BackgroundEnhanced Recovery After Surgery (ERAS) programmes aim at an early recovery after surgical trauma and consequently at a reduced length of hospitalisation. This paper presents the protocol for a study that focuses on large-scale implementation of the ERAS programme in major gynaecological surgery in the Netherlands. The trial will evaluate effectiveness and costs of a stepped implementation approach that is characterised by tailoring the intensity of implementation activities to the needs of organisations and local barriers for change, in comparison with the generic breakthrough strategy that is usually applied in large-scale improvement projects in the Netherlands.MethodsAll Dutch hospitals authorised to perform major abdominal surgery in gynaecological oncology patients are eligible for inclusion in this cluster randomised controlled trial. The hospitals that already fully implemented the ERAS programme in their local perioperative management or those who predominantly admit gynaecological surgery patients to an external hospital replacement care facility will be excluded. Cluster randomisation will be applied at the hospital level and will be stratified based on tertiary status. Hospitals will be randomly assigned to the stepped implementation strategy or the breakthrough strategy. The control group will receive the traditional breakthrough strategy with three educational sessions and the use of plan-do-study-act cycles for planning and executing local improvement activities. The intervention group will receive an innovative stepped strategy comprising four levels of intensity of support. Implementation starts with generic low-cost activities and may build up to the highest level of tailored and labour-intensive activities. The decision for a stepwise increase in intensive support will be based on the success of implementation so far. Both implementation strategies will be completed within 1 year and evaluated on effect, process, and cost-effectiveness. The primary outcome is length of postoperative hospital stay. Additional outcome measures are length of recovery, guideline adherence, and mean implementation costs per patient.DiscussionThis study takes up the challenge to evaluate an efficient strategy for large-scale implementation. Comparing effectiveness and costs of two different approaches, this study will help to define a preferred strategy for nationwide dissemination of best practices.Trial registrationDutch Trial Register NTR4058

The aim of this study was to evaluate the feasibility of Enhanced Recovery After Surgery (ERAS) protocol in high-risk patients undergoing colorectal surgery, and to analyze the influence of clinical and demographic features on efficacy of a multimodal rehabilitation.

Objectives: To describe a process change and evaluate compliance with use of preventive analgesia and deep venous thromboembolic (DVT) prophylaxis in an ESRP pathway following implementation of order set. Methods: The ESRP at MD Anderson was initiated in the Department of Gynaecologic Oncology in November 2014. We used the following medications for preventive analgesia; pregabalin (neuropathic pain), celecoxib (non-steroidal anti-inflammatory), and tramadol (mu-opioid receptor, synthetic opioid). An order set was developed to include these medications in all patients undergoing gynaecologic surgery provided there were no contraindications. All patients were also written in the order set to receive subcutaneous heparin 5,000 units administered subcutaneously on arrival to the holding area. Medications were administered upon arrival in the preoperative holding area by the nursing staff. Training on the new order set was provided prior to ESRP rollout in November 2014 to members of the gynaecologic oncology team as well as to the nurses in the preoperative holding area. To improve adherence to the process change, a repeat training was performed for the clinic staff 6 weeks after implementation. Attending anaesthesiologist for the case had final say on the medications to be administered to the patients. Statistical analyses with Wilcoxon ranksum, Fisher's exact, and unpaired t test were used for comparisons. Results: All 272 patients on our ESRP pathway had order set completion at the time of arrival to the surgical holding area for preventive analgesia and DVT prophylaxis. The rate of administration of each of the pre-medications found in the order set were as follows: heparin 262 (96.3%), celecoxib 251 (92.3%), pregabalin 254 (93.4%), and tramadol 257 (94.5%), respectively. The reasons for failure to achieve full compliance in these were: contraindications or allergic reactions. Conclusion: Development of a specific order set in ESRP gynaecologic surgery programme demonstrated excellent compliance with order completion. However, as with any new process change, audits of process flow can identify areas for improvement.Objectives: Generalisability of enhanced recovery after surgery (ERAS) programmes has been widely demonstrated. Spread of ERAS from colorectal surgery towards other intra-organisational settings could be expected, particularly after running a quality improvement collaborative (QIC). To examine the influence of QICs on interdepartmental spread, we examined spread of ERAS from colorectal towards gynaecologic surgery. Methods: A retrospective observational multicentre study was performed in 23 Dutch hospitals. Data of a consecutive sample of gynaecologic oncology patients who underwent open surgery in 2012-2013 were collected per hospital. Hospitals of which colorectal surgical teams participated in a breakthrough project were included in the intervention group (n¼10). The hospitals that did not have followed this project acted as controls (n¼13). The breakthrough project was a multidisciplinary programme...