Enhanced Recovery Program: ERAS
What is ERAS? ERAS is an acronym for enhanced recovery after surgery. The acronym is commonly used to describe a multimodal perioperative care program. The term enhanced recover after surgery can be and often is substituted for terms like enhanced recovery programs (ERP) or fast-track surgery, but ultimately the meaning is the same. Every program of ERAS is composed of several evidence-based perioperative care aspects that have been proven to be effective; however, when each aspect is put together into a protocol, they have been shown to result in substantially improved surgical outcome. The number of aspects in each ERAS protocol is different, but a common number is approximately twenty. Enhanced recovery after surgery protocols in major
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surgery has been shown to decrease recovery time and hospital length of stay by 2-3 days and complications anywhere from thirty to fifty percent.
History of ERAS The term ERAS was created by a group of academic surgeons who started the ERAS study group in London, England in the year 2001. The group was formed with the intention of developing the best perioperative care pathway using literature review and adaptation of treatments to give patients an opportunity for an optimal recovery. The group of academic surgeons consisted of Kenneth Fearon (University of Edinburgh, United Kingdom), Henrik Kehlet (University of Copenhagen, Denmark), Arthur Revhaug (University of Tromso, Norway), Maarten von Meyenfeldt (the Netherlands), Cornelis deJong (University of Maastricht, the Netherlands), and Olle Ljungqvist (Karolinska Insitutet, Sweden). The group began by reviewing all literature that involved impact on surgical outcomes and developed a care protocol for colonic resections. Henrik Kehlet was a tremendous asset to the group due to his already extensive work using a multimodal approach to perioperative care. In the early 2000’s, the typical length of stay for colonic resection surgery was 9-10 days; however, with Kehlet’s approach he reported patients being ready after only 2 days. After a collaborative period, the ERAS group established its first protocol; however, it was evident to each participant in the group that not a single organization had been fully complaint with the established protocol.
Dr. Kehlet and colleagues at the University of Copenhagen had the highest compliance than everyone else due to their familiarity with such protocol. When all parties realized their lack of compliance, they decided to aim for adoption of the ERAS best practice protocol while studying the change of practice. When the group monitored their change of practice it became clear that just having a uniform protocol was not enough so the decision to create and use a common database was made. Every consecutive patient from that point forward was inputted into the database for monitoring which led to an unintended revelation. The treatment at each organization that belonged to the study group was different from what the group thought. When each partner in the study group reviewed their individual best practices, they learned that everyone had problems with compliance to protocols with aspects they thought were working well. The database audit helped the group to identify true best practice and helped them make the correct changes so they could focus on areas where problems actually existed. The fact that some organizations were employing treatments that were opposed by other clinicians in other units made it easier for detractors to accept the different philosophy of practice. The study group made it a focus to met regularly during the early years of ERAS so they could support each other and present their findings. The result was improvements in compliance and outcomes emerged. In addition to their regular meetings, the group distributed surveys that found their organizations were not alone in keeping with outdated traditions and care instead of adopting better more evidence-based
treatments. Dr. deJong at the University of Maastricht had the opportunity to work with an organization called Centraal Begeleidings Orgaan (CBO) during the initial creation of ERAS protocols. CBO is government-led organization from the Netherlands that focuses on change management for healthcare organizations during their implementation phase. CBO helped show Dr. deJong that it is possible to have several units change engrained habits in order to get an improved result and the evidence-based tools to help with this change were readily available. ERAS has grown from a study group in 2001 to an international collaboration. This phenomenon presented the opportunity for the group to create a medical society with the goal of increasing ERAS network and giving improved perioperative care a greater breath from which to work.
surgery has been shown to decrease recovery time and hospital length of stay by 2-3 days and complications anywhere from thirty to fifty percent.
History of ERAS The term ERAS was created by a group of academic surgeons who started the ERAS study group in London, England in the year 2001. The group was formed with the intention of developing the best perioperative care pathway using literature review and adaptation of treatments to give patients an opportunity for an optimal recovery. The group of academic surgeons consisted of Kenneth Fearon (University of Edinburgh, United Kingdom), Henrik Kehlet (University of Copenhagen, Denmark), Arthur Revhaug (University of Tromso, Norway), Maarten von Meyenfeldt (the Netherlands), Cornelis deJong (University of Maastricht, the Netherlands), and Olle Ljungqvist (Karolinska Insitutet, Sweden). The group began by reviewing all literature that involved impact on surgical outcomes and developed a care protocol for colonic resections. Henrik Kehlet was a tremendous asset to the group due to his already extensive work using a multimodal approach to perioperative care. In the early 2000’s, the typical length of stay for colonic resection surgery was 9-10 days; however, with Kehlet’s approach he reported patients being ready after only 2 days. After a collaborative period, the ERAS group established its first protocol; however, it was evident to each participant in the group that not a single organization had been fully complaint with the established protocol.
Dr. Kehlet and colleagues at the University of Copenhagen had the highest compliance than everyone else due to their familiarity with such protocol. When all parties realized their lack of compliance, they decided to aim for adoption of the ERAS best practice protocol while studying the change of practice. When the group monitored their change of practice it became clear that just having a uniform protocol was not enough so the decision to create and use a common database was made. Every consecutive patient from that point forward was inputted into the database for monitoring which led to an unintended revelation. The treatment at each organization that belonged to the study group was different from what the group thought. When each partner in the study group reviewed their individual best practices, they learned that everyone had problems with compliance to protocols with aspects they thought were working well. The database audit helped the group to identify true best practice and helped them make the correct changes so they could focus on areas where problems actually existed. The fact that some organizations were employing treatments that were opposed by other clinicians in other units made it easier for detractors to accept the different philosophy of practice. The study group made it a focus to met regularly during the early years of ERAS so they could support each other and present their findings. The result was improvements in compliance and outcomes emerged. In addition to their regular meetings, the group distributed surveys that found their organizations were not alone in keeping with outdated traditions and care instead of adopting better more evidence-based
treatments. Dr. deJong at the University of Maastricht had the opportunity to work with an organization called Centraal Begeleidings Orgaan (CBO) during the initial creation of ERAS protocols. CBO is government-led organization from the Netherlands that focuses on change management for healthcare organizations during their implementation phase. CBO helped show Dr. deJong that it is possible to have several units change engrained habits in order to get an improved result and the evidence-based tools to help with this change were readily available. ERAS has grown from a study group in 2001 to an international collaboration. This phenomenon presented the opportunity for the group to create a medical society with the goal of increasing ERAS network and giving improved perioperative care a greater breath from which to work.