Adherence to an enhanced recovery protocol in colorectal surgery before and during a structured implementation – a prospective cohort study from nine German hospitals

Objectives: Enhanced recovery protocols (ERP) are considered as state of the art in perioperative management of elective colorectal resections. However, adoption of ERP in the clinical routine is not easy and a structured implementation process is recommended. The aim of the present data analysis was to evaluate the learning curve of the structured implementation of an enhanced recovery protocol in elective colorectal resections based on adherence to recommended ERP elements and clinical outcomes. Methods: During a 12-month structured implementation of an ERP in nine hospitals, perioperative management data were prospectively documented. Patients during the 3-month preparation phase were differentiated as a comparison group with traditional management from patients during the clinical ERP implementation. In addition, the 9-month ERP application phase was divided into three equal sections. Adherence to 23 recommended ER elements and to the pre-, intra- and postoperative elements was calculated. Results: One thousand one hundred fifty-three patients (48.3 % female) were included. Traditional perioperative treatments were applied in 313 patients (preERP), while 840 patients (249, 297 and 294 during months during the first [ERP3], second [ERP6] and last 3 months [ERP9] interval) were treated according to the enhanced recovery protocol. Overall preERP ERP-adherence was 52 (IQR: 48-57)% in 9 hospitals but increased to 87 (78-91)% at the end of ERP-implementation. Functional recovery after surgery increased from preERP to ERP9, and postoperative length of stay was reduced from 7 (6 - 8) to 5 (5 - 7) days. Major improvements in overall and preoperative ERP adherence were achieved during the first 3 months, while postoperative ERP adherence took 6-9 months to reach best results. Conclusions: Structured implementation of an enhanced recovery protocol resulted in high adherence to 23 ERP-elements within 12 months. Although major achievements occurred during the first 3 months of clinical ERP utilization, a total of 9 months are needed especially to improve postoperative ERP-adherence.