St George Hospital implemented enhanced recovery after surgery (ERAS) for colorectal surgery in 2015 after two years of planning. In July 2017, the hospital received innovation funding from the South Eastern Sydney Local Health District for 1.2 FTE for nurses to roll out ERAS for upper gastrointestinal (GI), urology and vascular procedures. One part-time nurse was allocated to each subspecialty area.
Levers for change
Presentations were made at the surgical safety and quality meeting and Grand Rounds to share the European evidence of process and outcomes of ERAS implementation to gain support to roll out the initiative locally. Presenting hospital-acquired complication (HAC) data and length of stay for their patients also helped gain surgeons' buy-in.
ERAS components
- Appointment of an ERAS nurse
- Development of overriding governing principles for pre-operative, intra-operative and post-operative stages
- Development of a booklet to educate patients on early recovery after their surgery
- Development of ERAS pathways for clinicians
- Establishment of post-operative clinical business rule
- Establishment of post-operative mobilisation protocol
- Establishment of a ‘Golden ticket’ system to allow any patients presenting to the emergency department after they had been discharged to be seen as soon as possible by the surgical registrar
- Phone call follow-up with the patient on day 1 and day 30 post-discharge
Implementation
A core group of multidisciplinary staff supported ERAS implementation for colorectal surgery. An ERAS steering committee was established, which included the Director of Surgery, a colorectal surgeon, an anaesthetist, the Clinical Nurse Consultant (CNC) Surgery, the CNC Pain, the CNC Stomal Therapy, a dietitian, a social worker, the Surgical Ward Clinical Nurse Educator (CNE), the Surgical Ward Nursing Unit Manager (NUM), the Preadmissions CNC and a consumer representative.
Audit and feedback mechanisms were established to monitor compliance and provide real-time feedback. Daily information was collected on ERAS patients and filed using an Excel spreadsheet. A balance of means and averages was used to indicate discontinuing, improving or keeping the status quo with the ERAS intervention. Audit indicators included procedure, surgeon, post-operative nausea and vomiting, pain, diet progression and length of stay.
Using learnings from the colorectal ERAS implementation, St George Hospital began developing ERAS pathways for upper GI, urology and vascular clinicians.
Committees were formed for each of the subspecialties of upper GI, vascular and urology, to support the ERAS rollout. Each committee was chaired by a CNC and included a nurse unit manager, ward educators, specialty fellows, physiotherapists, dieticians and social workers. Input was also provided by the consumer advisory committee.
Implementation enablers
Intervention source and adaptability: ERAS components were developed internally and tailored to the local needs and context. An important component of this was gaining consensus from all surgeons involved.
Implementation lead: an ERAS nurse was appointed in 2017, which enabled the program expansion. The key responsibilities of this role included:
- Developing and updating surgery specific care plans and supporting documents such as the patient information booklet
- Educating patients regarding ERAS principals pre- and post operatively
- Educating staff on ERAS principals
- Collecting, evaluating and re-evaluating data
- Promoting change or encouraging the status quo
External incentives: international evidence, benchmarking reports on HAC complications and length of stay.
Leadership: sponsorship from the hospital general manager. Regular presentations at the Grand Rounds, inservices, nursing morbidity and mortality reviews and department meetings. Subspecialty working groups were set up to roll out ERAS.
Governance: an ERAS steering committee was initially established as part of the governance structure to support ERAS rollout for colorectal surgery. As ERAS became business as usual for colorectal, governance was moved under the Patient Surgical Optimisation Multidisciplinary Group.
Champions: internal multidisciplinary staff supported implementation (e.g. collaborate with and influence others, deliver 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, pain, diet progression and length of stay.
Impact and outcome
- reduced length of stay
- improved nutritional intake
- reduced risk of indwelling catheter (IDC)–associated infection without risk to patients.
At St George Hospital, the initiative has resulted in:
The average length of stay for colorectal patients pre-ERAS implementation was 10.00 days. This was reduced to 5.88 (SD 3.06) days. Specifically, there was a reduction in the length of stay for patients undergoing a hemicolectomy from 10.3 to 5.07 days.
We have seen a return to light diet much faster since the implementation of ERAS. We have also seen a reduction in the number of IDCs and if in situ a reduction in the time to IDC removal, as well as reduced preoperative fasting and reduced use of pathology services.
Contact
Email ACI-Surgery@health.nsw.gov.au with any questions or to request a copy of the resources.