Enhanced Recovery After Surgery Program Significantly Improves Outcomes

    A study published in JAMA Surgery has demonstrated the value of a comprehensive Enhanced Recovery After Surgery (ERAS) program.

    Implemented in Kaiser Permanente’s 20 Northern California medical centers, the program involved nearly 9,000 surgical patients and resulted in a one-third relative reduction in postoperative complication rates and a 21% reduction in opioid prescribing rates.

    In addition, the study showed decreased hospital mortality among colorectal resection patients and increased rates of home discharge over discharge to skilled nursing facilities among hip fracture patients.

    “Ensuring patient safety is essential in US surgical care, where millions of inpatient procedures are performed annually and where perioperative complications are common and costly,” said lead author Vincent Liu, MD, of the Kaiser Permanente Northern California Division of Research.

    “All-inclusive approaches to surgery like this ERAS program aim to reduce the stress of surgery, reduce complications and maximize the potential for recovery.”

    Multidisciplinary Approach

    The Kaiser Permanente ERAS program, funded in part by the Betty & Gordon Moore Foundation, was designed and led by a multidisciplinary team of clinicians, performance improvement staff, and patient education staff. The program focuses on improving pain management, mobility, nutrition, and patient engagement.

    “In my 24 years as a surgeon, this has been the biggest change in our clinical practice,” said co-author Efren Rosas, MD, surgeon champion for Kaiser Permanente’s ERAS program.

    “For decades, surgeries were guided by commonly held principles including no food after midnight the night before surgery, strong opioids for pain management and bed rest for recovery.

    “The elements of an ERAS program — alternative medications for pain control, avoiding prolonged fasting, and encouraging walking — have been shown to reduce complications like blood clots, muscle atrophy, nausea, confusion, delirium and infection.”

    Focus Areas of the Program

    The pain management protocol involves opioid-sparing interventions using pain-relief alternatives including intravenous acetaminophen, non-steroidal anti-inflammatory drugs, intravenous lidocaine, and peripheral nerve blocks.

    Patients are also encouraged to begin walking within 12 hours of surgery and maintain a daily goal of walking at least 21 feet within the first 3 days of surgery.

    Efforts to reduce prolonged pre-surgical fasting include the use of a high-carbohydrate beverage within 2 to 4 hours before surgery. Postoperative nutrition is provided within 12 hours after surgery.

    To improve engagement in their care, an illustrated calendar is distributed to patients so they know what to expect from the night before surgery through hospital discharge. An informational video series also was designed to improve patient education and active involvement with recovery.

    2 Very Different Surgical Populations

    Program implementation started in 2014 and was completed over the course of 1 year among 2 surgical populations: colorectal surgery and hip fracture repair.

    A total of 3,768 elective colorectal resection patients and 5,002 emergent hip fracture repair patients were included in the study, as were 5,556 comparison surgical patients for elective gastrointestinal surgery and 1,523 for other types of emergency orthopedic surgery.

    ERAS patients demonstrated significant gains after the implementation of the program:

    • The rate of early ambulation increased among colorectal patients (34%) and hip fracture patients (18%).
    • The rate of early nutrition increased 26% for colorectal surgery patients and 12% for hip fracture patients.
    • The total dose of opioids decreased significantly in both surgical groups.
    • Hospital length of stay was significantly reduced among colorectal surgery and hip fracture patients.
    • There was a one-third reduction in relative postoperative complication rates.

    “This study demonstrates the effectiveness of a systems-level approach to an enhanced recovery program implementation, even across widely divergent target populations,” said senior author Stephen Parodi, MD, associate executive director of The Permanente Medical Group.

    “While prior studies have had limited ability to evaluate program implementation at scale in real-world settings, we were able to evaluate care patterns in over 16,000 surgical patients over a 2-year period. We were able to demonstrate the feasibility of large-scale ERAS program implementation over a relatively short interval because of the collaboration of thousands of clinicians.”


    Liu VX, Rosas E, Hwang J, et al. Enhanced recovery after surgery program implementation in 2 surgical populations in an integrated health care delivery system. JAMA Surg. 2017 May 10:e171032. doi: 10.1001/jamasurg.2017.1032. [Epub ahead of print]