Assessment of the implementation of the peri-operative nutrition ERAS guidelines in elective colorectal surgery patients in a tertiary hospital in South Africa

Kotlowitz, Jessica Rose (2017-03)

Thesis (MNutr)--Stellenbosch University, 2017.

Thesis

ENGLISH SUMMARY : Introduction: The ERAS (enhanced recovery after surgery) guidelines recommend a set of perioperative nutritional interventions which optimize recovery and reduce surgical stress. However, traditional perioperative nutritional practices still persist in many settings worldwide, many of which can be detrimental to patient recovery. The extent of compliance with the ERAS guidelines in South Africa has not been studied. Implementation of the guidelines locally has the potential to decrease morbidity, mortality and length of hospital stay, thereby lowering health care costs. This study aimed to evaluate the current practices and barriers to implementation of the ERAS guidelines in South Africa. Methods: An observational descriptive cohort study with an analytical component was conducted at a tertiary academic hospital in South Africa. Thirty adult colorectal surgery patients were observed throughout their surgical journey. Patients completed an interviewer-administered questionnaire to determine pre- and post-operative fasting times and experiences of current fasting practices. Nutritional risk of patients was determined using the NRS-2002 screening tool. A total of 58 health care professionals (HCPs) (29 professional nurses, 13 registered dietitians, three GIT surgery consultants and 13 anaesthesiology consultants) completed a self-administered questionnaire in order to assess knowledge, attitudes, practices and barriers to the implementation of the ERAS guidelines. Results: Twenty-seven percent of patients were nutritionally at risk on admission and 70% were weighed on admission to the ward. In contrast to the ERAS guidelines, patients were fasted preoperatively from solids and liquids for a mean of 19.5 hours (SD 13.2) and 14.92 hours (SD 7.8) respectively. None of the participants received a carbohydrate loading drink preoperatively. The first enteral feed after surgery was commenced at a mean of 13.64 hours (SD 8.6) postoperatively. Knowledge regarding the ERAS guidelines was poor, with HCPs scoring a mean of 36% (SD 27.7). The attitude questionnaire showed good awareness of the importance of nutrition with 93% of HCPs agreeing with the importance of patients being well nourished before surgery. Seventy one percent of HCPs indicated that they did not intend to order a preoperative carbohydrate drink for their patients. Participants reported advising patients to fast from solids and liquids for a mean of 9.59 hours (SD 5.69) and 4.30 hours (SD 4.31), respectively. Postoperatively, 75% of HCPs reported advising their patients to fast for between four and 24 hours, while 91% reported progressing patients slowly to a full oral diet. Lack of co-operation of the multidisciplinary team, resistance to change, the lack of a formal ERAS policy, the unpredictability of the surgical schedule and the lack of education regarding the ERAS guidelines amongst HCPs were identified as major barriers to ERAS implementation. Conclusion: Implementation of the ERAS guidelines in a tertiary hospital in South Africa was found to be poor and traditional perioperative nutrition practices were still largely used. This study provided further motivation for the implementation of ERAS guidelines and an insight into the barriers of such implementation in public hospitals in South Africa. Stakeholders should engage with these identified barriers in order to develop targeted strategies for successful ERAS implementation.

AFRIKAANSE OPSOMMING : Inleiding: Die ERAS (verbeterde herstel na ’n operasie)-riglyne beveel ’n stel perioperatiewe voedingsintervensies aan wat herstel na ’n operasie optimaliseer en die chirurgiese stres verminder. Tradisionele perioperatiewe voedingspraktyke duur egter steeds voort in verskeie instellings wêreldwyd, waarvan baie nadelig vir pasiënte se herstel kan wees. Die mate van voldoening aan die ERAS riglyne in Suid-Afrika is nog nie ondersoek nie. Plaaslike implementering van die riglyne het die potensiaal om morbiditeit, sterftes en die lengte van hospitaalverblyf te verminder en daardeur die gesondheidsorgkostes te verlaag. Hierdie studie het ten doel gehad om die huidige praktyke en aspekte wat die uitvoering van die ERAS riglyne in Suid-Afrika belemmer, te evalueer. Metodes: ’n Beskrywende waarnemingskohort-studie met ’n analitiese component is uitgevoer by ’n tersiêre akademiese hospital in Suid-Afrika. Dertig kolorektale chirurgiese pasiënte is deur hulle chirurgiese reis waargeneem. Pasiënte het ’n navorser-geadministreerde vraelys ingevul om die pre- en postoperatiewe vastye en ervaring van huidige vaspraktyke vas te stel. Voedingsrisiko’s is vasgestel deur die NRS-2002 siftingsinstrument te gebruik. ’n Totaal van 58 gesondheidswerks (GW’s) (29 professionele verpleegsusters, 13 geregistreerde dieetkundiges, drie GIK chirurgie-konsultante en 13 narkosekonsultante) het ’n self-geadministreerde vraelys ingevul om kennis, houdings, praktyke en struikelblokke tot implementering van die ERAS-riglyne te assesseer. Resultate: Sewe-en-twintig persent van pasiënte het voedingsrisiko’s ervaar ten tye van toelating en 70% is geweeg tydens toelating tot die saal. In kontras met die ERAS riglyne, het pasiënte ’n gemiddelde tydperk van 19.5 ure (SA 13.2) voor hul operasie van vaste kos gevas en 14.92 ure (SA 7.8) van vloeistowwe. Geen deelnemers het ’n koolhidraatladingsdrankie voor hul operasie ontvang nie. Die eerste enterale voeding na die operasie is gemiddeld 13.64 ure (SA 8.6) na die operasie toegedien. Kennis aangaande die ERAS-riglyne was swak met deelnemers wat ’n gemiddelde van 36% (SA 27.7) behaal het. Die houdingsvraelys het goeie bewustheid van die belangrikheid van voeding uitgelig, met 93% van deelnemers wat saamgestem het dat dit belangrik is dat pasiënte goed gevoed is voor die operasie. Een-en-sewentig persent van die deelnemers het aangedui dat hulle nie van plan is om ’n preoperatiewe koolhidraatladingsdrankie vir hul pasiënte te bestel nie. Deelnemers het aangedui dat hulle pasiënte adviseer om gemiddeld 9.59 ure (SA 5.69) en 4.30 ure (SA 4.31) van vastestowwe en vloeistowwe onderskeidelik te vas. Verder adviseer hulle pasiënte om tussen vier en 24 uur na hul operasie te vas, terwyl 91% aangedui het dat hulle hul pasiënte geleidelik aan ’n vol orale dieëet bekendstel. ’n Gebrek aan samewerking in die multidissiplinêre span, weerstand teen verandering, die gebrek aan ’n formele ERAS beleid, die onvoorspelbaarheid van die chirurgiese skedule, en die gebrek aan opleiding aangaande die ERAS riglyne onder gesondheidswerkers, is as hoof-struikelblokke tot die implementering van ERAS geïdentifiseer. Konklusie: Hierdie navorsing het gevind dat die implementering van die ERAS-riglyne by ’n tersiêre hospital in Suid-Afrika swak was en dat tradisionele perioperatiewe voedingspraktyke steeds grootliks gebruik word. Hierdie studie het verdere motivering vir die implementasie van die ERAS riglyne gebied en het insig tot die struikelblokke vir hierdie implementering in openbare hospitale in Suid-Afrika gebied. Belangegroepe moet by hierdie verskillende struikelblokke betrokke raak om sodoende gerigte strategieë vir ERAS implementasie te ontwikkel.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/101403
This item appears in the following collections: