Table 1.

Care Processes Included in the Kaiser Permanente Northern California Enhanced Recovery After Surgery Program

Care Process	Description
Preoperative
Patient education	Verbal counseling and written brochures provided preoperatively
No prolonged fasting	Clear liquids allowed up to 2 h and solids up to 8 h before surgery
Carbohydrate loading	Carbohydrate-rich drink or apple juice 2 to 4 h preoperatively
Decreased sedative medications	Recommended premedication limited to 2 mg of midazolam
Regional anesthesia	Peripheral nerve blocks in emergency department (hip fracture)
Intraoperative
Antimicrobial prophylaxis	Chlorhexidine skin preparation and antibiotics within 1 h before incision
Postoperative nausea and vomiting prophylaxis	Multimodal prophylaxis based on risk
Multimodal analgesia	Gabapentin, acetaminophen, intravenous lidocaine infusion, nerve blocks, or thoracic epidural
Standard anesthetic protocol	Hip fracture: neuraxial anesthesia preferred Colorectal: thoracic epidural, nerve block, or intravenous lidocaine infusion
Minimally invasive surgery	Laparoscopic approach preferred (colorectal)
Avoidance of drains and tubes	Routine nasogastric tubes and drains discouraged
Perioperative fluid management	Restrictive or goal-directed fluid replacement
Prevention of hypothermia	Active warming devices
Postoperative
Multimodal analgesia	Scheduled acetaminophen and ketorolac, intravenous lidocaine infusion (colorectal), or regional anesthesia
Early oral nutrition	Full liquid or regular diet within 12 h after surgery
Early and sustained ambulation	Ambulation accomplished within 12 h after surgery and twice daily thereafter
Early urinary catheter removal	Removal of urinary catheter within 24 h after surgery
Deep vein thrombosis prevention	Sequential compression devices unless ambulating
Restoration of gut function	Chewing gum (colorectal)