Barriers faced by surgeons in identifying and managing malnutrition in emergency general surgery: A qualitative study.

Abstract

Many patients undergoing emergency surgery are malnourished. Identifying malnutrition is a prerequisite to offering targeted nutritional support. Guidelines exist but little is known regarding exactly how surgeons identify malnutrition, or the barriers that influence surgeons' clinical decision-making. The aim of this work was to explore how consultant surgeons identify malnutrition in emergency general surgery (EGS) patients and the barriers to nutritional assessment and intervention. Consultant surgeons with emergency surgery duties were invited to participate. Semi-structured interviews were conducted online, audiovisually recorded and transcribed. An inductive approach was used for data analysis using the framework method. Coding and analysis were performed by two independent researchers using NVivo software. Themes were developed and reviewed with the supervising team. Interviews continued until data saturation was reached. Ethical approval was gained prior to interviews. Eighteen interviews were conducted across three hospital settings. Identification of malnutrition consisted of three themes: 'The surgeon' (knowledge, experience, planning ahead); 'The patient' (selection, composition, clinical progress, operative considerations); and 'The institution' (collaboration, extended surgical team). Three themes encompassed barriers experienced: 'The surgeon' (understanding, culture, ownership, time constraints); 'The institution' (provision, staffing, conflict, hospital setting); and 'The wider context' (research, external factors). These influenced clinical decision-making, which had two themes: 'To join or not to join' (risk taking, site of anastomosis) and 'Nutritional support' (timing, referral pathways). The identification and management of malnutrition in EGS is fraught with barriers, impacting operative and clinical decision-making. Improvements in surgeon education, culture, collaborative working and resources are needed.