ERAS Protocols Are Proven Effective, but Implementation Is Challenging

For a surgeon, the most challenging part of treating a patient may be the time from initial incision to wound closure.

For a patient, the most difficult part of the surgical process is—in most cases—recovery, including managing the pain, discomfort, potential nausea and vomiting, and returning to normal function.

With patient-centered care now a mandate, the surgeon and surgical care team are more closely aligned with the wants and needs of the patients in all phases of care, and efforts are being made to implement enhanced recovery after surgery (ERAS) protocols in an increasing number of cases.

ERAS protocols are standardized perioperative programs designed to reduce surgical stress, improve recovery, and have the patients return to functional health status more quickly. Most surgeons have an awareness of enhanced recovery, but what is the state of this multidisciplinary approach to perioperative care today, and what comes next?

State of the Art

ERAS is a nascent area of focus for healthcare, having been introduced in the 1990s (then referred to as “fast-track recovery,” which emphasized speed of return to functionality¹); it was formalized in the 2000s, led by groups such as the ERAS Society.

Myriad data and thousands of research studies have been conducted on the beneficence of various ERAS initiatives, and studies continue to emphasize their scope and effectiveness. Recent evidence continues to refine how enhanced recovery is conceptualized, but modern understanding reiterates that interventions span the scope of care.

The interventions can include carbohydrate loading and smoking cessation in the preoperative phase, minimally invasive techniques and euvolemia in the intraoperative phase, and early feeding and mobilization and opioid-sparing analgesia in the postoperative phase.² When successfully implemented, the protocols are shown to be effective.

“Contemporary research shows that we have better clinical outcomes such as reduced length of stay, readmission, and complications, which many times lead to better patient satisfaction,” said Jennifer Holder-Murray, MD, FACS, FASCRS, a colorectal surgeon, vice chair of quality integration, and surgical director of the Center for Perioperative Care at the University of Pittsburgh Medical Center (UPMC) in Pennsylvania.

A cursory literature review, focusing on only the last few years, suggests that enhanced recovery protocols can make a difference in quality indicators and patient experience across surgical domains—from colorectal surgery³ to cardiac surgery,⁴ from hip and knee arthroplasty⁵ to cesarean sections,⁶ and from craniotomies⁷ to emergency laparotomy.⁸

And even as these disease- and system-specific data continue to grow, high-quality literature reviews are strengthening the argument for the foundational impact of enhanced recovery by presenting the average estimated outcomes of these interventions.

Khara Sauro, PhD, an associate professor at the University of Calgary Cumming School of Medicine in Alberta, Canada in 2024, was the lead author on a meta-analysis of randomized clinical trials—the highest level of evidence for effectiveness of interventions—that explored the impact of ERAS on length of stay, readmission, and complications.⁹

“The findings of our systematic review were that enhanced recovery decreases hospital length of stay on average by about 2 days, which is remarkable, and can decrease complications by about 30%,” Dr. Sauro said, adding that the protocols did not increase readmission.

“I think what we can glean from both this study and some of the other research that we’ve done around synthesizing the evidence for ERAS is that this is a viable option for improving the quality of care for patients who are undergoing surgeries that are guided by ERAS guidelines,” she said.

Spanning Specialties, Aggregating Improvements

Despite differences in each discipline’s anatomical area of focus, core ERAS elements are mostly similar across specialties.

Cardiothoracic surgeon Daniel T. Engelman, MD, medical director of the cardiac surgical critical care unit and inpatient surgical services at Baystate Health in Springfield, Massachusetts, and founder and president of the ERAS Cardiac International Society, explained that cardiac surgery ERAS protocols also focus on goal-directed fluid therapy due to the large amount of fluid given during the cardiac procedure.

“Other than that, our enhanced recovery protocols are remarkably similar,” he said. Looking at fasting before surgery as an example, he noted that surgeons from every specialty now say that prolonged fasting should be avoided.

“We used to tell everyone to be NPO after midnight, no matter what time their surgery was—but that left patients miserable and slightly dehydrated, which didn’t help their kidney function. We’ve since learned that giving carbohydrate loading up to two hours before surgery reduces glucose variability, improves metabolism, and helps prevent dehydration. The body needs carbohydrates to manage the stress of surgery,” he shared.

Regardless of the intervention, patients can benefit by incorporating additional elements. As Dr. Engelman noted, the aggregation of marginal gains—a concept introduced by the British cycling team¹⁰—can provide for many smaller changes that lead to a large overall positive effect.

“By decreasing opioid use through multimodal analgesia, we can remove the breathing tube sooner, mobilize patients more quickly, reduce the risk of delirium, and help bowel function return faster. Ultimately, patients leave the ICU and get out of bed earlier. A small change upstream can improve everything downstream,” he said.

Care does need to be taken to ensure that patients are experiencing the maximum benefit of each intervention, however, and that they are working together, like a finely made soup.

“Patients benefit from a whole ‘recipe,’” Dr. Holder-Murray said. “It takes a lot of good ingredients to make the soup and ensure components together all enhance each other, thus achieving a better result by working together synergistically.”

And while the positives of these primary outcomes are self-evident and plentiful for surgeons and patients, the reduced length of stay, lower rate of complications, and other outcomes are also proving to have an important secondary outcome—reducing costs for hospitals and health systems. The data vary widely based on the procedure, but studies suggest that the cost savings could be in the thousands of dollars per patient.¹¹

“We want to show payers that investing upfront in these protocols yields a significant return,” Dr. Engelman said. “Avoiding readmissions, rehabilitation stays, and skilled nursing facility admissions by getting patients home sooner ultimately saves substantial costs on the back end.”

Start Early, Build Multidisciplinary Team

Some of the most important modern developments in the understanding of a successful ERAS program have been in finding the right time to introduce interventions and building the team to conduct the daily work before, during, and after an operation.

For timing, the right time is simple—enhanced recovery should be a consideration from the very first point of contact between the surgeon and the patient.

“We often focus on the postoperative phase, because many of our colleagues haven’t been fully aware of what can be done before or even during surgery,” Dr. Engelman said. “Patients would arrive in the hands of perioperative specialists, and we’d do our best with the situation as it stood. But if we truly want to get this right, it needs to begin the moment a surgeon first meets the patient in the preoperative setting.”

Starting with basics of smoking cessation, exercise, nutrition monitoring, and protein supplementation, patient education can have a dramatic impact on a patient’s preparedness for surgery—something that the ACS supports through its Strong for Surgery^® checklist system that screens for risk factors that can lead to postoperative surgical complications.¹²

To create an effective and sustainable program and one that starts the patient down the path of enhanced recovery as early as possible, it is critical that surgeons and their support staff build multidisciplinary teams.

“The first and foremost thing needed is for a surgeon, the hospital, or a specialty to find a multidisciplinary care team that is engaged and then get buy-in from the core team,” Dr. Holder-Murray said.

“The team doesn’t need to be huge, but it needs to have a few people who can make a difference and whose voices are positive,” she added, noting that in her work to implement ERAS at UPMC, she and an anesthesia colleague sought out nursing unit directors, a preoperative nurse leader, a pharmacist, and some office staff for their initial team.

Although it started small, its members were influential in their spaces and were able to create successful enhanced recovery workflows. From there, they took efforts to share their successes in changing surgical dogma.

A strong, effective team is particularly important for ERAS because healthcare and surgery have historically been siloed between aspects of patient care.

“We had a physical therapy team, a nutrition team, pharmacy, physicians, advanced practitioners, and nurses—but each operated in their own silo, following separate hierarchies, and writing their own orders,” Dr. Engelman said. “We’re trying to bring that all together where everybody has a piece of this care, but everybody is pushing in the same direction. There’s a big push toward multidisciplinary rounding with a person from each of these teams rounding together with the patient.”

Compliance, Audit, and Feedback

Despite a growing record of success, implementation of ERAS programs and subsequent compliance with the protocols are not seeing the penetration into health systems that reflect the positive findings.¹³

Compliance with ERAS protocols is a focus of Dr. Sauro’s work, which has found that even in recognized enhanced recovery centers of excellence, there are struggles with adhering to standards.

She noted that her team has worked through a Canadian Institutes of Health Research grant on research using data from their province, which is population-based and complete. They compared it with data from both Switzerland and the Netherlands to see how compliant care is across multiple types of surgeries.

“Even in these centers of excellence where there’s a lot of buy-in for ERAS, compliance is only moderate,” she said.

Dr. Sauro, whose background is in implementation science, said that for broadly applicable interventions like enhanced recovery, it is important to understand barriers and facilitators to implementing and maintaining innovation.

Because there is a paucity of data on the barriers to using enhanced recovery protocols, Dr. Sauro and her team developed some of their own through surveys and found that barriers are familiar to those seen in implementing other medical guidelines:

• Knowledge: Lack of awareness that ERAS guidelines exist for a certain type of surgery and understanding of recommended care
• Resources: Insufficient resources available to deliver care, especially as healthcare systems are increasingly strained
• Institutional support: Lack of top-down support and influence of healthcare leaders who express their desire to align with ERAS guidelines

“Creating strategies to overcome those barriers and leverage any facilitators, like the belief in benefits from implementing ERAS, are what’s going to improve the implementation and compliance with guidelines,” Dr. Sauro said, adding that as compliance increases, so does the improvement in patient outcomes.

As with many aspects of modern medicine, especially in the evidence-based quality improvement that the ACS and other pillars of healthcare oversee, some of the most effective facilitators for success are audit and feedback.

“In implementation science, we know that that audit and feedback are very effective at sustaining an intervention. When you start rolling out ERAS guidelines, if there is that audit and feedback element, it’s more likely to continue to be successful and can support slight changes in the pathways as needed,” Dr. Sauro said.

While an effective audit can continue successful program integration, its lack thereof can quickly lead to a less- effective process, or even a reversion to the pre-intervention state.

“You have to audit these interventions continuously—every month,” Dr. Engelman said. “It’s essential to track the outcomes, because the moment you take your eye off the process, things start to regress.”

Data and feedback—and making sure to share success stories about enhanced recovery—also are key for increasing resources and institutional support, which go hand in hand.

“Success builds on success, so share your wins,” Dr. Holder-Murray said. “That helps to create buy-in from executive leadership, and when you can demonstrate something that they see impacts not only patient care, but also the dollars they need to care for more patients—then it’s meaningful to them.They really see value in higher quality of care and lower cost of care together. Sharing your success stories in ways that speak to them is important.”

Even with a preponderance of evidence, some surgeons may not be fully invested in changing their practice or going outside their comfort zone. In those cases, Dr. Engelman said, surgeon champions can appeal to their colleagues’ desire to not be an outlier.

“It turns out that physicians, especially surgeons, don’t like to be outliers, and if they see that surgeon A is getting their patients home quicker and using less opioids, and they are surgeon B who is using more opioids, and the patients are in the hospital a little longer, they will change their behavior,” he said.

Looking Forward

Two thoughts become clear when reviewing the latest best practices and research in ERAS—the protocols are effective, but a lack of implementation and compliance are holding them back from achieving maximum patient, surgeon, and health system benefit.

At Baystate Health, Dr. Engelman and his colleagues are working to reduce friction in implementation by providing clear instructions to care teams. They have been publishing turnkey order sets on topics, including surgical site infection, prevention, and management of postoperative atrial fibrillation after surgery,^14,15 and other topics for cardiac surgeons in peer-reviewed journals that are free to access.

“We provide programs with specific bedside orders to implement enhanced recovery—not just general recommendations to limit opioids,” he said. “We outline the exact medications, dosages, and order sets so they can easily integrate them into their electronic medical record systems.”

There is a similar refrain elsewhere—to increase the scale and spread of enhanced recovery protocols, they need to be packaged in a simple, easier-to-access manner.

“We are developing a toolkit that will make it easier for sites to implement ERAS guidelines. Having tangible tools that they can rely on, which are evidence-based in implementation science, but are also pragmatic and practical, is key,” Dr. Sauro said.

Implementing a full suite of ERAS protocols can be a complex undertaking due to the many changes that would be required in pre-, intra-, and postoperative processes, but patients could receive benefits if a hospital is able to follow a few key principles.

Dr. Sauro shared that she and her team are involved in research aimed at highlighting a limited number of key elements that will provide surgeons and patients with considerable benefit right away.

“The other elements are critical as well. But if you can only do so much, here’s what you should do, and ideally that will make it easier to implement ERAS at more centers, especially the centers that may not have the resources or money to implement them otherwise,” Dr. Sauro said.

Dr. Holder-Murray emphasized that successful patient care starts long before the patient arrives in the OR. “It starts before surgery, and it continues afterward. As surgeons, we need to lead this effort from beginning to end, but it takes a team to sustain. Sometimes we must step back and realize that there are many components here and other people that are going to execute various components, and then we must rely on those colleagues to further drive the message and drive the ERAS practice—realizing the patient’s success is key.”

Matthew Fox is the Digital Managing Editor in the ACS Division of Integrated Communications in Chicago, IL.

References

1. Engelman RM, Rousou JA, Flack JE 3rd, et al. Fast-track recovery of the coronary bypass patient. Ann Thorac Surg. 1994;58(6):1742-1746.
2. Elias KM, Brindle ME, Nelson G. Enhanced Recovery after Surgery - evidence and practice. NEJM Evid. 2025;4(3):EVIDra2400012.
3. Antoniv M, Nikiforchin A, Sell NM, et al. Impact of multi-institutional enhanced recovery after surgery protocol implementation on elective colorectal surgery outcomes. J Am Coll Surg. 2025;240(2):158-166.
4. Grant MC, Crisafi C, Alvarez A, et al. Perioperative care in cardiac surgery: A joint consensus statement by the enhanced recovery after surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS) [published correction appears in Ann Thorac Surg. 2024;118(2):524-525]. Ann Thorac Surg. 2024;117(4):669-689.
5. Zhang Q, Chen Y, Li Y, et al. Enhanced recovery after surgery in patients after hip and knee arthroplasty: A systematic review and meta-analysis. Postgrad Med J. 2024;100(1181):159-173.
6. Pinho B, Costa A. Impact of enhanced recovery after surgery (ERAS) guidelines implementation in cesarean delivery: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2024;292:201-209.
7. Kim SH, Choi SH, Moon J, Kim HD, Choi YS. Enhanced recovery after surgery for craniotomies: A systematic review and meta-analysis. J Neurosurg Anesthesiol. 2025;37(1):11-19.
8. Amir AH, Davey MG, Donlon NE. Evaluating the impact of enhanced recovery after surgery protocols following emergency laparotomy - A systematic review and meta-analysis of randomised clinical trials. Am J Surg. 2024;236:115857.
9. Sauro KM, Smith C, Ibadin S, et al. Enhanced recovery after surgery guidelines and hospital length of stay, readmission, complications, and mortality: A meta-analysis of randomized clinical trials [published correction appears in JAMA Netw Open. 2024 Jul 1;7(7):e2428433.
10. Clear J. Marginal gains: This coach improved every tiny thing by 1 percent. James Clear. Published January 6, 2014. https://jamesclear.com/marginal-gains
11. Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced recovery after surgery (ERAS) protocols: Time to change practice?. Can Urol Assoc J. 2011;5(5):342-348.
12. American College of Surgeons. Strong for Surgery. ACS. https://www.facs.org/quality-programs/strong-for-surgery/.
13. Shah TA, Knapp L, Cohen ME, Brethauer SA, Wick EC, Ko CY. Truth of colorectal enhanced recovery programs: Process measure compliance in 151 hospitals. J Am Coll Surg. 2023;236(4):543-550.
14. Crisafi C, Grant MC, Rea A, et al. Enhanced Recovery after Surgery Cardiac Society turnkey order set for surgical-site infection prevention: Proceedings from the American Association for Thoracic Surgery ERAS Conclave 2023. J Thorac Cardiovasc Surg. 2024;168(5):1500-1509.
15. Chatterjee S, Cangut B, Rea A, et al. Enhanced Recovery after Surgery Cardiac Society turnkey order set for prevention and management of postoperative atrial fibrillation after cardiac surgery: Proceedings from the American Association for Thoracic Surgery ERAS Conclave 2023. JTCVS Open. 2024;18:118-122. Published February 19, 2024.