Enhanced perioperative nutritional care for patients undergoing elective colorectal surgery at Calvary North Adelaide Hospital: a best practice implementation project

Objectives: The aim of this project was to evaluate the current practice and implement best practice related to Enhanced Recovery After Surgery (ERAS) nutrition care protocols amongst elective colorectal surgery patients at Calvary North Adelaide Hospital. A second aim was to improve outcomes regarding length of hospital stay and rate of unplanned readmissions within 28-days in patients undergoing elective colorectal surgery. Introduction: The rate of postoperative morbidity remains high after elective colorectal surgery. Enhanced Recovery After Surgery is an evidence-based program incorporating multimodal interventions (including nutrition interventions) in the perioperative period to reduce postoperative morbidity and expedite recovery. Methods: This evidence implementation project used the JBI Practical Application of Clinical Evidence System (JBI PACES) and Getting Research into Practice (GRiP) audit and feedback tool. This project was conducted across the preadmission clinic, intensive care unit and surgical wards of a 153-bed, private, acute care hospital in Australia, along with five private surgical clinics. The sample size included 20 patients undergoing elective colorectal surgery and five colorectal surgeons. Seven audit criteria based on the ERAS Society nutrition care protocols for elective colorectal surgery were used, and patient outcomes were length of stay and rate of unplanned readmission within 28 days. A pre-implementation audit was conducted, which informed the development of an implementation plan for ERAS nutrition care protocols using the GRiP analysis. A follow-up audit was conducted to measure change in practice and patient outcomes. Results: Improvement in compliance was observed in four audit criteria: preoperative fasting is minimized (from 0% to 15%), early feeding is implemented postoperatively (from 10% to 65%), preoperative carbohydrate drinks are given (from 20% to 25%) and oral supplements are given postoperatively (from 0% to 20%). Compliance for one audit criterion remained constant: patients are screened for malnutrition risk in preadmission clinic (100% for both audits). Two audit criteria saw a drop in compliance: nutrition support is provided preoperatively to malnourished patients (from 60% to 15%) and nutrition education is provided preoperatively (from 60% to 20%). There was a 2.5-day reduction in length of stay (average 10.8 days length of stay pre-implementation versus 8.3 days post-implementation) and an increase from 0% to 20% in the rate of unplanned readmissions within 28 days post-implementation; however, these were not statistically significant (p=0.7 and p=0.11, respectively). Conclusions: Changes in patient outcomes could not be attributed to the implementation of ERAS nutrition care protocols, given the mixed compliance with audit criteria in the post-implementation audit. This project has, however, raised awareness of the importance of having operational definitions for audit criteria, systems to ensure adherence to protocols, and audits of calendar year data for reliability and validity of results. It has also increased knowledge of ERAS nutrition care protocols amongst those involved in the care of patients undergoing elective colorectal surgery and strengthened relationships within the multidisciplinary team. This project represents the first step toward the development of an effective ERAS nutrition care program for patients underoing elective colorectal surgery at Calvary North Adelaide Hospital and informs future audits and feedback cycles.