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Introducing enhanced recovery after surgery (ERAS) program in Rwanda: a step-by-step approach from KAP study to protocol development and preliminary implementation

BMC Surgery volume 25, Article number: 173 (2025) Cite this article

Abstract

Background

Enhanced Recovery After Surgery (ERAS) programs improve postoperative outcomes through evidence-based practices. However, implementing ERAS in resource-limited settings like Rwanda remains challenging. This study aimed to introduce an ERAS program at the Centre Hospitalier Universitaire de Kigali (CHUK) by tailoring it to the local context.

Methods

A multi-phase strategy was employed, beginning with a Knowledge, Attitudes, and Practices (KAP) study following an ERAS webinar to identify gaps in awareness and application of ERAS principles among perioperative care providers. Targeted training sessions were conducted to address these gaps, leading to the development of a locally adapted ERAS protocol.

Results

The KAP study revealed limited awareness of ERAS protocols, including international Nil Per Os (NPO) guidelines, with only 45.7% of participants familiar with them and 48% unknowingly applying some ERAS elements. Early postoperative feeding was supported by 45.7%, and 92.5% agreed that preventing nausea and vomiting enhances recovery. Regarding opioid use, 88.4% supported selective use, while 81.5% disagreed with eliminating opioids entirely. Almost all respondents (97.7%) believed ERAS improved perioperative care, and 79.2% felt it reduced hospital expenses. Additionally, 85% of respondents recognized laparoscopic surgery as enhancing ERAS protocols. The insights gained informed the design of targeted training sessions and the development of a locally adapted ERAS protocol, supported by the formation of collaborative groups and ERAS champions.

Conclusion

The introduction of ERAS at CHUK demonstrates the feasibility of implementing evidence-based surgical protocols in resource-limited settings. Addressing knowledge gaps and adapting protocols to the local context represent a promising step toward improving surgical care in Rwanda and enhancing perioperative management.

Clinical trial number

Not applicable.

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Introduction

Enhanced Recovery After Surgery programs, first developed in Northern Europe, have transformed perioperative care by improving patient outcomes and speeding up recovery [1,2,3]. Introduced by Henrik Kehlet in the 1990s, ERAS protocols showed that patients undergoing major surgeries like open sigmoid resection could be discharged within two days postoperatively, compared to the traditional 10-day stay [4]. These protocols have since expanded globally, being implemented in over 25 countries, focusing on minimizing surgical stress through evidence-based perioperative strategies [4]. Core components of ERAS include preoperative optimization, minimally invasive surgery (MIS), multimodal analgesia, optimal fluid management, and early postoperative mobilization and nutrition [4,5,6,7]. Studies have shown these strategies reduce complications by 50%, shorten hospital stays, and provide both clinical and economic benefits [8,9,10,11,12].

In Rwanda, despite significant advancements in healthcare, perioperative care still faces challenges. Issues such as infrastructure constraints, inconsistent perioperative care standards, limited Intensive care unit (ICU) capacity, and suboptimal use of advanced medications present barriers to optimal surgical care. However, Rwanda’s healthcare system, structured in a pyramidal model from community health workers to tertiary hospitals, is well-positioned for the integration of enhanced perioperative care strategies like ERAS, particularly with the introduction of Community-Based Health Insurance (CBHI) covering over 85% of the population and has a strong positive impact on access to health care [13, 14].

This study focused on the introduction of an ERAS program in Rwanda, adapted for the local context, with laparoscopic cholecystectomy as the targeted initial procedure. The program follows a stepwise approach, beginning with a Knowledge, Attitudes, and Practices (KAP) assessment of perioperative care providers, leading to targeted training, protocol adaptation, and pilot implementation. Through this process, the authors aimed to improve the quality of surgical care in Rwanda, providing both clinical and economic benefits, and laying the groundwork for nationwide implementation of ERAS protocols (Tables 1, 2, 3 and 4).

Table 1 Professional of study respondents
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Table 2 Awareness and knowledge of ERAS guidelines
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Table 3 Frequence of the application of ERAS protocol and laparoscopic surgery
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Table 4 Respondents’ views on the benefits of ERAS protocol
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Methods

Study design

This study utilized a descriptive, multi-phase approach to introduce and develop a modified ERAS protocol at CHUK. The study consisted of an initial educational intervention, a knowledge assessment survey, targeted training sessions, and the development of a context-adapted ERAS protocol.

Study setting and population

The study was conducted at CHUK, a tertiary teaching hospital in Rwanda. The study population included perioperative care providers such as surgeons, anesthesiologists, non-physician anesthetists (NPAs), gynecologists, surgical residents, nurses, midwives, and clinical psychologists from CHUK. These healthcare professionals were involved in perioperative patient care and represented key stakeholders in ERAS implementation.

Intervention and procedures

The study was implemented in the following phases:

Educational webinar

A half-day webinar was organized in collaboration with the Departments of Surgery and Anesthesia to introduce ERAS principles to perioperative care providers. The webinar featured presentations by ERAS experts on key principles and challenges of implementation in low- and middle-income countries (LMICs), with a focus on laparoscopic surgery. This session facilitated discussions on ERAS adaptation in the Rwandan healthcare setting.

Knowledge, attitudes, and practices assessment

Following the webinar, a cross-sectional KAP study was conducted to assess perioperative care providers’ understanding, perceptions, and current practices regarding ERAS. A structured online questionnaire was used, consisting of multiple-choice and open-ended questions covering demographic information, knowledge of ERAS principles, attitudes towards ERAS implementation, and current perioperative practices. Participation was voluntary, and data were anonymized.

Targeted training sessions

Based on the KAP survey findings, structured training sessions were developed to address identified knowledge gaps. These sessions focused on ERAS principles such as preoperative optimization, multimodal analgesia, fluid management, and early postoperative mobilization and nutrition. Training aimed to equip perioperative staff with the necessary skills to implement ERAS within the available resources at CHUK.

Establishment of ERAS teams and champions

To ensure sustainable ERAS implementation, multidisciplinary ERAS teams were formed across various hospital wards. Departmental champions were appointed from surgery, anesthesia, and nursing to oversee ERAS adherence, provide ongoing education, and troubleshoot implementation challenges.

Development of the modified ERAS protocol

A multidisciplinary team, including surgeons, anesthesiologists, and nursing staff, collaborated to develop a modified ERAS protocol (Fig. 1) tailored to CHUK’s clinical environment. The protocol was adapted from standard ERAS guidelines for colorectal surgery [15, 16], considering local constraints and available resources. Key modifications included the incorporation of multimodal analgesia strategies, a focus on minimizing unnecessary interventions (such as routine drains and tubes), and structured perioperative care pathways. The finalized protocol was reviewed and approved for integration into hospital practice.

Fig. 1
figure 1

Modified ERAS pathway for laparoscopic cholecystectomy at the Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda

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Pilot implementation and evaluation

Although the pilot study results are not part of this study, their mention highlights that the developed ERAS protocol was successfully implemented, yielding promising outcomes. The findings supported the broader adoption of ERAS at CHUK, reinforcing its potential to improve surgical care beyond laparoscopic cholecystectomy. Key recommendations were made to ensure the program’s sustainability, emphasizing continuous education, local adaptation, and multidisciplinary collaboration to address implementation challenges in resource-limited settings [17].

Data collection and analysis

Data from the KAP study were collected using an online survey platform and analyzed descriptively. No statistical comparisons were conducted, as the study aimed to identify broad knowledge trends and training needs rather than test hypotheses. Data were summarized using Microsoft Excel and presented as frequency distributions and thematic analyses for qualitative responses. Ethical approval was obtained from the CHUK ethic committee. Informed consent was secured from all participants involved in the study, including those who participated in the knowledge assessment survey and training sessions.

Results

Most respondents were aged between 30 and 40 years (50.3%), followed by those over 40 (44.5%), with only 5.2% aged 22–30. The gender distribution was predominantly female (77.5%), and 43.9% of the participants held a Diploma, while 43.4% had a bachelor’s degree. Nurses formed the largest professional group (51.5%), with midwives comprising 24.9%. Most respondents had more than 10 years of work experience (64.8%).

Approximately 63.6% of respondents were aware of international NPO guidelines. However, knowledge about specific elements of ERAS protocols was inconsistent. While 88.4% supported selective opioid use during surgery, 81.5% disagreed with avoiding opioids entirely. Only 45.7% endorsed early feeding post-abdominal surgery, but 92.5% agreed that preventing nausea and vomiting improves postoperative outcomes.

Laparoscopic surgery was widely recognized as enhancing ERAS protocols (85%). Awareness of ERAS protocols was relatively low (45.7%), and only 48% of respondents reported applying ERAS principles in their daily practice. Application frequency varied, with 13.9% using ERAS principles more than 75% of the time, and 30.6% applying it 50–75% of the time.

Nearly all respondents (97.7%) believed that ERAS protocols could improve the standard of perioperative care, and 94.8% supported the use of multidisciplinary teams. Furthermore, 79.2% agreed that ERAS reduces hospital expenses, while 77.5% felt it decreases out-of-pocket costs for patients.

Discussion

The implementation of an Enhanced Recovery After Surgery (ERAS) program in a resource-limited setting such as Rwanda presents unique challenges and opportunities. This study demonstrates the feasibility of introducing an ERAS protocol at CHUK through a structured, stepwise approach involving knowledge assessment, targeted training, protocol adaptation, and pilot implementation.

Knowledge and perceptions of ERAS in Rwanda

The findings from our Knowledge, Attitudes, and Practices (KAP) study highlight both knowledge gaps and positive perceptions toward ERAS among perioperative care providers. A significant proportion of respondents (45.7%) were unfamiliar with ERAS principles, yet many unknowingly applied some ERAS elements in routine practice. Notably, the recognition of ERAS benefits was high, with 97.7% of respondents acknowledging its role in improving perioperative care and 79.2% perceiving a potential reduction in healthcare costs. The limited awareness of international Nil Per Os (NPO) guidelines and postoperative feeding recommendations aligns with previous studies in similar settings, underscoring the need for context-specific educational initiatives [18,19,20]. Addressing these gaps through structured training was a crucial step in the successful adaptation of ERAS principles to our local environment.

Protocol adaptation and implementation challenges

Developing a modified ERAS protocol required careful integration of evidence-based principles with the realities of a low-resource healthcare system. Key adaptations included:

  1. 1.

    A multimodal analgesia approach tailored to available medications.

  2. 2.

    Selective opioid use based on provider consensus, given the concerns surrounding opioid availability and overuse.

  3. 3.

    Emphasis on early oral feeding and mobilization, acknowledging cultural and institutional barriers to early postoperative recovery.

  4. 4.

    Strategic involvement of multidisciplinary ERAS teams and champions to oversee implementation.

The observed resistance to eliminating opioids entirely (81.5%) suggests that education on alternative analgesia strategies remains critical for the successful transition to opioid-sparing protocols [17, 21]. Furthermore, despite strong support for laparoscopic surgery (85%) as a facilitator of ERAS, infrastructural and training limitations remain key barriers to its widespread adoption in Rwanda.

Impact on perioperative care and patient outcomes

Our preliminary implementation of the modified ERAS protocol in laparoscopic cholecystectomy reported already [17], patients demonstrated promising trends in perioperative outcomes. Early mobilization and feeding were well tolerated, and no significant increase in complications was observed. While further data collection is necessary to quantify improvements in postoperative recovery and hospital stay duration, these initial findings suggest that ERAS is both feasible and beneficial in this setting. The establishment of ERAS groups and champions played a critical role in maintaining protocol adherence and addressing challenges in real-time, reinforcing the importance of a structured implementation framework.

Barriers to long-term implementation

Despite the promising results, several challenges must be addressed for long-term ERAS sustainability. Institutional resistance to change, variability in provider adherence, and resource limitations particularly regarding laparoscopy and multimodal analgesia pose ongoing obstacles. Additionally, patient-related factors, including cultural beliefs regarding perioperative fasting and postoperative pain management, require targeted education to enhance acceptance of ERAS principles. Future efforts should focus on continuous training, quality improvement initiatives, and advocacy for policy support to scale ERAS beyond laparoscopic cholecystectomy to other surgical procedures.

Studies in similar settings have shown the value of educational initiatives in encouraging the uptake of ERAS, even in resource-constrained environments [16]. Dr. Ravi Oodit and his team have similarly highlighted the importance of implementing ERAS in LMICs [22] and stressing the need for adapting perioperative programs like ERAS to improve surgical outcomes in low-resource settings, urging the global health community to make such tools more accessible and context-specific [22,23,24].

Limitations

This study has some limitations that should be considered. The study was limited to healthcare professionals at CHUK, which may restrict the generalizability of findings. Additionally, the questionnaire used consisted of a single-item question, which, while appropriate for the study’s objectives, may have constrained the depth of responses. Additionally, an overview of the ERAS program and its principles was provided during a webinar session, which a small proportion of respondents attended. Given the limited number of attendees, we believe this factor did not significantly affect the overall findings. Despite these limitations, we are confident that the conclusions drawn from the study remain reliable.

Conclusion

This study represents a critical first step in the introduction of ERAS principles in Rwanda. By addressing knowledge gaps, adapting protocols to local constraints, and leveraging multidisciplinary collaboration, we have demonstrated that ERAS implementation is feasible even in resource-limited settings. Our findings suggest that a structured, educational approach can facilitate good adherence and adoption of ERAS program in a specific setting. However, ongoing evaluation and strategic investments in infrastructure and provider training are essential to ensure the sustainability and expansion of ERAS protocols in Rwanda. Future studies should focus on long-term patient outcomes, cost-effectiveness, and strategies for national implementation to further optimize surgical care in low- and middle-income countries.

Data availability

The data generated and analyzed during this study are available from the corresponding author upon reasonable request.

Abbreviations

CBHI:

Community-Based Health Insurance

CHUK:

Centre Hospitalier Universitaire de Kigali

CMHS:

College of Medicine and Health Sciences

EC:

Ethics Committee

ERAS:

Enhanced Recovery After Surgery

ICU:

Intensive Care Unit

IRB:

Institutional Review Board

KAP:

Knowledge, Attitudes, and Practices

LMICs:

Low- and Middle-Income Countries

MIS:

Minimally Invasive Surgery

NPA:

Non-Physician Anesthetist

NPO:

Nil Per Os

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Acknowledgements

The authors extend their gratitude to the perioperative care providers at the Centre Hospitalier Universitaire de Kigali for their invaluable support.

Funding

This research was not supported by any external funding agencies.

Author information

Authors and Affiliations

  1. Department of Surgery, University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda

    Martin Nyundo, Miguel Gasakure, Esperance Muhawenayo & Julien Gashegu

  2. Department of Surgery, Rwanda Military Hospital, Kigali, Rwanda

    King Kayondo

  3. Department of Anesthesia and Critical Care, University of Rwanda, Kigali, Rwanda

    Paulin Banguti

  4. Department of Surgery, Inkuru Nziza Orthopedic Hospital, Kigali, Rwanda

    Jean Damascene Twagirumukiza

  5. Department of Human Anatomy, University of Rwanda, Butare, Rwanda

    Julien Gashegu

  6. Department of Abdominal Surgery and Transplantation, CHU Liege, University of Liege, Liege, Belgium

    Olivier Detry

  7. Centre de Recherche et d’Enseignement du Département de Chirurgie (CREDEC), GIGA Metabolism, University of Liege, Liege, Belgium

    Olivier Detry

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  1. Martin Nyundo
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Contributions

M.N. created research idea, developed the protocol, supervised data collection, conducted data analysis, wrote the manuscript, and performed final revisions.M.G. developed the protocol, collected data, analysed data, and wrote some sections of the manuscript.E. M. developed the protocol and collected data.K.K. wrote the manuscript and reviewed the last version.P.B. refined the research idea and reviewed the manuscript text.J.T. analysed data, contributed to sections of the manuscript and prepared figure 1.J.G. provided guidance on study design and contributed significantly to manuscript editing.O.D. played a major role in the creation of the study concept, supervised the research process, and critically reviewed the manuscript for intellectual content.

Corresponding author

Correspondence to Martin Nyundo.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Institutional Review Board (IRB) of the University of Rwanda (Approval number: 412/CMHS IRB/2021) and the Ethics Committee of the University Teaching Hospital of Kigali (Approval number: EC/CHUK/1/074/2021). Informed consent was obtained from participants upon their agreement to complete the study questionnaire. The study adhered to institutional and national ethical standards and complied with the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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Nyundo, M., Gasakure, M., Muhawenayo, E. et al. Introducing enhanced recovery after surgery (ERAS) program in Rwanda: a step-by-step approach from KAP study to protocol development and preliminary implementation. BMC Surg 25, 173 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12893-025-02909-6

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Keywords

BMC Surgery

ISSN: 1471-2482

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