Improved Adherence to Evidence-Based Early Recovery After Surgery (ERAS) Through Enhancement of the Preoperative Environment for Elective Colorectal Surgical Patients
Summary
This Advanced Clinical Practice Fellowship (ACPF) took place at Southlake Regional Health Centre (SRHC) to improve the quality of patient care post-colorectal surgery, and improve awareness of Enhanced Recovery After Surgery (ERAS) interventions. Specifically, the fellowship was aimed at improving consistency of care given to colorectal patients – in both the preoperative and postoperative environments. Within the last fiscal year, it was noted through a retrospective chart audit that less than one hundred elective colorectal cases are done at SRHC. At this community hospital, this population is considered a low-volume surgical population – and therefore has limited resources available to them during their surgical journey. As a small surgical population and as bowels/colorectal surgery are a taboo subject, this population becomes a vulnerable population. At SRHC, there are current preoperative environments for the larger surgical populations – such as thoracic, orthopedic, and cardiac surgery. High-volume surgical patients often attend detailed preoperative sessions with health teaching surrounding their preparatory phase prior to surgery, what to expect on their surgical day, what their goals and expectations are postoperatively, and what to expect in terms of length of stay (LOS) and discharge criteria. With this knowledge, patients arrive to the postoperative phase as an active partner in their surgical journey – thus resulting in positive patient outcomes, which lead to early and safe discharge. As a community hospital, for the past few years, SRHC has been attempting to follow in the footsteps of the university hospitals with the launch of ERAS for colorectal patients. During the initial launch phase, ERAS was introduced to the frontline staff. Unfortunately, due to periodical fluctuations and staff turnover, ERAS education was not a priority at the frontline. In addition, due to the inability to participate in an audit, the level of compliance was difficult to establish. As a result, it was noted at the frontline that care given to colorectal patients was inconsistent and incomplete – thus reducing the quality of the care they were receiving at SRHC.
My overall learning goal for this ACPF period was to improve the quality of care delivered to colorectal patients by providing accessible resources, and to improve the consistency of care delivered through the education of pre- and postoperative nurses. The ACPF funded by RNAO was an opportunity that was much needed, as two General Surgeons were expressing interest in optimizing colorectal patient experience. These two General Surgeons became secondary mentors in this ACPF experience. In addition to this interest, it was noted that there were no resources available to colorectal patients prior to entering the surgical pathway. As a result, they are largely unprepared for their surgery – creating the gap in quality of delivered care and anecdotal reports of decreased patient satisfaction. Therefore, my learning activities centered around assessing the current processes present in pre- and postoperative environments for colorectal patients. A gap analysis was conducted using stakeholder surveys; silent observations of preoperative colorectal appointments; a retrospective chart audit – taken from the last fiscal year between March 2018 – April 2019; a literature review, to understand current standards of care surrounding ERAS; site visits of neighbouring hospitals; and a retrospective Patient Focus Group, to further understand the patient perspective post-colorectal surgery. The gap analysis indicated the lack of patient resources prior to colorectal surgery – as mentioned above – and highlighted the knowledge gap present among pre- and postoperative nurses. As this gap analysis was conducted, it was evident how time-consuming it could be for a thorough analysis to be conducted without the extra resources provided through the ACPF. This ACPF provided the protected time required to conduct a thorough gap analysis and the time to focus on multiple initiatives, simultaneously.
Outcomes
Interventions carried out during this ACPF for colorectal patients include: the development of a standardized Bowel Preparation Instruction Sheet for Colorectal Surgery – incorporating the best practice of pairing oral antibiotics with mechanical bowel preparation; Continual Patient Surveys, to monitor process measures while interventions were being delivered to pre- and postoperative nurses; the creation of a Bowel Surgery information Booklet, to be delivered to colorectal patients prior to surgery; and the development of an audiovisual online resource to be accessed through SRHC's website, as a supplementary resource for colorectal patients. The Patient Focus Group held to understand the patient perspective postoperatively significantly aided in the creation of these resources for current patients. A Patient Focus Group can be held one-year post-implementation in order to identify persistent gaps and/or improvements that have been made since the last session.
The gap analysis conducted indicated a need to target two major stakeholders – the pre- and postoperative nurses, and colorectal patients. Interventions carried out during this ACPF for pre- and postoperative nurses consisted of: the development of a colorectal teaching template for the preoperative nurses, to improve consistent health teaching for preoperative colorectal patients; an education session surrounding Patient Engagement for preoperative nurses, to improve methods od health teaching and engaging the patient population; six weeks of ERAS-focused education for the postoperative nurses, to re-introduce goals and expectations for postoperative colorectal patients; and a condensed "Blitz Sheet" to summarize each weekly ERAS topic – later compiled into an ERAS refresher binder. From post-administration surveys, positive feedback was obtained from staff stakeholders.
Overall experience
I look forward to see all the patient-focused interventions come to fruition – once the official launch occurs in Fall 2019. I would say my biggest accomplishment would be the Patient Education booklet developed for the colorectal patients. As there was no formal education resource previously at SRHC, I am happy that I was able to help create some resources for future colorectal patients. A copy of the published Patient Education booklet was mailed to those individuals who had come back for the retrospective Patient Focus Group - their positive feedback further validated the creation of this resource. I would like to thank the mentors involved in my learning experiences throughout this ACPF, and those unofficial mentors who guided me throughout the ACPF period. I would also like to thank the pre- and postoperative nurses who welcomed the educational opportunity, despite the patient acuity and quick patient-flow. Finally, I would like to thank the patients who were willing to come back postoperatively to speak during the Patient Focus Group. Their feedback and perspectives were a valuable asset to driving the patient-focused interventions. Thank you RNAO and SRHC for this opportunity.
