By Dr. Gajan Srikanthan, Director Clinical Pathways, Lumeon
Preparing for surgery is a complex process, which can become chaotic without careful management. It’s essential to prioritize both patient and caregiver pre-surgical readiness to make sure that everything goes according to plan, and that patients arrive well prepared for their procedure.
For patients, this means receiving clear information and easy-to-follow instructions about what to do before surgery, how to prepare, and when and where to arrive. On the caregiver side, best practice calls for organized and thorough processes that help with the mitigation of risk.
Pre-surgical assessment is fundamentally risk management, with risk varying from patient to patient and from procedure to procedure. Standardized systems allow for identification of patients at increased risk, allowing care teams to take steps to mitigate that risk, and where needed to delay or cancel the surgery. Mitigation includes medical optimization, such as managing blood pressure, anemia, or smoking status; managing medications like anticoagulants; and undertaking procedures to manage cardiac risk, such as coronary stent insertion.
Readiness can also revolve around logistics, such as the patient knowing where to be and where to go. It’s also important that patients understand the procedure they’re about to have — the risks, the benefits, the recovery process. They should be informed that choices like smoking habits and alcohol consumption can result in a complicated and prolonged recovery phase.
Enhancing patient and caregiver readiness involves two important elements: well-coordinated, personalized communication and proactive patient care, which includes pre-habilitation and post-op follow-up. Let’s look at how each of these works in practice and why each is essential.
Well-coordinated, personalized communication
A well-coordinated communication plan for pre-surgical readiness has many elements, including the expression of welcome and an introduction to the surgical process. The provider should give the patient information specific to the procedure to be undertaken, including risks and benefits, and clarity about what tests and investigations need to be done, where, when, and by whom.
The patient should leave the pre-surgical appointment with knowledge of whether a more specialized workup is needed by their primary care physician or other provider, and whether there may be a delay to their date of surgery due to issues that may need to be optimized. Communication should include clear directions about when to stop specific medications and what else to do just before surgery, such as bowel prep, carbohydrate loading, or food and fluid restrictions.
The patient should also be informed about logistics for the day of surgery and what to expect in the phases of recovery. The family or carer should be provided instructions regarding pick-up and care immediately following surgery, as well as what complications or early warning signs to look out for.
Little of this information is standard across patients and surgical procedures. Personalized communication is particularly important because requirements vary depending on the particular surgery being done, as well as on the specifics of the patient. For example, how to manage anticoagulants and thromboembolic risk depends on the reason the patient is receiving anticoagulants. Caregiver communication tailored to the situation at hand will result in better outcomes.
Proactive patient care
Proactive patient care is the idea of full-surround care that guides patients before, during, and after surgery. This includes both pre-habilitation and post-operative follow-through, ensuring that patients are cared for not just during their surgical procedures but also engaged in active preparation and coached through recovery.
Pre-habilitation — or “training for surgery”— involves engaging patients in one or all of four activities before surgery: physical exertion, pulmonary rehabilitation, nutritional optimization, and stress reduction. This can be important preparation because surgery represents a significant physiologic stress comparable to intense exercise. It causes increased metabolism and catabolism, increased oxygen uptake, stress hormone production, and release of inflammatory cytokines.
Although this stressor affects all patients undergoing surgery, frail patients with poor cardiopulmonary reserve and overall physical deconditioning are particularly taxed and may do better with focused and sustained pre-habilitative intervention. Frailty has been shown to be associated with increased mortality, morbidity, and poor outcomes overall, resulting in increased hospital costs and greater resource use for frail patients compared with non-frail patients.
Pre-habilitation can improve a patient’s functional status before this major stressor, thereby reducing the physiologic dysregulation and postoperative complications for which the frail are at particular risk after surgery. While data are mixed on the effects of pre-habilitation, it is generally accepted that it results in a more rapid return to baseline functional capacity after surgery. Pre-habilitation has also been shown to reduce postoperative complications, though studies that have investigated mortality outcomes have had equivocal results.
Proactive care also dictates thorough post-operative follow-through, including clear instructions to patients and carers about recovery, assistance in making the requisite follow-up appointments and reminders to attend them, and open lines of communications for questions and advice.
With a personalized communication plan and an orientation to proactive patient care, surgical teams can better engage patients from the start to the end of their relationship, enabling better surgical experience and enhanced outcomes.