A new paper from the ERAS® Society, published in World Journal of Surgery (April 2026), revisits two decades of Enhanced Recovery After Surgery, confronting an uncomfortable truth about how it is implemented in practice.
The paper, authored by Prof. Olle Ljungqvist, Prof. Mary Brindle, Prof. Martin Hubner, Prof. Gregg Nelson and Assoc. Prof. Ulf Gustafsson, traces the development of ERAS® from early Fast Track surgery in the 1990s to a global perioperative care movement now active in more than 30 countries. It is, in many ways, a celebration of what ERAS® has achieved: shorter hospital stays, fewer complications, lower cost of care, and a growing body of evidence that ERAS® compliance is associated with improved long-term survival.
But the most important passage in the paper is not about success. It is about the gap between perceived and actual practice.
The “we do ERAS®” problem
The authors write:
“Most clinical units involved in surgery today claim they ‘do ERAS’. While some may in fact have successful ERAS in place, on closer inspection most units are not truly practicing ERAS or producing the results that would be anticipated if ERAS was truly, meaningfully adopted.”
It is the conclusion of the people who built ERAS®, after more than a decade of training hospitals and auditing their perioperative care.
The numbers are specific:
- Most units, even those with dedicated ERAS® programs, achieve only 40–60% compliance with ERAS® guidelines
- National length-of-stay data in many countries shows twice that of true ERAS® care
- Clinical benefits become visible when compliance rises above 70–80%
- As ERAS® compliance increases, length of stay and complications decrease in a clear dose-response relationship
In other words: partial ERAS® delivers partial results. And most hospitals are doing partial ERAS® without knowing it.
Why a protocol on paper is not enough
One of the most striking observations in the paper is from the original ERAS® Study Group itself. When the clinicians who wrote the ERAS® protocol reviewed their own daily practice, they found their actual care was quite different from what they believed they were delivering. Even the architects of ERAS® were not fully practicing ERAS®.
This is not a failure of intent. It is a structural problem. Perioperative care involves dozens of decisions, multiple professions, and several handovers across the patient pathway. Without continuous measurement, it is almost impossible for a team to know whether the full pathway is being followed for every patient.
The authors point to early implementation work in the Netherlands, where structured training reduced length of stay by 30–50% within a year. But follow-up showed that compliance dropped and outcomes regressed once the project finished. The conclusion was clear: implementation as a one-time project is not enough. Sustainability requires a different way of working.
Audit as the foundation of sustainable ERAS®
This is where the paper makes its most direct statement about what works. The authors describe audit and feedback as a core part of any ERAS® program, and note that the ERAS® Interactive Audit System (EIAS) was developed as the Society’s endorsed audit system to record demographics, care processes and a rich set of outcome measures for all patients continuously.
The mission statement of the ERAS® Society, reproduced in the paper, places audit alongside evidence-based practice, implementation, research and education as one of four pillars. Implementation is explicitly defined as supporting protocol and tool development
“based on a foundation of continuous audit and feedback (i.e., EIAS) with an ultimate goal of achieving sustained and meaningful compliance.”
This framing matters. Audit is not a quality assurance add-on. It is the mechanism that makes ERAS® visible, measurable and sustainable.
What this means for hospitals and health systems
For clinical leaders, the implication is direct. If a hospital cannot show its actual compliance rates across the full ERAS® pathway, patient by patient, then it does not know whether its ERAS® program is delivering the outcomes the evidence promises. It may be. It may not be. Without measurement, it is a question of belief, not knowledge.
For health system leaders and payers, the implication is equally direct. The return on investment for ERAS®, reported in the paper as up to seven times, depends on meaningful implementation and sustained compliance. Funding ERAS® without funding the audit infrastructure that sustains it means funding a protocol, not necessarily an outcome.
The work ahead
The paper closes by noting that ERAS® is far from being adopted universally, and that much work remains. The ERAS® Society’s stated focus going forward is to deepen its impact in places where adoption remains poor, support the democratization of ERAS® knowledge, and use robust data to inform the future of Enhanced Recovery care.
What this means for Encare’s work
At Encare, we have been the commercial partner of the ERAS® Society since 2010. Through EIAS, we support hospitals in more than 30 countries in measuring ERAS® compliance, outcomes and care processes across the full patient pathway.
We see the gap the authors describe every day: the difference between hospitals that say they do ERAS® and hospitals that can prove how consistently ERAS® is delivered.
Closing that gap is the work Encare was built to support.
The full paper is open access and worth reading in its entirety.
Read the paper: ERAS—Enhanced Recovery After Surgery: The ERAS Society Story, World Journal of Surgery, April 2026
