The Intensive Recovery Programs, also called "Fast-track" Surgery or ERAS (Enhanced Recovery After Surgery Program), start right at the time of diagnosis and are intended to identify the individual needs of our patients to optimize treatment, before, during, and after surgery,^1,2 by reducing perioperative stress and improving clinical practice, adopting evidence-based medicine to manage the patient.^1,3 These programs shorten the hospital stay without increasing the rate of complications or readmis-sions.^1,3-8 This approach requires a close collaboration among surgeons, anesthesiologists, endocrinologists, nurses, and other healthcare staff. Several trials have shown the effectiveness of the ERAS protocols in colorectal surgery, as compared against the conventional strate-gy.^2,9,10 However, these protocols challenge the traditional doctrine of surgery, and hence, their implementation has been slow and have not been universally adopted yet.^11,12

The impact of these protocols on the level of patient satisfaction is unclear, as few articles have been published on the topic.^9,10,13

The purpose of this study is to describe the level of satisfaction of the first 57 patients over 70 years of age, who underwent elective colorectal surgery according to the guidelines of an ERAS protocol, based on the Enhanced Recovery Guidelines in Abdominal Surgery (ERGAS)¹⁴ and on the recommendations of the ERAS society¹⁵ at the Hospital Universitario de Guadalajara (Spain), considered a tertiary hospital. The ERGAS guidelines were prepared in November 2014 by the Ministry of Health, Social Services and Equality in Spain, and edited in 2015. The guidelines included a survey to identify the level of patient satisfaction during hospitalization. This survey (Annex 1) is the one we have used for our study. The guidelines are a multimodal rehabilitation protocol that reviews the traditional perioperative practices and has analyzed the scientific evidence thereof.¹⁴

This is descriptive, cross-sectional study approved by the Ethics Committee of the Hospital Universitario de Guadalajara on April 25, 2016. Since May 1, 2016 the Protocol of Enhanced Recovery for Elective Colorectal Surgery of the Hospital Universitario de Guadalajara, based on the ERGAS guidelines and the recommendations of the ERAS society¹⁵ was implemented as a standard clinical practice in our hospital. The inclusion and exclusion criteria are those under the ERGAS guidelines.¹⁴

Inclusion criteria: Major abdominal surgery procedures, not susceptible to a major ambulatory surgical approach, that meet the following characteristics: Age 70 years or older, adequate cognitive status (able to understand the surgical procedure), American Society of Anesthesiologists I, II, and III.

Exclusion criteria: Emergent surgery and younger than 70 years old.

Since that time, all patients undergoing elective colorectal surgery and meeting our inclusion and exclusion criteria shall be operated on in accordance with the guidelines. Every patient signed an informed consent before surgery, which explained that the procedure was going to follow the guidelines of a new protocol and that the patient could withdraw his/her informed consent at any time. A specific pre-anesthesia visit was planned 1 day/ week, with the participation of maximum 10 patients that were going to be operated on based on the ERAS protocol. At least 45 minutes were assigned to each patient. During this time, patients were educated about their preparation, the use of respiratory incentives during the pre and operative phase, quitting harmful lifestyles, and the patient received all the information required about their surgery and tailoring of their surgical treatment. Nutritional enhancement protocols and pre-operative anemia treatment were also administered. In addition, the patients received a document with all the written information and a timeline for the whole process. They were informed about their participation in the study, and an explanation was given about the contents of the telephone survey. The decision was made not to administer the survey using a written form on the day of discharge, because of the work overload of the healthcare staff. So, it was decided to administer the survey over the phone, 4 days following patient discharge, so that the patient had time to adapt back to their home environment, but soon enough so that they could remember and respond as accurately as possible.

The anonymous telephone interview (the interviewer was blind to the patient's identity, diagnosis, type of surgery, presence or absence of complications; the only information was the telephone number-Annex 1) was conducted by the same person.¹⁴ The interviewer just read the questions one-by-one and recorded the patient's answer. The survey was divided into several sections and the patients had to chose one of the options to the various questions: (1) quality of the information before surgery; (2) healthcare staff kindness; (3) satisfaction with hospital facilities: operating room and comfort of patient rooms; (4) rate level of postoperative pain on a numeric scale, 0 no pain and 10 excruciating pain; (5) subjective opinion regarding whether the start of oral fluids and ambulation was early or not. Whenever possible, based on the patient's progress, the surgeon prescribed oral feeding and ambulation over the first 24hours postop^16,17; (6) postoperative nausea or vomiting (PONV); (7) quality of the information received from the surgeon and nurse following discharge; (8) professionalism and skill of the healthcare staff; (9) level of satisfaction during hospitalization; (10) indicate whether you would undergo surgery again according to this same protocol, and whether you would recommend it to a friend; (11) observations, positive and negative experiences, and room for improvement.

The clinical and demographic information was also collected. All tumors were staged-Tumor, Node, Metastasis (TNM)-¹⁸ based on T.¹⁹ Any complications were evaluated according to the Clavien-Dindo classification.²⁰ The mean hospital stay is recorded as the number of inhospital days from the day of admission (which is 1 day before surgery, as per our protocol) until the day of hospital discharge, both included. Readmissions refer to the rate of rehospitalization for any cause, over the 30 days after discharge.

The SPSS (version 20.0, SPSS Inc.) program was used for the statistical analysis. The results are presented as the number of patients that experienced an event and the percentage in discrete variables; and mean ± standard deviation or median and interquartile range in continuous variables.

The clinical and surgical data of our 57 first patients, aged 70 or more years old, consecutively undergoing elective colorectal surgery in accordance with the ERAS protocol at the Hospital Universitario de Guadalajara, since the adoption of the protocol on May 1, 2016 until January 31, 2017, are shown in Tables 1 and 2. Two of these patients died during hospitalization, so the survey was conducted in only 55 patients. None of the patients undergoing this surgery was excluded over the study period, as all of them met the inclusion criteria.

Table 1

ASA=American Society of Anesthesiologists; ERAS=Enhanced Recovery After Surgery; ICU=Intensive Care Unit; SD = Standard Deviation; TNM= Tumour, Node, Metastasis.

Table 2

ERAS=Enhanced Recovery After Surgery; SD = Standard deviation.

As shown on Table 3, 47 (85.5%) patients indicated that they were very well treated by the healthcare staff, 7 (12.7%) said that they were well treated by surgeons and anesthesiologists, 5 (9.1%) said that they were treated well by nurses and a minority said that they were treated fairly. Only 2 (3.6%) of the patients said that they had been badly treated by nurses and 1 (1.8%), very badly treated.

The results of this survey show that most of our patients aged 70 years or older, undergoing elective colorectal surgery according to the ERAS protocol at the Hospital Universitario de Guadalajara, are very pleased with the care received during their hospitalization and are willing to undergo a new surgery under the guidelines of the ERAS protocol, in addition to recommending it to a family member or friend. There are very few articles published regarding the level patient satisfaction when operated on in accordance with an ERAS protocol, and the outcomes are similar to ours.^13,17,22 It is fundamental that patients are satisfied with the care received to establish this type of protocol where the patient's collaboration is indispensable. Most of our patients rate the way they were treated by the healthcare staff during their hospitalization as very good or good and consider that the team that participated in their surgical procedure was very coordinated. Moreover, the surgeon is a point of reference for patients, and the fact that the same surgeon was involved from the time of diagnosis until discharge was considered a very important feature by over 50% of the patients. Probably this fact raises the level of patient satisfaction. None of the patients decided to withdraw the informed consent or relinquish the guidelines of the ERAS protocol to switch to conventional surgical procedure.

Most patients rated the level of coordination and professional competence of the medical staff involved in the surgery as very high. It is critical that patients trust the medical team at all times. The adoption of the ERAS programs requires a very motivated team, where the surgeon, the anesthesiologist, and nurses are the cornerstones. It is an absolute requirement to involve the patient and his/her family, as they should help us in accomplishing our objectives. The ERAS programs entail some changes with regards to traditional medicine, particularly with regards to early oral feeding and ambulation, not leaving any drainages or nasograstric tubes after the surgical procedure, avoiding the mechanical colon preparation, stressing the importance of respiratory physical therapy which we should explain to patients and their families before surgery, to get them involved in perioperative care and avoid overloading the healthcare staff, particularly in the floors, and help them understand why we do things as we do, and generate confidence in this new approach. All of this is done together with the pre-anesthesia and surgery consultations, and is reflected in the written information given to the patient. The medical team as a whole, the patient, and his/her family shall all agree with this approach and join efforts; they must understand on which aspects we should focus our efforts each day, and why we do it.⁸

One of the most relevant aspects of the ERAS programs is to emphasize the importance of any verbal and written communication to our patients before surgery. Most patients rated the information as very good or good. The patient must be acquainted with the treatment options and have realistic expectations about the risks and benefits. The intent is to get the maximum collaboration and involvement of patients with their treatment process.^23,24 The purpose of the pre-anesthesia and surgery consultations and of the information shared with patients was to reduce their fear and anxiety before surgery, and make them understand why we changed our practice and get them involved in that change. The written information given to patients during consultation comprised the complete process from the day of hospital admission to discharge, with particular emphasis on early mobilization, early oral feeding, and respiratory exercise.^15,25 Over 80% of patients rate the pre-anesthesia and surgery consultations as very positive, based on the time specifically devoted to explain the process to each patient and optimize their health status-approximately 45 minutes per patient.

Most of our patients did not experience any PONV, and the level of pain was rated as less than, or equal to 3, which contributes to a higher level of satisfaction. Optimizing pain control during the perioperative period, reducing the use of opiates, is another key objective of the ERAS programs.^14,15 Our protocol includes using epidural analgesia (if possible thoracic in case of laparotomy), regional blocks (of the transverse plane of the abdomen, the fascia and the rectus muscles), infiltration with local anesthetic of the laparoscopic ports or of the surgical incisions, and use of non-steroidal anti-inflammatory drugs and opiates if necessary.^14,15,26,27

Early mobilization and early introduction of oral feeding in the first 24 hours^14,15,28,29 postoperatively under the surgeon's indication are 2 important items in the ERAS protocol and reflect good patient progress. Early mobilization reduces pulmonary complications and insulin resistance; to accomplish this goal, adequate pain control is essential, as well as limiting the use of catheters and drains.^14,15 Notwithstanding the fact that patients were educated at length about the importance of this approach during the pre-anesthesia consultation, over 40% of our patients felt the introduction or oral feeding and mobilization were somewhat soon; 36.4% felt it was on time, and a minority considered it late or too late. This is one of the key changes of the ERAS protocol approach and patients should be educated during the consultation, so that they understand the reasons behind this approach and be cooperative.

Other authors associate the level of education and the patient's nationality as factors that could impact patient satisfaction.³⁰ However, this was not the case with our patients, as all of them are very satisfied or satisfied, regardless of their level of education.

Notwithstanding the fact that almost all of our patients were in a double room during their hospitalization and many thought that the room was somewhat inadequate, and referred to the work overload of the healthcare staff, this did not affect their satisfaction, as all of them expressed a high level of satisfaction. We believe then that the actual care and the way patients were treated by the healthcare staff was more important than the hospital facilities.

Patients' satisfaction was not affected either by whether they experienced complications or not during their hospitalization, as none of the patients who were satisfied experienced complications, and the rest were all very satisfied, regardless of experiencing complications or not. This is probably due to the fact that one of the aspects mentioned by over 50% of the patients was that the same surgeon did the follow-up throughout the process, from diagnosis to discharge, taking care of any potential complications and treatment. This gave a lot of confidence in their physician and probably increased their satisfaction.

Our study has some limitations. The major limitation is the fact that it is not randomized, as all the patients undergoing elective colorectal surgery since May 2016 were included in the ERAS protocol and we cannot compare the results of the satisfaction survey against a group of patients undergoing conventional surgery. Furthermore, we have no control group to contrast our results with, and we could not call the patients who underwent elective colorectal surgery before the ERAS protocol, because it had been more than 1 year ago and it made no sense to survey them then because they would have forgotten much of the data. There is only 1 non-randomized trial comparing the satisfaction of patients undergoing conventional surgery and then following an ERAS protocol; the conclusions were that patients were equally satisfied in both groups.⁸ In this study, faster recovery with the implementation of the protocol may make patients more satisfied. Another potential limitation is that in our first 57 patients, the healthcare staff was attentive to administer the different items of the protocol, and consequently were very attentive to the patients at all times, which could have increased their satisfaction. It is quite complicated to compare these results against other trials, as the number of existing satisfaction studies is small and each one measures different variables, and as there are no standardized scales or indexes to measure the level of satisfaction of our patients. For this reason, we conducted the study based on the survey used in the enhanced recovery in abdominal surgery guidelines, as a model established by the Ministry.

Further studies are needed to determine exactly the level of patient satisfaction, and standardized surveys or questionnaires should be developed so that we all measure the same variables and be able to compare results.

We may conclude that all patients aged 70 years or older, undergoing elective colorectal surgery at the Hospital Universitario de Guadalajara, following the implementation of an ERAS protocol, were very satisfied or satisfied with the care provided; the results obtained with these protocols in terms or shorter mean hospital stay, less complications and lower rate of readmissions, represent a high level of patient satisfaction.

Protection of human and animal subjects. The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data. The authors declare that they have followed the protocols of their work center on the publication of patient data.

Right to privacy and informed consent. The authors have obtained the informed consent of the patients and/or subjects referred to in the article. This document work in the power of the correspondence author.