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Transforming surgical nutrition care with Enhanced Recovery After Surgery

Clinical dietitians play a key role in implementing protocols that ultimately decrease length of stay in their hospital.

LH-HS.jpgLeslee Hilkewich is a Calgary based clinical dietitian and certified diabetes educator, working for Alberta Health Services. Since completing her internship, from the University of Saskatchewan in 2006, she has been especially interested in surgery, research, sports nutrition and chronic disease management. Leslee contributed to the implementation of Enhanced Recovery after Surgery (ERAS) protocols in Alberta. She has also explored her interest in research over the past two and a half years by conducting a study on these protocols. Leslee can be researched at


If I were to categorise the individuals I work with at the Peter Lougheed Centre (PLC) in Calgary, I would have to say that they are innovators and early adaptors.  

I transferred to the PLC in 2012, but even before I started in my position there, I was receiving emails  about developing a colorectal class with a nutrition component. The purpose of the class was to educate and prepare patients for colorectal surgery. I worked together with another dietitian, Sophia Young Leslee-and-Sophia-(1).JPG(pictured on the right), to develop a 20-30 minute presentation that focused on key nutrition messages for patients before and after surgery. To my knowledge, this was the first time a class like this was being developed for colorectal patients in Alberta.
Once development of the class was complete, we were teaching it weekly and receiving positive feedback from patients and their families. Then, we received an e-mail about attending the Enhanced Recovery after Surgery (ERAS) Conference in Montreal, which would help us to continue to enhance the patient experience. To be honest, I was not sure what ERAS was when I first opened the email. However, by the time I was finished reading it and the attached documents I had a general sense of what it was and I was excited about it! 
ERAS guidelines encompass best practice care elements for before, during, and after surgery to support early patient recovery. Nutrition was discussed in all of the sections! This was the first set of protocols for surgery where nutrition was highlighted, and old standards, such as long fasting times before surgery and NPO after surgery, were challenged and changed. ERAS nutrition components include malnutrition screening, carbohydrate loading, reduced preoperative fasting time, and eating earlier post-surgery combined with nutrition supplements.
ERAS conference in Montreal
The next month, the nurse educator, unit manager, charge nurse, the manager and director of Nutrition and Food Service and myself went to Montreal. It was exciting to hear Dr. Ljungqvist speak about how he and his colleagues developed the ERAS protocols.
During the conference, we also had the opportunity to listen to an RN, from a Montreal hospital, speak about her teams experience using ERAS protocols. Hearing about their experience in implementing ERAS was very beneficial and increased our knowledge about the process. That night, while enjoying delicious French dishes at a quaint restaurant in old Montreal, the discussion regarding ERAS continued. We all thought that ERAS would be a great addition to PLC. 
Implementing ERAS

Once we got back from Montreal, we were eager to implement ERAS at our site, so we set the wheels in motion! Speciality groups where brought to the table and open discussions with anaesthetists, surgeons, nurses, dietitians, managers and directors took place across the province. We received provincial support to implement ERAS from the Diabetes, Obesity and Nutrition Strategic Clinical Network (with support from Nutrition Services), and obtained project funding, which included funding for a site coordinator and the international ERAS database.


ERAS was going to be implemented at PLC and Grey Nuns Hospital in Alberta, with other hospitals in the province to follow. Provincial working groups were formed, meetings were held and plans were developed. The ERAS Nutrition Working Group was made up of dietitians across the province that work in colorectal surgery. This group worked on developing nutrition practice guidelines for carbohydrate loading before surgery, screening for malnutrition, what oral supplement(s) should be given after surgery, and what diet should be provided on post-operative day one.

The amount of research I conducted and meetings I attended increased significantly during this time. At the meetings, it was interesting to see individual’s interpretation of the research and how the research could be practically applied to the different hospitals.  

Ensuring optimal implementation was a long process; I cannot tell you how many meetings we discussed carbohydrate loading and diabetes. Eventually, the ERAS Nutrition Working Group developed guidelines and recommendations that worked within our specific hospital settings.


Getting the surgeons on board

From the start, we had a surgeon that was interested in implementing ERAS. Even before our trip to Montreal, one of our colorectal surgeons had attended a conference in Europe where he learned about the protocols. In addition, there were some newer surgeons willing to try ERAS at PLC.

The surgeons that were unsure about certain pieces of the protocols slowly came on broad once they saw them in action without causing harm. Other factors that got our surgeons on board included not requiring them to attend meetings regularly, and having the order sets for ERAS developed for them. All the surgeons needed to do was review the order sets and provide input. We did it in a way that did not take time away from their demanding schedules.   

Educating the residents

The PLC receives a new set of surgical residents every three months, which means we are doing a lot of education. We are very lucky to have a wonderful, knowledgeable charge nurse who is in communication with the residents daily.

At first, the new residents were taught about ERAS by the charge nurse and via discussions with the surgeons. Now, there is a handout, “ERAS 101: The Need to Know Briefer for PLC Surgical Residents and Interns.” This handout is provided to residents on their first day.


An order set developed for ERAS in our electronic medical system also helps to ensure the right orders are entered. It prevents an NPO diet from being chosen and makes the post-surgical transition diet the diet of choice.

The glue that holds ERAS together at the Peter Lougheed Centre (PLC)

We are also very lucky to have a project coordinator, who was the nurse educator on the surgical unit before ERAS started, to keep us on track. I provide her with the nutrition data for the ERAS database and suggestions when I see a process that needs changing. Our project coordinator truly is the glue that keeps this project together: she keeps the unit updated on new developments in ERAS, talks to all the ERAS patients, collects data, meets with the lead surgeons, anaesthetists and the preoperative assessment clinic, and the list could go on.  
Implementing ERAS takes a committed group of individuals from many different professions within the hospital. Even once ERAS is up and running, you still need a team of dedicated individuals that won’t let the protocols be forgotten about or accept when they are not being followed.
Conducting ERAS research

While working to implement ERAS, we were reviewing the literature, having in-depth discussions and working on guidelines and handouts. This really got our minds working. One day, Sophia Young, RD research.jpgand I were discussing ERAS and how a couple of studies reported that patients could consume 1200-1500 calories after surgery.1

Could you image eating three full meals and snacks right after surgery? We both thought that this was a significant amount of calories and more than our patients would eat. From that discussion and a couple of emails to authors of ERAS articles, we found some gaps in the literature. The information on calorie intake after surgery was based on nutritional supplements and not on solid foods. Additionally, protein intake after surgery was not reported. There were also no studies that compared the oral intake of ERAS patients to those treated traditionally.

During 2013, we put together a proposal for a research project that addressed the gaps in the literature and submitted it to the Canadian Foundation for Dietetic Research (CFDR). All of the support from the nutrition management team during the writing of our proposal paid off – we received grant money to start our research project! 

Today, our research project is still in process. Sophia and I have a keen interest in research that has helped move this project along. This is my first time doing research and I am learning a lot working with Sophia and Tanis Fenton, who both have published research papers.   

Implementing ERAS at your site

From the start, ERAS has increased my knowledge of the surgical process significantly. For us at the PLC, it has reinforced that each health professional plays a key role in impacting the overall status of patients and that working together produces better outcomes.

If you are thinking of implementing ERAS at your hospital, ensure that you have a few key individuals (a surgeon, unit manager, anaesthetist, etc.) that are willing to assist you in this project. Not everyone at your site needs to be interested but a few key individuals are needed and others will change their minds in time.

Consider hiring a projector coordinator that will help move the project forward and keep it going long after implementation. Data needs to be collected and reviewed to see if everyone is being compliant with the ERAS protocols. In addition, reviewing the data provides direction on ways to improve. Our provincial working group still has meetings regarding how the different hospitals are doing with compliancy and we brain storm as a team to determine different ways to help improve it.

ERAS needs ongoing assessment, evaluation and modification if you truly want it to be successful at your hospital. With ERAS in place, I find that patients have a better understanding of what to expect during their admission and they are actively taking part in the recovery process. All the members of the healthcare team have a good understanding of ERAS and help to guide the patients. Most notably, the length of stay at our hospital has decreased!

  1. Gustafsson, U. O., Scott, M. J., Schwenk, W., Demartines, N., Roulin, D., Francis, N., ... & Ljungqvist, O. (2013). Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World Journal of Surgery, 37(2), 259-284.

Editor’s Note: Changing old practices is a challenging task. It involves getting health professionals to step outside of their comfort zone and try something new. Leslee and her team did a great job at getting others on board with the ERAS protocols. It is exciting to hear that the length of stay in their hospital has decreased!

Have you thought about working towards implementing ERAS or changing standard practices to better align with current evidence at your workplace? Please share your thoughts, comments or questions below.

  1. I'm a dietitian working in a health team outside the hospital. The ERAS concept has been slow to develop in our local hospitals. Any suggestions on how dietitians can help move this concept forward when you many not directly work in the inpatient setting?
  2. Congratulations on taking the leadership on this initiative and advancing dietetic practice.

    Have you considered submitting it for the DC National Conference 2016 or Intl Congress of Dietetics, Leslee?


    Great work!
  3. Bravo... as a former surgery RD, it is so inspiring to hear of this work and the leadership of dietitians in fostering interdisciplinary change.
    Well done!

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