Impact of a Colorectal Enhanced Recovery Program Implementation on Clinical Outcomes and Institutional Costs: A Prospective Cohort Study With Retrospective Control

Introduction The Enhanced Recovery Program (ERP) is a scientific evidence-based perioperative care approach based on multidisciplinary team working and multimodal methodology, with the aim to reduce metabolic response to surgical stress and organ dysfunction induced by surgery, thereby accelerating postoperative recovery. Consequently, the hospital length of stay (LOS) after surgery would be significantly reduced, with no increase in morbidity and mortality rates 2-4 resulting in a potential economic benefit.

Although the concept of enhancing recovery after surgery implementing specific pathways is now widely recognized, the diffusion of ERPs is still limited to Northwestern Europe, USA, and Canada, and slightly less common in Southern Europe, where it prevails in Spain, Portugal, and Italy.

The implementation of an ERP relies on the establishment of a motivated multidisciplinary team including surgeons, anesthesiologists, and nurses who agree on the end points of management and act in close coordination throughout the perioperative phases (outpatients clinic, preoperative unit, operating theater, postoperative recovery room, surgical ward). It has been shown that compliance to the elements of the ERP protocol correlates with clinical outcomes.

The aim of this study is three-fold: 1) to investigate the impact of the colorectal ERP implementation in an Italian University hospital, on postoperative recovery, evaluating the efficacy (functional recovery, LOS), the safety (postoperative complications, 30-day readmission and mortality), the adherence to the protocol, the nursing workload, and the cost-effectiveness; 2) to assess the predictive factors of prolonged hospital LOS after colorectal resection; and 3) to measure patients' satisfaction in the ERP group.

Methods A prospective series of patients (N=100) undergoing elective colorectal resection and completing a standardized ERP in 2013-2015 (ERP group) at the S. Anna University Hospital in Ferrara (Italy) will be compared to a retrospective series of patients (N=100) operated on at the same academic hospital in 2009-2011 (Pre-ERP group), and before the introduction of ERP methodology. The Italian Ministry of Health will fund this study, which will begin in January 2013. In 2012 the ERP multidisciplinary team was built, the ERP protocol was prepared, and informative meetings were scheduled. All consecutive patients between the ages of 18 and 79 years of age and scheduled for elective colorectal resection will be enrolled for the study. The exclusion criteria for both groups are: age >80 years old, American Society of Anesthesia (ASA) score IV, Tumour Node Metastasis (TNM) stage IV, inflammatory bowel disease.