LAUSR

The evidence for Enhanced Recovery After Colorectal Surgery (ERAS) practices is well established in the literature, however, it has been observed that the various elements have been inconsistently implemented. The application of early resumption of oral diet has demonstrated the poorest adherence. A recent Australia and New Zealand (ANZ) study evaluated colorectal surgeons’ attitudes towards several ERAS interventions but excluded early postoperative diet upgrade as this was an early feature of fast-track surgery and there is substantial evidence that return to solid oral diet within 24 hours after colorectal surgery is safe, may facilitate early discharge, and should therefore be the standard of care. Ward-based practice across Australia and New Zealand is currently unknown, with the only reported data an extremely small sample (n = 4) of surgeons from a 2009 Australian Safety and Efficacy Register of New Interventional Procedures—Surgical (ASERNIP-S) report. The aim of this paper is to report the findings from a survey of usual ward-based practice related to standardised post-operative diet upgrade processes in colorectal surgical patients and whether practice change is sustained at publicly funded Australian and New Zealand facilities. A multicentre cross-sectional study was undertaken by online survey developed in Qualtrics XM (https://www.qualtrics.com/), a proprietary platform to collate and categorise survey responses hosted by the University of Queensland. The survey questions (open and closed) were developed based on the literature and local practice of the research team, and included logic depending on participant’s responses (see Appendix S1). A survey link was distributed (October–December 2020) via relevant professional associations and clinical networks to clinicians at Australian and New Zealand facilities. Individuals were eligible to participate if they were a surgeon, dietitian or senior nurse working in colorectal surgery at a publicly funded adult hospital that performs major elective colorectal surgical procedures. Participants self-identified by voluntarily completing the survey. This study was reviewed and approved as quality assurance by the local Human Research Ethics Committee Office (LNR/2020/QRBW/68289). The Qualtrics system recorded 106 entries into the survey, of which 68 responses were eligible and sufficiently complete for analysis. Respondents were primarily surgeons (n = 50) and represented 41 sites across Australia and New Zealand (25 sites had a single respondent, 16 sites had multiple respondents (range: 2–7)). Among responses from these 16 multiple respondent sites, poor agreement was found at every survey question. For example, when asked whether their site had a standardised process for post-operative diet upgrades, seven of 16 multiple respondent sites (44%) disagreed about the existence of a standardised process. Similarly, when those sites who reported having a standardised process were asked about the day post-operatively patients are allowed a solid diet (Q26), there was disagreement among four of five multiple respondent sites (80%). Further disagreement was found when inquiring about the person responsible for making the decision to commence or upgrade a patient’s diet following surgery (Q28), with disagreement at three of five sites (60%). No multiple respondent site demonstrated agreement at both Q26 and Q28. Due to the poor agreement among sites and therefore limited reliability of the survey findings, no further data has been summarised. This study has highlighted considerable disagreement among ANZ institutions regarding an important aspect of post-operative care, with nearly half of sites with multiple respondents disagreeing about the existence of a standardised diet upgrade process. Furthermore, post-operative day that first solid diet is permitted and who is responsible for commencing or upgrading a patient’s diet (i.e., who is responsible for doing what and when) are arguably the key aspects of any standardised diet upgrade process indicating poor understanding of existing protocols. The findings of this study suggest that despite being a key element of ERAS protocols, inconsistency in practice still exists regarding early resumption of diet following colorectal surgery and this likely presents a major barrier to successful implementation and sustainability of this practice. Adequate stakeholder engagement to align priorities and communicate change are important steps in achieving consistency in practice and these findings suggest this may be lacking among colorectal surgery teams at many ANZ facilities. When using survey methodology, it is important to acknowledge that the responses will reflect how the question is asked and this could have contributed to the disagreement observed. In an attempt to account for this, the quantitative responses were cross-checked with qualitative descriptions of how post-operative diet upgrades were provided at the respondent’s facility (Q19), however both questions identified inconsistencies among sites and therefore it is unlikely simply due to the question phraseology. This is the first multi-site study describing the existence of standardised post-operative diet upgrade processes in the ANZ context and should be broadly generalisable across other ANZ institutions.