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Volume 14
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This is an early access version, the complete PDF, HTML, and XML versions will be available soon.
Article

ERAS Implementation Fidelity, Care Complexity, and Postoperative Outcomes in Oncological Colorectal Surgery: A Real-World Observational Study

by
José Antonio Jerez González
1,
Miguel Ángel Hidalgo-Blanco
2,*,
Montserrat Puig Llobet
3,
Jordi Adamuz
4,
Maria Eulàlia Juvé-Udina
5,
Oliver Polushkina-Merchanskaya
6,
Bernat Miguel-Huguet
7,
Mireia Mariscal Cabeza
8 and
Carmen Moreno Arroyo
2
1
Bellvitge University Hospital, Faculty of Nursing, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona and Nursing Research Group (GRIN), 08907 L’Hospitalet de Llobregat, Spain
2
Department of Fundamental and Clinical Nursing, Faculty of Nursing, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona and Nursing Research Group (GRIN), 08907 L’Hospitalet de Llobregat, Spain
3
Department of Public Health, Mental Health, and Maternal and Child Health Nursing, Faculty of Nursing, University of Barcelona, 08907 L’Hospitalet de Llobregat, Spain
4
Nursing Knowledge Management and Information Systems Department, Bellvitge University Hospital, Faculty of Nursing, Bellvitge Biomedical Research Institute (IDIBELL), Nursing Research Group (GRIN), University of Barcelona 08907 L’Hospitalet de Llobregat, Spain
5
Catalan Institute of Health, 08007 Barcelona, Spain
6
Nursing Research Group (GRIN), Bellvitge Biomedical Research Institute (IDIBELL), 08907 L’Hospitalet de Llobregat, Spain
7
Data Management and Evaluation Unit, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
8
Nursing Research Group (GRIN), Bellvitge Biomedical Research Institute (IDIBELL), Digestive Endoscopy Unit, Viladecans Hospital, 08840 Barcelona, Spain
*
Author to whom correspondence should be addressed.
Healthcare 2026, 14(11), 1519; https://doi.org/10.3390/healthcare14111519
Submission received: 18 March 2026 / Revised: 13 May 2026 / Accepted: 26 May 2026 / Published: 29 May 2026
(This article belongs to the Special Issue Advancing Healthcare Delivery and Patient Quality of Care Through Healthcare Professionals’ Development)
Versions Notes

Abstract

Background: Enhanced Recovery After Surgery (ERAS) programmes are structured perioperative care pathways in which clinical outcomes are closely linked to the degree of implementation fidelity. However, the interaction between ERAS adherence, care complexity, and postoperative outcomes in real-world settings remains insufficiently explored. Objective: To evaluate the association between ERAS adherence and postoperative length of stay in oncological colorectal surgery and to analyse whether Care Complexity Individual Factors (CCIFs) influence this relationship. Methods: A retrospective observational cohort study was conducted in two university hospitals in Barcelona, including 90 adult patients undergoing elective colorectal cancer surgery (2022). ERAS adherence was assessed globally and by phase (pre-, intra-, and postoperative) using structured indicators. CCIFs were classified into five domains. Associations between adherence, care complexity, and outcomes were analysed using bivariate methods. Results: Overall adherence was 64%. Higher adherence was associated with shorter hospital length of stay (median 4 vs. 5 days; p = 0.033) and greater compliance with expected length of stay (37.8% vs. 17.0%; p = 0.047). Adherence varied across perioperative phases, with higher compliance in the preoperative phase and lower compliance postoperatively. Care complexity was high (mean CCIF 2.62) and was not significantly associated with adherence or compliance with expected length of stay. Conclusions: Higher ERAS adherence is associated with shorter hospital stay in oncological colorectal surgery within a real-world context. These findings support the importance of implementation fidelity across the perioperative pathway. Further research incorporating multivariable analyses and patient-centred outcomes is needed to better understand the interaction between care complexity and recovery trajectories.
Keywords: ERAS; adherence; care complexity; perioperative care; colorectal surgery; healthcare delivery; length of stay ERAS; adherence; care complexity; perioperative care; colorectal surgery; healthcare delivery; length of stay

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MDPI and ACS Style

González, J.A.J.; Hidalgo-Blanco, M.Á.; Puig Llobet, M.; Adamuz, J.; Juvé-Udina, M.E.; Polushkina-Merchanskaya, O.; Miguel-Huguet, B.; Mariscal Cabeza, M.; Arroyo, C.M. ERAS Implementation Fidelity, Care Complexity, and Postoperative Outcomes in Oncological Colorectal Surgery: A Real-World Observational Study. Healthcare 2026, 14, 1519. https://doi.org/10.3390/healthcare14111519

AMA Style

González JAJ, Hidalgo-Blanco MÁ, Puig Llobet M, Adamuz J, Juvé-Udina ME, Polushkina-Merchanskaya O, Miguel-Huguet B, Mariscal Cabeza M, Arroyo CM. ERAS Implementation Fidelity, Care Complexity, and Postoperative Outcomes in Oncological Colorectal Surgery: A Real-World Observational Study. Healthcare. 2026; 14(11):1519. https://doi.org/10.3390/healthcare14111519

Chicago/Turabian Style

González, José Antonio Jerez, Miguel Ángel Hidalgo-Blanco, Montserrat Puig Llobet, Jordi Adamuz, Maria Eulàlia Juvé-Udina, Oliver Polushkina-Merchanskaya, Bernat Miguel-Huguet, Mireia Mariscal Cabeza, and Carmen Moreno Arroyo. 2026. "ERAS Implementation Fidelity, Care Complexity, and Postoperative Outcomes in Oncological Colorectal Surgery: A Real-World Observational Study" Healthcare 14, no. 11: 1519. https://doi.org/10.3390/healthcare14111519

APA Style

González, J. A. J., Hidalgo-Blanco, M. Á., Puig Llobet, M., Adamuz, J., Juvé-Udina, M. E., Polushkina-Merchanskaya, O., Miguel-Huguet, B., Mariscal Cabeza, M., & Arroyo, C. M. (2026). ERAS Implementation Fidelity, Care Complexity, and Postoperative Outcomes in Oncological Colorectal Surgery: A Real-World Observational Study. Healthcare, 14(11), 1519. https://doi.org/10.3390/healthcare14111519

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