Primed for Recovery

Anesthesia

By: Joe Paone

Published: 7/23/2019

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Optimizing patients' nutrition before surgery prepares their bodies for the physical rigors of surgery.


APPLE A DAY Patients who eat the right foods in the weeks leading up to surgery are more likely to experience positive outcomes.

If your idea of surgical nutrition involves handing out Saltines and ginger ale in the PACU, it's time to buy into pre-op nutrition programs that help patients endure procedures, recover more quickly, experience better outcomes and reduce their need for opioids to control post-op pain.

Experts estimate that only about 1 in 5 surgical facilities uses enhanced recovery techniques, including managing how patients prepare their bodies for the physical stress of going under the knife. That needs to change. "We know how important it is to make sure patients, nutritionally, are ready for surgery," says Ron Gauthier, CRNA, BSA, BSN, MS, director of anesthesia and perioperative services at Oaklawn Hospital in Marshall, Mich. "What they eat and drink beforehand makes a big difference."

Set up for success
There's a growing movement to do away with traditional pre-op fasting requirements.

It's important to engage patients in enhanced pre-op nutrition as soon as surgeries are scheduled, says Desiree Chappell, CRNA, of Louisville, Ky., who's a member of the board of directors of the American Society for Enhanced Recovery. The initial pre-op connection with patients is the perfect opportunity to talk about the importance of nutrition and how to start them down the enhanced recovery pathway, which usually involves getting them on an immunonutrition program — eating the right foods and taking vitamin D and omega-3 fatty acid supplements, for example — as soon as possible, according to Ms. Chappell.

But pre-op nutrition is a major shift in thinking for many patients. They generally aren't aware of the benefits and requirements, and the active participation it demands on their part, so ensuring compliance can be tricky. Experts stress providing them with detailed instructions.

"Patients need to understand what they're supposed to be doing. It's not enough to say, "Here you go, take this, and here's some written instructions' that may not make sense to a lot of people," says Ms. Chappell. "Anytime you're implementing something that's non-traditional, which this really is for surgery, you give not only written instructions, but also pictures of the products they're going to be taking."

She says some facilities have developed patient diaries or checklist pages — and some have even set up HIPPA-compliant smartphone apps that provide patients with alerts about what to eat and when, along with the ability to digitally communicate with their providers.

There's another half of the equation, too: making sure relevant staff are experts on pre-op nutrition and enhanced recovery. "Whoever's talking to the patient really needs to understand why you are doing it and what the benefits of it are," says Ms. Chappell.

"You can do so much when the patient is informed from the surgeon's office," adds Lynn Reede, DNP, MBA, CRNA, FNAP, senior consultant for education and practice at the American Association of Nurse Anesthetists.

"Work with the staff in those offices to help them understand how to talk with patients in a way that gives them confidence that they will be part of the decision-making and their care.

Making it work

Much of enhancing pre-op nutrition involves foods patients can buy at a grocery store — high"quality proteins, fish, whole grains, and fruits and vegetables — but there's a growing movement to do away with traditional pre-op fasting requirements, which have been standard in surgery for decades. In fact, Enhanced Recovery After Surgery (ERAS) protocols recommend having patients drink a carbohydrate-rich surgical nutritional beverage a couple hours before procedures.

Many members of your staff might not be aware of enhanced recovery or pre-op nutrition, or resistant to the idea on principle, especially if NPO has been their standard practice for years or decades. "You have to take a psychosocial approach and realize that not everyone is going to buy into this very quickly," says Ms. Chappell. "To me, the biggest thing is making sure your surgeons are on board, and usually that's not that difficult because they don't really have to do anything. They might say, "Does it add more time to my job? No? Okay.'"

Oaklawn Hospital is in the process of getting its enhanced recovery program off the ground. Mr. Gauthier says the process began about 3 years ago, and his team, which includes a nurse navigator and a dietitian, has just brought the pre-op nutrition aspect online. "It's still in progress," says Mr. Gauthier. "We're still trying to fight those battles and get everyone on board."

Getting pre-op drinks into patients' hands is not a straightforward endeavor. First, you need to determine which drinks you'll use. There are several options to choose from that come in a variety of flavors, sizes and formulas (osmag.net/HQ6Gcd).

Then it becomes about figuring out the logistics. Should patients pay for the drinks? Should your facility or the surgeon's office pick up the tab? Does the patient's insurance plan cover the cost? When it comes to selecting a specific drink, will some patients complain or not comply because of its flavor or consistency? And how do patients access the drinks?

You might stock the drinks — by cutting deals with a manufacturer or distributor to get the beverages at a discount or by ordering them in bulk off Amazon — and bundle them into the cost of surgery in claims sent to insurers. You might even have patients buy the drinks themselves at a pharmacy or retailer. You can also consider including the drinks in pre-op care packets, which might include supplies for pre-op bathing with chlorhexidine gluconate, that patients receive before surgery as part of an enhanced recovery program.

DRINK UP Ron Gauthier, CRNA, BSA, BSN, MS, director of anesthesia and perioperative services at Oaklawn Hospital in Marshall, Mich., wants to make carbohydrate-rich pre-op beverages part of standard surgical care.   |  Oaklawn Hospital

Mr. Gauthier wants pre-op drinks to be part of standard surgical care and is trying to convince his hospital's administration to include about 25 drinks in the packet of information patients receive when they schedule surgery.

"It'll cost us around $57 per patient for the bundle, which includes the drinks with instructions to the patient about how much and how often they need to drink before surgery, and also a visit from a surgical navigator who explains the program," says Mr. Gauthier. "We're just trying to figure out a way to pay for it. But patients feel better, they go home faster, and there are less complications. Why wouldn't we spend $57? That's cheap."

To make the financial case, develop a business plan that makes sense for your facility based on a solid return on investment, says Ms. Chappell. In that vein, you have some good cost-saving facts on your side, such as the benefits of quicker wound healing, reductions in SSIs, fewer readmissions and shorter stays.

"When you first look at enhanced recovery, it looks like it's more expensive to provide that care," says Ms. Reede. "But the truth is that it decreases length of stay and complications, and increases patient satisfaction, which contributes mightily to the bottom line of your facility."

Progress reports

Ms. Reede stresses the need to continually monitor your enhanced recovery process, including the impact pre-op nutrition makes on it, in order to make improvements. A big component of that is data analysis. "Once you have your program implemented, make sure you have solid metrics and outcome measures in place," she says. "Then you can really make changes that are valuable and informed."

Track surgical outcomes and how many patients are compliant with pre-op nutrition directives. Also observe how well your staff is implementing the program. Ms. Reede says a major impediment to getting a truly holistic view of the process is the fact that multiple facilities might be involved — the surgeon's office, the preadmission testing clinic, your facility and the physical therapy provider.

At Oaklawn, the team tracks and analyzes numerous data points, including readmission rates, nausea, and the length of time until the patient is walking around and eating solids. A nurse also calls the patient at 2 days, 2 weeks and 2 months after surgery to acquire feedback and data.

Ms. Reede says enhanced recovery is making inroads at academic medical centers because they have advanced resources and infrastructure. Maybe your facility doesn't have the resources or need to implement a comprehensive enhanced recovery program. That's OK, says Ms. Reede. Just adding the pre-op nutrition component can provide big benefits.

She adds, "Keeping patients hydrated, by giving them carbohydrate beverages or nutritional beverages before their procedures, improves their ability to respond to the physical stress of surgery and means they're able to begin eating again sooner and metabolize at a regular blood sugar level with their insulin working properly."

Ms. Reede recommends at the very least adopting the American Society of Anesthesiologists preoperative fasting guidelines, which state patients can drink clear liquids up to 2 hours before surgery. "That alone, for them to have fluids up until they come for surgery, is such a huge value," she says. "They're not thirsty or grouchy. They feel better and their neurotransmitters are working, so they can actively participate in their care. Patients are very comfortable, even after major surgeries, because they're not dizzy and dehydrated from not eating or drinking." OSM

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