Abstract
Limited surgical capacity remains a major barrier to timely care, particularly in resource‐constrained health systems. An estimated five billion people lack access to safe and affordable surgical care, emphasizing the need to improve efficiency within existing resources. Enhanced recovery after surgery (ERAS) pathways improve postoperative recovery through standardized perioperative care, and higher protocol adherence is associated with better clinical outcomes. However, the broader health‐system effects of ERAS adherence, particularly on hospital bed utilization and surgical capacity, remain insufficiently quantified. This study evaluated the association between ERAS adherence and postoperative outcomes and estimated its impact on hospital bed utilization.
1. Introduction
Limited surgical capacity remains a major barrier to timely care, particularly in resource‐constrained health systems. An estimated five billion people lack access to safe and affordable surgical care, emphasizing the need to improve efficiency within existing resources [1, 2, 3]. Enhanced recovery after surgery (ERAS) pathways improve postoperative recovery through standardized perioperative care, and higher protocol adherence is associated with better clinical outcomes [4, 5, 6, 7, 8]. However, the broader health‐system effects of ERAS adherence, particularly on hospital bed utilization and surgical capacity, remain insufficiently quantified [9, 10]. This study evaluated the association between ERAS adherence and postoperative outcomes and estimated its impact on hospital bed utilization.
2. Methods
This secondary analysis included adults undergoing common gastrointestinal surgery at a tertiary care hospital in India between August 2022 and October 2023. Patients undergoing appendectomy, cholecystectomy, hollow viscus perforation repair, or intestinal obstruction surgery were included. Both emergency and elective procedures were analyzed.
Perioperative care was assessed using seven ERAS elements: early oral feeding, early mobilization, avoidance of prolonged nasogastric tube use, early urinary catheter removal, appropriate antibiotic prophylaxis timing, avoidance of excessive intravenous fluid administration, and avoidance of routine surgical drains. Patients were categorized into low (0–2 elements), moderate (3–4), and high (5–7) adherence groups. Common clinical reasons for ERAS deviation are summarized in Supporting Information S1: Table S1.
The primary outcome was occurrence of any postoperative complication during index admission. Secondary outcomes included postoperative length of stay and healthcare resource utilization. Multivariable logistic regression adjusted for age, ASA class, surgical urgency, and procedure type. Health‐system impact was estimated using postoperative length of stay. Preoperative carbohydrate loading was excluded as an ERAS component.
3. Results
A total of 522 patients were included: 176 (33.7%) low adherence, 208 (39.8%) moderate adherence, and 138 (26.4%) high adherence. Most procedures were emergency operations (68.6%), particularly in the low‐adherence group. Baseline characteristics are presented in Table 1.
TABLE 1.
Baseline demographic, clinical, surgical, and perioperative characteristics according to ERAS adherence (n = 522).
| Variable | Overall (n = 522) | Low ERAS (n = 176) | Moderate ERAS (n = 208) | High ERAS (n = 138) | p value |
|---|---|---|---|---|---|
| Demographic characteristics | |||||
| Age, years (mean ± SD) | 41.8 ± 15.6 | 42.4 ± 17.5 | 41.0 ± 16.8 | 39.6 ± 16.9 | 0.24 |
| Age ≥ 65 years, n (%) | 86 (16.5) | 34 (19.3) | 32 (15.4) | 20 (14.5) | 0.32 |
| Male sex, n (%) | 312 (60.5) | 108 (61.4) | 123 (59.1) | 81 (58.7) | 0.81 |
| Preoperative clinical status | |||||
| ASA class I–II, n (%) | 358 (68.5) | 121 (68.8) | 143 (68.8) | 94 (68.1) | 0.09 |
| ASA class III–IV, n (%) | 164 (31.5) | 55 (31.2) | 65 (31.3) | 44 (31.9) | — |
| Hemoglobin (g/dL, mean ± SD) | 11.3 ± 1.8 | 11.0 ± 1.9 | 11.4 ± 1.7 | 11.6 ± 1.6 | 0.07 |
| Preoperative anemia, n (%) | 202 (38.7) | 82 (46.6) | 76 (36.5) | 44 (31.9) | 0.04 |
| Surgical characteristics | |||||
| Emergency surgery, n (%) | 358 (68.6) | 144 (81.8) | 142 (68.3) | 72 (52.2) | < 0.001 |
| Elective surgery, n (%) | 164 (31.4) | 32 (18.2) | 66 (31.7) | 66 (47.8) | — |
| Procedure type | |||||
| Appendectomy, n (%) | 167 (32.0) | 64 (36.4) | 71 (34.1) | 32 (23.2) | 0.93 |
| Cholecystectomy, n (%) | 143 (27.4) | 36 (20.5) | 57 (27.4) | 50 (36.2) | 0.28 |
| Hollow viscus perforation repair, n (%) | 118 (22.6) | 44 (25.0) | 44 (21.2) | 30 (21.7) | 0.16 |
| Intestinal obstruction surgery, n (%) | 94 (18.0) | 32 (18.2) | 36 (17.3) | 26 (18.8) | 0.42 |
| Operative variables | |||||
| Operative duration, minutes (median IQR) | 96 (72–130) | 104 (80–140) | 94 (70–126) | 90 (66–118) | 0.03 |
| Perioperative ERAS components | |||||
| Early oral feeding, n (%) | 282 (54.0) | 26 (14.8) | 138 (66.3) | 118 (85.5) | < 0.001 |
| Early mobilization, n (%) | 264 (50.6) | 22 (12.5) | 126 (60.6) | 116 (84.1) | < 0.001 |
| Nasogastric tube use, n (%) | 296 (56.7) | 146 (83.0) | 108 (51.9) | 42 (30.4) | < 0.001 |
| Prolonged NG tube (> 48 h), n (%) | 206 (39.5) | 118 (67.0) | 66 (31.7) | 22 (15.9) | < 0.001 |
| Urinary catheter use, n (%) | 332 (63.6) | 148 (84.1) | 118 (56.7) | 66 (47.8) | < 0.001 |
| Early catheter removal, n (%) | 244 (46.7) | 32 (18.2) | 118 (56.7) | 94 (68.1) | < 0.001 |
| Appropriate antibiotic prophylaxis timing, n (%) | 346 (66.3) | 86 (48.9) | 142 (68.3) | 118 (85.5) | < 0.001 |
| Excessive IV fluids, n (%) | 198 (37.9) | 102 (58.0) | 64 (30.8) | 32 (23.2) | < 0.001 |
| Avoid routine surgical drain, n (%) | 360 (69.0) | 92 (52.3) | 150 (72.1) | 118 (85.5) | < 0.001 |
Note: Values are presented as mean ± standard deviation, median (interquartile range), or number (percentage). Early oral feeding and early mobilization were defined as initiation within 24 h after surgery. Prolonged nasogastric tube use was defined as retention beyond 48 h postoperatively. Early urinary catheter removal was defined as removal within 48 h after surgery. Continuous variables were compared using analysis of variance and categorical variables using chi‐squared testing.
Abbreviations: ASA = American Society of Anesthesiologists, ERAS = enhanced recovery after surgery, IV = intravenous, NG = nasogastric tube.
Overall, 238 patients (45.6%) experienced postoperative complications. Complication rates decreased progressively with increasing ERAS adherence, from 62.5% in the low‐adherence group to 42.3% in the moderate‐adherence group and 29.0% in the high‐adherence group (p < 0.001). After adjustment for age, ASA class, surgical urgency, and procedure type, moderate ERAS adherence were associated with lower odds of postoperative complications (adjusted OR 0.52 and 95% CI 0.34–0.78), whereas high adherence demonstrated a stronger association (adjusted OR 0.34 and 95% CI 0.21–0.56) (Table 2). Detailed complication profiles are summarized in Table 3 and Figures S1 and S2.
TABLE 2.
Population‐level impact of ERAS adherence on postoperative complications (n = 522).
| ERAS adherence category | Patients (n) | Observed complication rate n (%) | Adjusted odds ratio (95% CI) | Adjusted predicted complication probability | Absolute risk reduction (%) | Relative risk reduction (%) | Number needed to treat | Estimated preventable complications if applied to entire cohort |
|---|---|---|---|---|---|---|---|---|
| Low ERAS adherence | 176 | 110 (62.5) | Reference | 0.61 | Reference | Reference | — | — |
| Moderate ERAS adherence | 208 | 88 (42.3) | 0.52 (0.34–0.78) | 0.43 | 19.5 | 31.2 | 6 | 42 |
| High ERAS adherence | 138 | 40 (29.0) | 0.34 (0.21–0.56) | 0.30 | 33.5 | 53.6 | 3 | 87 |
Note: Values are presented as number (percentage) unless otherwise indicated. Adjusted odds ratios were derived from multivariable logistic regression models adjusting for age, ASA class, surgical urgency, and procedure type. Absolute risk reduction represents the difference in complication rates compared with the low ERAS adherence group. Relative risk reduction represents the percentage reduction in complication risk relative to the low ERAS adherence group. Number needed to treat (NNT) represents the number of patients requiring high ERAS adherence to prevent one postoperative complication, calculated as the inverse of the absolute risk reduction. Estimated preventable complications were calculated by applying the observed complication rate of the high‐adherence group to the entire study cohort.
Abbreviation: ERAS = enhanced recovery after surgery.
TABLE 3.
Detailed spectrum and severity of postoperative complications according to ERAS adherence (n = 522).
| Variable | Overall (n = 522) | Low ERAS (n = 176) | Moderate ERAS (n = 208) | High ERAS (n = 138) | p value |
|---|---|---|---|---|---|
| Any postoperative complication | 238 (45.6) | 110 (62.5) | 88 (42.3) | 40 (29.0) | < 0.001 |
| Clavien–Dindo complication severity | |||||
| Grade I | 78 (14.9) | 30 (17.0) | 32 (15.4) | 16 (11.6) | 0.29 |
| Grade II | 92 (17.6) | 44 (25.0) | 32 (15.4) | 16 (11.6) | 0.01 |
| Grade IIIa | 28 (5.4) | 14 (8.0) | 10 (4.8) | 4 (2.9) | 0.08 |
| Grade IIIb | 18 (3.4) | 8 (4.5) | 6 (2.9) | 4 (2.9) | 0.39 |
| Grade IV (life‐threatening complication) | 6 (1.1) | 4 (2.3) | 2 (1.0) | 0 | 0.14 |
| Grade V (death) | 16 (3.1) | 10 (5.7) | 6 (2.9) | 0 | 0.04 |
| Infectious complications | |||||
| Surgical site infection | 122 (23.4) | 58 (33.0) | 44 (21.2) | 20 (14.5) | < 0.001 |
| Sepsis | 48 (9.2) | 26 (14.8) | 14 (6.7) | 8 (5.8) | 0.02 |
| Pneumonia | 34 (6.5) | 16 (9.1) | 12 (5.8) | 6 (4.3) | 0.19 |
| Catheter‐associated urinary tract infection | 26 (5.0) | 12 (6.8) | 8 (3.8) | 6 (4.3) | 0.31 |
| Gastrointestinal complications | |||||
| Postoperative ileus | 68 (13.0) | 34 (19.3) | 22 (10.6) | 12 (8.7) | 0.01 |
| Anastomotic leak | 12 (2.3) | 6 (3.4) | 4 (1.9) | 2 (1.4) | 0.42 |
| Other complications | |||||
| Postoperative bleeding | 14 (2.7) | 8 (4.5) | 4 (1.9) | 2 (1.4) | 0.16 |
| Wound dehiscence | 10 (1.9) | 6 (3.4) | 2 (1.0) | 2 (1.4) | 0.18 |
| Multiple complications | 54 (10.3) | 30 (17.0) | 16 (7.7) | 8 (5.8) | 0.003 |
Note: Values are presented as number (percentage). Postoperative complications were classified according to the Clavien–Dindo grading system, where: Grades I–II represent minor complications requiring pharmacologic treatment or bedside interventions. Grades III–IV represent major complications requiring surgical, endoscopic, or intensive care interventions. Grade V represents postoperative death. Surgical site infection was defined according to Centers for Disease Control and Prevention criteria. Postoperative ileus was defined as delayed gastrointestinal recovery requiring nasogastric decompression or inability to tolerate oral intake beyond postoperative day 3. Sepsis was defined according to Sepsis‐3 criteria. Multiple complications indicate the occurrence of two or more postoperative complications in the same patient during the index hospital admission. Comparisons between ERAS adherence groups were performed using chi‐squared testing, with statistical significance defined as p < 0.05.
Abbreviation: ERAS = enhanced recovery after surgery.
Median postoperative length of stay decreased from 9 days (IQR 7–12) in the low‐adherence group to 7 days (IQR 5–9) in the moderate‐adherence group and 6 days (IQR 4–8) in the high‐adherence group (p < 0.001). ICU admission rates were highest in the low‐adherence group (19.3%) compared with moderate (9.6%) and high (7.2%) adherence groups. Additional healthcare utilization metrics are summarized in Table 4.
TABLE 4.
Healthcare resource utilization and hospital stay outcomes according to ERAS adherence level (n = 522).
| Variable | Overall (n = 522) | Low ERAS (n = 176) | Moderate ERAS (n = 208) | High ERAS (n = 138) | p value |
|---|---|---|---|---|---|
| Intensive care utilization | |||||
| ICU Admission, n (%) | 64 (12.3) | 34 (19.3) | 20 (9.6) | 10 (7.2) | 0.004 |
| ICU Stay > 48 h, n (%) | 36 (6.9) | 20 (11.4) | 10 (4.8) | 6 (4.3) | 0.01 |
| Operative resource use | |||||
| Reoperation during index admission, n (%) | 22 (4.2) | 12 (6.8) | 6 (2.9) | 4 (2.9) | 0.12 |
| Blood transfusion, n (%) | 46 (8.8) | 22 (12.5) | 16 (7.7) | 8 (5.8) | 0.07 |
| Hospital stay metrics | |||||
| Postoperative length of stay, median (IQR), days | 7 (5–10) | 9 (7–12) | 7 (5–9) | 6 (4–8) | < 0.001 |
| Hospital stay > 7 days, n (%) | 216 (41.4) | 116 (65.9) | 70 (33.7) | 30 (21.7) | < 0.001 |
| Prolonged stay (> 10 days), n (%) | 118 (22.6) | 72 (40.9) | 32 (15.4) | 14 (10.1) | < 0.001 |
| Discharge outcomes | |||||
| Discharged home without complication, n (%) | 284 (54.4) | 66 (37.5) | 120 (57.7) | 98 (71.0) | < 0.001 |
| 30‐day mortality, n (%) | 16 (3.1) | 10 (5.7) | 6 (2.9) | 0 | 0.04 |
Note: Values are presented as number (percentage) or median (interquartile range). Postoperative length of stay was defined as the number of days from surgery to hospital discharge. Prolonged hospitalization was defined as hospital stay exceeding 10 postoperative days. Comparisons between ERAS adherence groups were performed using chi‐squared testing for categorical variables and Kruskal–Wallis testing for continuous variables, with statistical significance defined as p < 0.05.
Abbreviations: ERAS = enhanced recovery after surgery, ICU = intensive care unit, IQR = interquartile range.
High ERAS adherence was associated with an absolute risk reduction of 33.5%, corresponding to a number needed to treat of three patients to prevent one postoperative complication. Applying the high‐adherence complication rate to the entire cohort suggested 87 potentially avoidable complications.
Based on observed median length‐of‐stay values, the cohort consumed approximately 3868 hospital bed‐days. If all patients achieved high ERAS adherence, projected bed utilization would decrease to 3132 bed‐days, representing 736 fewer hospital bed‐days and approximately 105 additional surgical procedures within the same hospital capacity (Figure 1). The relationship between ERAS adherence and postoperative length of stay is shown in Figure S3. Additional modeling metrics are presented in Supporting Information S1: Table S2.
FIGURE 1.
Projected reduction in postoperative hospital bed utilization associated with increasing ERAS adherence. Estimated cumulative postoperative hospital bed utilization across the study cohort (n = 522), based on median postoperative length of stay values according to ERAS adherence level. Increasing adherence to high ERAS levels was associated with a projected reduction in total postoperative bed utilization from approximately 3868–3132 bed‐days, representing an estimated reduction of 736 hospital bed‐days. These projections were derived using modeled assumptions and should be interpreted as estimates of potential system‐level impact.
4. Discussion
Higher ERAS adherence was associated with reduced postoperative complications, shorter hospital stay, and improved healthcare resource utilization. These findings are consistent with previous studies showing that adherence to ERAS pathways is a key determinant of improved perioperative outcomes [8]. Reduced postoperative stay translated into measurable system‐level benefits, suggesting ERAS may improve surgical throughput in resource‐constrained settings [9, 10].
Improving efficiency within existing infrastructure is particularly relevant in health systems facing limited surgical capacity and increasing demand for essential surgical services [1, 2, 3]. Many ERAS components require minimal additional resources and can be implemented without infrastructure expansion [4, 5, 6, 7].
This study has limitations. The observational design limits causal inference, and differences in emergency surgical burden between adherence groups may have contributed to residual confounding despite statistical adjustment. Patients with lower ERAS adherence more frequently required intensive perioperative support, and deviations from ERAS elements often reflected clinically appropriate decisions related to patient instability or disease severity rather than failure of implementation. Additionally, estimates of hospital bed utilization were derived from modeling assumptions and should be interpreted as projections rather than precise operational outcomes. Nevertheless, the observed dose–response relationship supports ERAS implementation when clinically feasible.
Author Contributions
Rudraksh Kesharwani: conceptualization, methodology, data curation, formal analysis, visualization, project administration, writing – original draft, writing – review and editing, software. Saurabh Raj: writing – review and editing, writing – original draft, supervision, methodology, validation, formal analysis, software. Arundati Ramdas Raikar: methodology, validation, supervision, formal analysis, writing – original draft, writing – review and editing, software. Sheryl Francisca Godinho: data curation, formal analysis, writing – review and editing, software. Rishabh Rao Singaraju: validation, writing – review and editing, writing – original draft. Dhruvin Patel: data curation, writing – review and editing, validation. Abhimanyu Vishnoi: data curation, formal analysis, writing – review and editing. Rehan Ali: methodology, data curation, writing – review and editing. Raj Vaghani: methodology, investigation, writing – review and editing.
Funding
The authors have nothing to report.
Ethics Statement
Ethical approval for this study was obtained from the Institutional Ethics Committee of Late Shri Lakhiram Agrawal Memorial Government Medical College, Raigarh. The study was conducted in accordance with the principles of the Declaration of Helsinki.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Supporting Information S1
Figure S1: Distribution of ERAS adherence score.
Figure S2: Postoperative complication rates according to ERAS adherence.
Figure S3: Relationship between ERAS adherence and length of stay.
Data Availability Statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request. Due to the inclusion of sensitive patient‐level clinical information, the data are not publicly available to protect patient confidentiality.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supporting Information S1
Figure S1: Distribution of ERAS adherence score.
Figure S2: Postoperative complication rates according to ERAS adherence.
Figure S3: Relationship between ERAS adherence and length of stay.
Data Availability Statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request. Due to the inclusion of sensitive patient‐level clinical information, the data are not publicly available to protect patient confidentiality.