Background Enhanced recovery programme (ERP) after surgery needs development in Assistance Publique Hôpitaux de Paris (APHP). Methods A retrospective before-and-after study was performed in 2015 and 2017 on three surgical models (total knee arthroplasty (TKA), colectomy and hysterectomy) in 17 hospitals including 29 surgical departments. Data were collected in one control intervention (total hip arthroplasty (THA), gastrectomy and ovariectomy). In 2016, Massive Open Online Course on ERP and a day meeting information were developed by APHP. A national update on ERP was also organized by HAS and a regional professional partnership programme was started. Primary outcomes were length of stay (LOS) and complications after surgery. Data on ERP items were collected in the patients’ chart and in anaesthetist and surgeon interview. Seventy percent application rate reflects application of ERP procedure. Results 1321 patient’s files were analysed (812 in 2015 and 509 in 2017). The LOS (mean (SD)) is reduced by 1.6 day for TKA (2015, 8.7 (6.7) versus 7.1 (3.4) in 2017; p<0.001) but stable for colectomy and hysterectomy. Incidence of severe complications after surgery is unchanged in all types of surgical models. For TKA and hysterectomy respectively applied items of ERP (i.e. >70% application) increased respectively from 5 to 7 out of 17 and 16 in 2015 and 2017. For colectomy, they were stable at 6 out of 21 in 2015 and 2017. The mean application rates of ERP items stayed below 50% in all cases in 2017. The LOS was negatively correlated with ERP items’ application when data collected in 2015 and 2017 were analysed together. Conclusion ERP application did not significantly improved between 2015 and 2017 for three surgical models after an institutional information and diffusion of recommendations in 29 surgical departments of seventeen French University hospitals underlining the limit of a top-down approach.

Background: Enhanced recovery program (ERP) after surgery needs development in Assistance Publique Hôpitaux de Paris.Methods: a retrospective before-and-after study was performed in 2015 and 2017 on three surgical models (total knee arthroplasty (TKA), colectomy, and hysterectomy) in 17 hospitals including 29 surgical departments. For each elective surgery, data were collected in one control intervention (Total hip arthroplasty (THA), gastrectomy and ovariectomy).To favour development of ERP strategy, in 2016, institutional mobilization developed with one day meeting of information, development of a Massive Open Online Course on ERP, diffusion of national update on ERP by Haute Autorité de Santé and inclusion in a regional professional partnership program. Primary outcomes were length of stay (LOS) and complications after surgery. Data on ERP items were collected in the patients’ chart and in anaesthetist and surgeon interview. 70 % application rate reflects application of ERP procedure.Results: 1321 patient’s files were analysed (812 in 2015 and 509 in 2017). The length of stay (LOS, mean (SD)) is reduced by 1.6 day for TKA (2015: 8.7 (6.7) versus 7.1 (3.4) in 2017; p<0.001) but increases of 0.5 day for THA (2015: 8.2 (4.1) versus 8.7 (15.5) in 2017; p=0.011). LOS is stable for colectomy and hysterectomy as in their control groups (i.e. gastrectomy and ovariectomy). Incidence of severe complications after surgery is unchanged in all type of surgical models except in THA patients (11.1% in 2015 and 1.5% in 2017, p=0.029). For TKA and hysterectomy respectively applied items of ERP (i.e: >70% application) increased respectively from 5 to 7 out of 17 and 16 in 2015 and 2017. For colectomy, they were stable at 6 out of 21 in 2015 and 2017. All centres progressed in ERP between 2015 and 2017 for TKA (7/7 centres) and hysterectomy (6/6 centres). The LOS was negatively correlated with ERP items application when data collected in 2015 and 2017 were analyzed together.Conclusion: ERP application improved between 2015 and 2017 for three surgical models after an institutional information and diffusion of recommendations in 29 surgical departments of seventeen French University hospitals