht, University Medical Centre, Maastricht, The Netherlands

    Freek Gillissen

  6. Department of General Practice, CAPHRI, School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, The Netherlands

    José M. C. Maessen

  7. Department of Methodology and Statistics, CAPHRI, School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, The Netherlands

    Bjorn Winkens

  8. CBO—Centraal Begeleidings Orgaan, Dutch Institute for Healthcare Improvement, Utrecht, The Netherlands

    Jitske H. F. A. Teeuwen

  9. Nutrim School for Nutrition, Toxicology, and Metabolism, Maastricht University, Medical Centre, Maastricht, The Netherlands

    Maarten F. von Meyenfeldt & Cornelis H. C. Dejong

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Correspondence to Freek Gillissen.

Appendix 1

Appendix 1

Elements of the ERAS protocol

Elements

Conditions

Preoperative phase

 Preoperative counseling

Extensive information on the ERAS protocol

 Bowel preparation

No or single phosphate enema

 Carbohydrate drink

400 ml of Pre-op® (or comparable) 2 h before operation, unless diabetic

 Sedation

No sedation (short-acting if extremely anxious)

Perioperative phase

 

 Thoracic epidural analgesia/anesthesia

For all elective bowel surgery

 Prevention of hypothermia

Temperature ≥36.0 °C at end of operation

 Thromboembolic prophylaxis

Started 2 h after epidural and continued until mobilization

 Nasogastric tube

Removed before return to ward on day 0

 Abdominal drains

No drains

 Prophylactic antibiotics

Two drugs, given before incision

 Incision

Short midline or transverse incisions

 Oral fluid intake

800 ml on day 0 (400 ml if operated on in the afternoon)

 Sitting up

At least 15 min on day 0

Postoperative phase

 

 IV fluids

Stopped on day 1

 Normal diet

Resumed on day 1

 Oral supplements

200 ml twice daily from day 1

 Sitting up

At least 3 times 30 min in chair on day 1

 Oral laxatives

MgO tablets 1,000 mg from day 1

 Oral analgesics

Paracetamol from day 0; NSAID started before removal of epidural catheter

 Removal of epidural catheter

On day 2

 Removal of urinary catheter

At the time of removing the epidural catheter

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Gillissen, F., Hoff, C., Maessen, J.M.C. et al. Structured Synchronous Implementation of an Enhanced Recovery Program in Elective Colonic Surgery in 33 Hospitals in The Netherlands. World J Surg 37, 1082–1093 (2013). https://doi.org/10.1007/s00268-013-1938-4

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  • DOI: https://doi.org/10.1007/s00268-013-1938-4

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