Enhanced recovery after surgery
Local case study – Calvary Mater Newcastle, Hunter New England Local Health District

Enhancing outcomes for breast surgery: mastectomy and wide local excisions

2 Sep 2022 Reading time approximately

Each year, Calvary Mater Newcastle performs approximately 360 mastectomies and wide local excisions for women with breast cancer.

In 2018, the hospital received a $10,000 research grant from the McGrath Foundation to reduce variation in surgery. Variation was identified for the length of stay following breast cancer surgery. This was higher than similar hospitals, based on benchmarking data from Health Roundtable.1 Variation also occurred in surgical drain management following surgery.

Consumer feedback identified that fundamental needs were not being met. For example, women were unaware that the blue dye used for lymphoscintigram was visible in urine following their operation. This was then causing patients unnecessary concern.

How the service enhanced recovery after surgery

Three key information resources were developed to support enhanced recovery after surgery (ERAS):

  • A booklet for patients on Early Recovery After Breast Surgery
  • An ERAS Pathway for Mastectomy/Wide Local Excision for clinicians
  • An information booklet for hospital-in-the-home and community nursing on drain management

The resources were reviewed by clinical specialists, women who have experienced breast surgery and nurses from the McGrath Foundation.


The three resources were implemented concurrently as an initial three-month trial. It then took around 12 months to embed into clinical practice.

Implementation followed the NSW Health Essentials of Care framework and methodology: preparation, assessment, feedback, action planning, implementation and re-evaluation.2

The Director of Surgery, Director of Anaesthesia and three clinical nurse specialists supported implementation locally.

Implementation enablers

Intervention source and adaptability: ERAS components were developed internally and tailored to local needs and context.

Design quality: high-quality presentation of resources and integration with point-of-care prompts (e.g. laminated cards on files and clipboards, and use of the electronic patient journey board to indicate an ERAS pathway).

External incentives: benchmarking reports on the length of stay.

Champions: internal multidisciplinary staff supported implementation (e.g. prompted at the daily safety huddles and delivered workplace learning opportunities on ERAS).

Reflecting and evaluating: audit and feedback mechanisms were established to monitor compliance and provide real-time feedback. Audit indicators included procedure, the surgeon, post-operative nausea and vomiting, and length of stay.

Impact and outcome

Between 2019–2020, the initiative resulted in:

  • approximately 80% compliance with the inpatient pathway
  • around 92% of patients receiving the information about early recovery after breast surgery
  • all ERAS components were embedded into clinical practice
  • the average length of stay reduced from 3.7 days to 2 days.

The pathway has reduced variation, and everyone is now on the same page. It took 12 months to get the length of stay down to 2 days and stay there. I believe there has also been a reduction in post-operative complications.

Cheryl Cooley, Nurse Manager Surgery, Calvary Mater Newcastle


Contact aci-surgery@health.nsw.gov.au with any questions or to request a copy of the resources.


  1. The Health Roundtable. Health Roundtable [cited Sept 2022].
  2. NSW Health. Essentials of care. Sydney: NSW Health; 2014 [cited Sept 2022].
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