Targeted ERAS implementation for postoperative care after Bellwether procedures in Africa: A pragmatic cluster-randomized trial from Ethiopia

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Introduction: In Africa, where access to timely and safe surgical care remains limited, postoperative complications and prolonged hospital stays continue to challenge health systems. The Enhanced Recovery After Surgery (ERAS) protocol has been shown to improve perioperative outcomes by reducing hospital length of stay (LOS) and complications, but compliance remains inconsistent. Objective: To determine whether improving ERAS compliance in Ethiopia, through a "Triple Intervention Strategy" of early postoperative feeding, ambulation, and urinary catheter removal, could reduce hospital LOS for patients undergoing laparotomy and cesarean section (CS). Methods: This study was designed as a cluster-randomized clinical trial conducted across 10 hospitals within the National Perioperative Quality Improvement Network (NaPQIN) in Ethiopia. Hospitals were randomly assigned to either the intervention group (n=5), which received structured ERAS training reinforced through continuous monitoring and supervision, or the control group (n=5), which continued standard perioperative care without additional reinforcement. The primary outcome was hospital LOS, and secondary outcomes included compliance with the ERAS components, determinants of LOS, and postoperative complications. Data were managed through the NaPQIN platform and analyzed using R statistical software. Results: A total of 8,256 patients were enrolled, with 5,887 (71.3%) in the intervention group and 2,369 (28.7%) in the control group. Full compliance with the ERAS bundle improved to 76.5% in the intervention group compared to 57.9% in controls (p < 0.001). Patients in the intervention group had a significantly shorter LOS (mean 80.75 vs. 89.24 hours; p < 0.001). The intervention group also had significantly fewer postoperative complications (2.1% vs 4.8%; p < 0.001), and more patients were discharged without any complications. Conclusions and Relevance: This pragmatic trial, enabled by a national perioperative data system, demonstrated that the targeted implementation of postoperative ERAS elements, early oral feeding, mobilization, and timely urinary catheter removal significantly improved compliance and reduced hospital stay without requiring additional resources. While full ERAS pathways remain the ideal, focused, context-adapted strategies can offer scalable benefits in LMIC settings burdened by surgical backlogs and limited perioperative capacity. Broader adoption should prioritize tailored integration, ongoing evaluation, and provider engagement to maximize system-wide impact. Trial Registration: identifier PACTR202502863551536.

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