Title : ERAS compliance in elective colorectal surgery: Assessment, protocol development, and impact on post-operative outcomes. A closed-loop audit
Abstract:
Background: Enhanced Recovery After Surgery (ERAS) is an evidence-based, multimodal perioperative care pathway proven to reduce complications, shorten hospital stays, and improve patient experience following colorectal surgery. Despite the strength of the evidence, compliance with ERAS principles varies considerably across clinical teams and settings. Incomplete adherence has direct financial consequences: each postoperative complication following colorectal surgery adds substantial cost to an already resource-pressured NHS. We undertook a closed-loop audit to assess compliance with ERAS Society guidelines at our unit, identify knowledge gaps, implement a targeted intervention, and measure the impact through a re-audit.
Methods: The initial cycle was a retrospective audit of 61 patients who underwent elective colorectal resection at Countess of Chester Hospital between June and December 2024. Compliance with 22 ERAS data points was assessed across the perioperative pathway using EPR records, operative notes, anaesthetic charts, and discharge summaries, benchmarked against ERAS Society guidelines. A staff knowledge quiz was administered to 34 multidisciplinary team members to identify educational gaps. Findings were presented at a departmental Morbidity and Mortality meeting in August 2025. Following discussion, a standardised, locally applicable ERAS protocol was developed and formally agreed at departmental level, with dissemination to surgical wards and the intensive therapy unit. A daily ward round checklist was also introduced to embed ERAS principles into routine post-operative care. A retrospective re-audit of 36 patients treated between September and December 2025 was then conducted using identical methodology.
Results: The baseline audit showed variable compliance. Opioid-sparing analgesia was used in 63.9 percent of patients, early mobilisation in 68.9 percent, and abdominal drains were avoided in only 39.3 percent. The overall post-operative complication rate was 41 percent (25/61), with a 30-day readmission rate of 18 percent and a mean length of stay of 10 days. The staff knowledge quiz identified key gaps in drain use (70.6%), antibiotic timing (76.5%), and pre-operative fasting guidance (85.3%). Following implementation of the standardised ERAS protocol and targeted education, the re-audit demonstrated marked improvements. Opioid-sparing analgesia increased to 91.7 percent (from 63.9%), early mobilisation within 24 hours to 83.3 percent (from 68.9%), and early oral intake reached 100 percent (from 91.8%). Pre-operative education was documented in 100 percent of patients. Most significantly, the post-operative complication rate fell from 41 percent to 16.7 percent (6/36), representing a reduction of more than half. The 30-day readmission rate remained comparable at 19.4 percent, reflecting the multifactorial nature of readmission.
Conclusions: Development and implementation of a standardised, locally agreed ERAS protocol, supported by targeted staff education and a structured ward round checklist, led to significant and sustained improvements in ERAS compliance across the perioperative pathway. The reduction in post-operative complications from 41 percent to 16.7 percent is clinically meaningful and carries direct cost implications: with each complication-related extended stay costing the NHS thousands of pounds, preventing complications in this cohort alone represents substantial savings in direct healthcare costs, reduced critical care utilisation, and improved bed availability. This project demonstrates how structured quality improvement work, combining data-driven identification of gaps with multidisciplinary engagement and protocol standardisation, can translate evidence into measurable improvements in patient outcomes. The framework is practical and replicable across other surgical units aiming to optimise ERAS delivery.
Keywords: ERAS; colorectal surgery; quality improvement; clinical audit; protocol; post-operative complications; NHS; perioperative care
