Introduction

Enhanced Recovery After Surgery (ERAS®) guidelines are evidence-based recommendations for preoperative, intraoperative, and postoperative care aimed at reducing length of stay (LOS), and improving patient outcomes following surgery¹. Studies have demonstrated that the implementation of ERAS programs improves outcomes in colorectal, pancreatic, thoracic, hepatic, gynecologic, and urologic surgery^2-5. Furthermore, ERAS programs have been found to be cost-effective by reducing LOS, readmission rates, and complications in hospitals around the globe⁶. The majority of previously published studies have involved individual sites, often in major centers⁷.

Alberta Health Services (AHS) is a single-payer public provincial health system responsible for healthcare provision for the province of Alberta, Canada. Alberta Health Services provides surgical care at 57 sites for a population of over 4 million people and an operating budget exceeding 15 billion dollars annually⁸. In 2013 AHS aimed to adopt a program that would improve surgical quality while attempting to curb spending and improve value in surgical care. After consideration of several programs, ERAS was chosen and implemented first in colorectal surgery⁶. ERAS was initially implemented in 2 lead hospitals followed closely with the addition of 4 hospitals ultimately representing 75% of all colorectal surgery in the province⁹. After demonstrating success in colorectal surgery⁷ the program was expanded to gynecologic oncology in November of 2016 and, following that it was expanded to pancreatic surgery, urologic surgery, and hepatic surgery. Implementation in obstetrics (cesarean delivery), benign gynecology, breast reconstructive surgery, head and neck cancer surgery, neonatal intestinal surgery, and cardiac surgery as well as other surgical fields is currently underway⁶.

This article will discuss the published outcomes of implementation of ERAS across multiple sites and surgical specialties in AHS, as well as the lessons learned while implementing this program on a systemic level. Finally, this review will discuss how the system wide implementation of ERAS in Alberta has shaped the landscape of ERAS internationally through development of guidelines used globally.

Patient-Centered Outcomes

The introduction of ERAS in colorectal surgery in Alberta demonstrated an improvement in LOS, surgical complication rates, and readmission compared to historical controls⁹. The first publication on patient outcomes following ERAS implementation in Alberta involved data on 978 colorectal patients from 6 hospitals. Patient outcomes were captured via ongoing audit using the ERAS Interactive Audit System (EIAS) and were compared to a historical cohort of 350 patients. Following ERAS implementation, the rate of surgical complications decreased from 56.9% to 45.3% (p=0.014). Median LOS following colorectal surgery decreased from 6 days (average 9.8 days) pre-ERAS to 5 days (average 7.5 days) post-ERAS implementation (p<0.0001). This reduction in LOS remained consistent even 15 months following implementation. Rate of post-operative readmission was also decreased from 17.5% in the pre-ERAS cohort compared to 9.6% post-ERAS implementation. Patients in the pre-ERAS group had a relative risk of readmission 30 days post-operatively of 1.73 (p=0.018) compared to patients in the post- ERAS group⁹. These benefits were demonstrated in association with an improvement in ERAS guideline compliance from 39% pre-ERAS to 60% post ERAS implementation.

Implementation of ERAS in gynecologic oncology surgery also demonstrated benefits in LOS, complications, and readmission. In November 2016 ERAS was implemented at the major gynecologic oncology centers in Alberta (Foothills Medical Centre, and Royal Alexandra Hospital). Outcomes of 367 patients following ERAS implementation were compared to 152 pre-ERAS patients. Immediate surgical complications decreased from 53.3% to 36.2% following ERAS implementation (p<0.001) without an increase in 30- day complications or readmission. Length of stay across the cohort decreased from a median of 4.0 days to 3.0 days following ERAS implementation with an adjusted decrease in LOS of 31.4% (p<0.0001). In medium and high complexity surgery median LOS decreased from 5.0 days to 3.0 days (p<0.0005). In low complexity surgery LOS decreased from 3.0 days to 2.0 days following ERAS implementation (p < 0.001). Compliance with ERAS guideline elements improved from 55% pre-ERAS to 76% post-ERAS implementation.

Systemic Outcomes

In addition to the demonstrated improvements in patient care and surgical outcomes, ERAS implementation in Alberta was also cost-saving. Both immediate and long term cost-effectiveness analyses of ERAS in colorectal surgery have been performed in Alberta^6,7,9. The initial phase of ERAS implementation in Alberta over 3 years included 1295 patients at 6 hospitals and was associated with a reduction in health system utilization. Overall net health system savings were estimated at $2,290,000 or $1798 per patient (all values reported in Canadian dollars, CAD). At that time it was estimated that every dollar invested in ERAS would yield $3.8 in savings (a return on investment ratio of 3.8)⁷.

In gynecologic oncology, ERAS saved an estimated $1862 per patient after implementation. The estimated cost of implementation in this population was $906 and yielded an estimated net cost savings of $956 with a return on investment ratio of 2.1¹⁰. The gynecologic oncology ERAS cost savings were lower per patient than demonstrated in colorectal surgery and this was thought to be due to the smaller economy of scale associated with the smaller volume of gynecologic oncology surgery relative to colorectal surgery in Alberta¹⁰.

Long-term economic analysis of ERAS in Alberta was reported in 2020 after province-wide implementation of ERAS guidelines for colorectal, pancreas, urology, liver, and gynecologic oncology procedures. This analysis involved 9 hospitals and 9406 patients between September 2013 and September 2018 who underwent ERAS surgery⁶. Over 5 years it was estimated that ERAS implementation was associated with a savings of $12.6 million in health care utilization in the 30 days following surgery. Costs of ERAS implementation from 2013 to 2018 were estimated at $5.38 million dollars for a net savings of $7.22 million dollars over 5 years ($768 per patient) in the first 30 days following surgery alone. The benefit of ERAS was more apparent when looking at health care utilization for the year following surgery where savings ranged from $26.35 to $3606.44 per patient. The return-on-investment ratio calculated for this cohort ranged between $1.05 and $7.31.

Lessons learned

Implementation of ERAS required communication and collaboration between multiple stakeholders and sites. Studies have looked at ERAS implementation in Alberta to identify enabling factors and barriers along the timeline of implementation^11,12. Barriers and enablers to implementation were identified at the level of the patient, care provider, organizational, and system level and early lessons in each area were acted upon to facilitate ongoing implementation and continued compliance with guidelines.

Focus groups of ERAS patients have demonstrated that patients were highly invested in working towards improving their own outcomes, but that they often were not given the information necessary to understand how to do this^11,13. Patients play a major role in their own nutrition, mobilization, and symptom control following an operation. Patients wanted to know as early as possible why it was important to maintain compliance with ERAS guidelines, and how to advocate for themselves to ensure this was possible. Standardized educational programs and materials in the early preoperative period were developed and sought to replace outdated, conflicting, and confusing information previously presented across multiple surgical sites. Consistent messaging using simplified chronologic materials was developed to facilitate patient education. ERAS educational materials continue to be updated with the goal of delivering consistent messaging for all individuals while still accommodating for differences in language, cognition, and geography¹¹. Patient stress surrounding surgery was also identified as a barrier to ERAS compliance¹³. Patient stress was related to fears about the surgery, financial worries associated with the surgery, bowel preparation for those with mobility issues or having to travel long distances, and lack of information. Stress reduction strategies aside from education are currently a subject of further research in Alberta¹³.

At the level of the care provider, many barriers to implementation related to clinical knowledge, provider motivation, resistance to change, and capacity building to support implementation were identified in Alberta¹¹. Common clinical knowledge deficiencies were identified in the areas of fluid management, pain and symptom control, modern fasting guidelines, mobilization, and carbohydrate loading. These barriers were effectively identified and, using a collaborative approach, addressed at monthly interdisciplinary meetings during implementation. For example, perioperative fluid management was identified as a gap in clinical knowledge (and was associated with low compliance within the ERAS protocol); this was managed with standardized education of care providers (notably residents), and implementation of new standard practice guidelines for nursing (ensuring daily weights were performed and normalizing the practice of locking off intravenous fluids when appropriate). Although identified as time-consuming, audit of outcomes played a crucial role in gaining staff buy-in. Demonstrating ongoing patient benefit helped with obtaining provider buy-in and influenced a culture-shift towards ERAS compliance¹¹. Lack of support for staff during implementation was identified as a barrier, and this led to the creation of site-based teams including funded ERAS nurse coordinator positions, and physician champions to provide feedback, education, and encouragement on the ward.

Ongoing challenges inherent with system-wide implementation include inconsistency in existing ERAS guidelines for different disease sites¹². Early challenges of inconsistent messaging and decision making were addressed by including senior management leadership on a provincial scale. By having the support of senior management, adjustments could be made on a system wide level to better support frontline staff during implementation, including reallocating resources for the essential nurse-coordinator position. Consistent communication within and across teams was essential for implementation both within sites and across the province. Leadership on a local, hospital, and provincial level is essential to ensuring sustainability of ERAS programs beyond initial implementation. This has been accomplished by ongoing ERAS audit, and establishing ERAS practice as standard of care by demonstrating ongoing improved patient outcomes and healthcare savings¹².

Our experience has demonstrated that when assessing economic impact on ERAS it is important to have a broad longitudinal assessment of total healthcare utilization. Looking at only the first 30 days of utilization following surgery runs the risks of underestimating savings associated with ERAS as many of the health care savings are found within the first 180 days following surgery⁶.

Global Impact

The implementation of ERAS at AHS has not only improved patient and system outcomes in Alberta; the lessons learned from implementing ERAS across the province have led to numerous academic outputs. Alberta ERAS clinicians have developed and published ERAS guidelines for gynecologic oncology^14,15, cesarean delivery¹⁶, head and neck cancer surgery¹⁷, and breast reconstruction surgery¹⁸. Ongoing audit and feedback has enabled researchers in Alberta to publish on outcomes of ERAS implementation^6,9,10 as well as studies of patient and provider perceptions about the implementation^11-13.

Conclusions

The implementation of ERAS in the Alberta Health System has demonstrated value by improving perioperative outcomes while saving money relative to historical care. Experience gained with province wide implementation has led to numerous publications by Alberta researchers thereby establishing Alberta as a world leader in ERAS. Early evidence demonstrates ongoing compliance with these programs for several years after initial implementation, but this ongoing culture shift has required dedication and leadership at the provincial, hospital, provider, and patient-level. Consistent communication, education, leadership, and demonstration of value are essential to ensure buy-in and compliance in clinical practice. Further research on outcomes and cost-savings is ongoing regarding implementation in other surgical specialties and in smaller and rural community hospitals. Methods to achieve sustained ERAS clinical gains and improved compliance across the entire healthcare system are needed.