The ERAS Society was born out of a collaborative network in Northern Europe. Ken Fearon from Edinburgh and Olle Ljungqvist from Stockholm met at a conference outside London in 2000 and decided to start collaboration with some other groups interested in perioperative care. Ken had good contacts with Maarten von Meyenfeldt and Cornelius Dejong in Maastricht, the Netherlands and Olle had similar good relations with Henrik Kehlet in Copenhagen, Denmark and Arthur Revhaug in Tromsö, Norway. These leaders were invited to a small conference in London early the next year to discuss the prospects of further developing what was then often referred to as fast track surgery, and probably first mentioned in cardiac surgery [1]. These ideas in cardiac surgery had been further developed by Henrik Kehlet who described a multimodal approach to improve the rate of recovery after colonic surgery [2]. Kehlet’s work had been developed from the use of epidurals for pain relief and stress reduction. All participants had a keen interest in the stress response to surgery, nutrition and metabolism and the role that manipulating aspects of the stress response may have on outcomes after surgery. The Maastricht group had shown the effectiveness of nutritional support on outcomes in surgery, Tromsö had implemented early post-operative food and studied anabolic factors, Edinburgh had done studies on cancer and nutrition, and Stockholm had presented the idea of fluid and carbohydrate loading instead of overnight fasting and the role of insulin resistance in recovery.

Together the ERAS Group set out to put metabolism and nutrition back on the agenda for surgery and anaesthesia. The group started to hold regular meetings and began to review the literature available for perioperative care that could make a difference for improving outcomes and recovery. A very important aspect for the group was how to name the process of improvement. It was felt that “Fast track” had a negative cling to it by focussing on “fast” rather than the patient. The group therefore decided to change the name of the process to Enhanced Recovery After Surgery—ERAS, and that is how the word was invented. This placed the focus on the patient’s recovery and by improving recovery secondary gains could be achieved such as shorter length of stay and financial savings. However, for the group and later the ERAS Society, the focus remains with patient outcomes first and foremost. A key aspect throughout this work has been the involvement of nursing and other disciplines making the work truly multidisciplinary and involving these disciplines in the academic work has broadened the reach to all parties involved in patient care. Dothe Hjort-Jacobsen from Copenhagen, and Jose Maessen from Maastricht have been forerunners in this work.

Using colorectal surgery as their model, the group documented their own patterns of care and outcomes using either traditional care or the “ERAS programme” [3]. It was evident to the group that none of them were doing the ideal perioperative care programme. While Kehlet’s group was closest to the ideal protocol, the others were further from it, and all units were doing things differently. They also surveyed specific aspects of perioperative care as practised at that time in five different European countries [4] and showed marked diversity of practice. For example, some patients were fed immediately after surgery whereas others were fasted routinely for 3 days! To try and unify management, the group then developed an evidence-based consensus perioperative care protocol with about twenty different elements [5].

It was decided to have all units move to using the “ideal ERAS” protocol and to study the process of change. This way it was thought that the units could support each other to overcome some of the obstacles that were presented. To support the project a common database was developed to document the results and audit the change. Once the data was reviewed a second revelation was made: it became clear that what was actually performed in the respective clinics was not what the leads had thought, and the units had problems and issues to deal with that they had not known before. It was also obvious that having a protocol was not going to be enough to make the change to an ideal care pathway [6]. Continuous data was the only way to truly know what was ongoing in the perioperative care path.

Using data and working together, progress was made and the units improved their outcomes successively, this time addressing the true issue that needed to be dealt with and not what were the perceived problems. Data was the key to drive change. Dr. Jonatan Hausel at Ersta hospital in Stockholm was the main creator behind initial database. This was the forerunner to the later developed ERAS^® Interactive Audit System.

At around that time the Dutch group had the opportunity to work with professional change management experts in the Kwaliteitsinstituut CBO in the Netherlands. Using the protocol and the experiences from the ERAS study group and combining it with modern change management principles they ran a series of three consecutive implementation programmes each lasting 1 year and including 33 hospitals in the Netherlands (i.e. one third of all hospitals nationwide). These were very successful and showed that the principles of the ERAS protocol had a major impact and helped the units to reduce length of hospital stay by 3 days [7]. This occurred as the compliance with the ERAS Study group protocol was raised from around 45 % to 75 %.

From the early start of the group, research was high on the agenda and several papers including randomised trials of individual elements of the protocol (e.g. [8]) and Ph.D. theses were produced from the work of the group. Some of the key papers that came form the group were the reports on better outcomes with improved compliance with the protocol [9], which is actually a test of the guidelines. While testing of guidelines may seem very basic for any Medical Society to do, such testing is actually not performed commonly. For the ERAS Study Group, however, this work gave support to the ideas that the group were developing. In a meta analysis published in 2010 [10] it was shown for the first time, that applying the principles of ERAS actually had major impact on post-operative complications. An almost 50 % reduction in complications after colorectal surgery was found in that analysis. This was the first time that such evidence had been presented. Previously the focus had been on shortening of length of stay. While the principles had been developed in colorectal surgery there was also a movement exploring these principles in other surgical domains (see below).

The group expanded over time and Robin Kennedy from St Marks joined with his focus on laparoscopic colorectal surgery as an addition to the knowledge base, while Dileep Lobo from Nottingham brought expertise in fluid management, and the Berlin group with Claudia Spies and Arne Feldheiser strengthened the academic input from anaesthesia for the group. During the first 10 years the Study group had generous support from initially Nutricia, the Netherlands, and later from Fresenius-Kabi, Germany with unrestricted grants.

As the ERAS Study Group developed and experience accrued, it became obvious that ERAS was right at the heart of the needs of perioperative care in general. ERAS was leading to better care resulting in faster recovery of the patient/return to autonomy as well as a major reduction in post-operative complications. The information gathered showed that there was a need for a movement to begin to secure that best practice was gathered into guidelines, that the guidelines were being employed in practice and that perioperative care was constantly being improved and updated.