Researching implementation of ERAS

It is well over 25 years ago that enhanced recovery after surgery (ERAS) pathways started a movement to change how perioperative care is being practiced around the world in just about all surgical disciplines.1 The results of ERAS have repeatedly shown reductions in complications and need for hospital stay in the ranges of 30%–50%, while the cost of care is significantly reduced. Despite these superb results, it is clear from national registry data from countries where most clinicians involved would claim they "do ERAS," this is far from true.1,2 In this issue of Journal of the Italian Surgical Association the iCral group reports their combined efforts to implement ERAS in Italy.3 The report has several interesting results and an approach that clearly has been successful: engaging colleagues in research. By combining two large studies, the authors present the largest set of national data on ERAS published to date. This helps to confirm several previous findings that are of key interest in understanding the effects of ERAS and more detail to what is needed to achieve better results. Probably the most important finding is the confirmation that higher adherence to ERAS guidelines results in the best outcomes. For major morbidity, overall morbidity a significant dose dependency with compliance is shown. This also holds true for infectious complications and specifically for surgical site infections, a main target for many units to control. In addition, the authors report a reduction in 30-day mortality, in line with data on short-term mortality benefits from Spain.4 This is a finding of obvious interest to all stakeholders not least the patients. While it seems logical this would be the case given the reduction in complications with ERAS, it takes large numbers for this to be revealed. These real-life data also help add information to another issue under debate. In this article, avoiding bowel preparation was shown to be an independent factor in reducing anastomotic leaks. It is also striking, again, how even basic care elements that all surgeons would expect to be functional in their practice, such as preoperative antibiotics, are not in place everywhere or perhaps not all the time.3 The same is true for a range of simple care elements as reported in the current article. This article points at what ERAS is all about in the end—delivering the right care on the floor, every day and for every patient. To reach this goal we need to know what is going on in detail all the time and make everyone aware their specific role in making this happen. Perioperative care is too complex, involves many care elements that all make a small but significant difference, and with too many people involved to be managed by guessing. It is knowing what is going on that is the only secure way forward. This is the approach of the ERAS Society (www.erassociety.org) successfully used in more than 30 countries worldwide. What the authors behind iCral has shown is that engaging many colleagues in recording ERAS-related items and publishing together seems to have had a very positive effect as well as indicated by the LOS data reported. It is gratifying to see how nicely implementation and research can work hand in hand to achieve both useful data and better clinical practice at the same time. In the end, we all need to know what is going on in our own practice to be ready to be responsible.