Patient Engagement: Preparing Patients for Surgery

UTMC’s optimization clinic helps patients on the fringes of eligibility.

A healthy patient population is a cornerstone of outpatient surgery. Those fortunate enough to be greenlighted for same-day procedures get to reap their benefits, which include recovering in the comfort of their home in a familiar environment at which they’re at a significantly lower risk of developing an infection.

Obviously, many surgical patients are in poor-enough health that this isn’t an option — an inpatient recovery stay is a must. But what about those who are on the cusp of being approved to have their procedures done in an HOPD or ASC?

Pre-surgery bootcamp

When rejected, patients are often simply given instructions on how to lose or gain weight, stop smoking, get their diabetes in check or walk daily until they’re not short of breath at the slightest physical exertion. Many fail to follow through, and the lack of oversight and support they receive after they’re given the recommendations is a contributing factor.

At The University of Tennessee (Knoxville) Medical Center’s optimization clinic, however, we work with patients for weeks or months to get them surgery-ready. Our prehabilitation work with this high-risk-for-complications population allows us to evaluate and intervene before their surgeries and provide a coordinated care plan to help them qualify for their outpatient procedures.

We often tell our patients who are getting ready for surgery that this is their Rocky Balboa moment. We explain that there’s some work involved, because you can’t just show up for a big fight. You’ve got to prepare for it.

Why and how we optimize

When patients undergo emergency surgeries, it’s no surprise that a healthier person would have to stay in the hospital for a shorter period of time than a less-healthy person. That’s where an optimization clinic has its strength: In nonemergent cases, we have the luxury of increasing a patient’s baseline health so their body can better react to the stress and strain that surgery produces.

Once the pause button is pushed on scheduling a surgery, we begin to work to create a plan to get the patient’s health in better standing temporarily so they can go through a surgery and have the same results that a healthier person would experience. Selecting healthy patients isn’t enough for outpatient success. We work to modify and improve other patients’ risk levels in order to make complications rates go down.

The timeframe for treatment at our clinic varies, depending on the surgery that’s needed and the health of the patient. We use a team approach, so patients are seen by a combination of doctors, nurses, dieticians or exercise educators for comprehensive evaluations. If patients are having trouble following a personalized treatment plan, multiple appointments might be needed, or they might need to call in to speak to one of our team members to stay on track. Our patients experience a variety of challenges. Nicotine is a vasoconstrictor that decreases blood flow to the surgical wound that needs to heal, and those patients are four times more likely to experience a surgical site infection. Patients who are overweight or underweight also have higher risks for complications and the immune systems of people with diabetes often aren’t strong enough to ward off infection to the tissue that is damaged by surgery. Medications are offered or adjusted to make some improvements in addition to the short-term behavior-modification plans we craft to help them improve.

We’re not asking patients to quit smoking forever or to join a gym. Getting them to reduce or eliminate nicotine for 30 days before and after their surgery is enough, as is taking the long walk from the house to the mailbox in East Tennessee twice a day.

After a few months with us, we’ll coordinate with the surgeons, telling them the patients are close to being optimized, so they’ll have time to get them on their schedule. Just getting that surgery date can motivate patients to stick with the plan we’ve designed for them in the event they’ve hit a wall.

Getting ready for surgery is a patient’s Rocky Balboa moment.
Gregory J. Mancini, MD

At first, the delays aren’t popular with patients or doctors, the latter of which are used to operating as soon as possible. They soon realize, however, that optimization allows them to move many of their procedures to outpatient settings and avoid cases with complications that cause expensive hospital stays.

While most patients just want to get their surgery over with, they come to understand the health benefits from putting in the time to prehabilitate, which gives them what they genuinely want — a surgery that went well so they can go on with their lives after a short recovery period. They’d rather put in the two months of work on the front end than need to visit the ER afterward to deal with a complication.

Putting engagement to the test

As we talk to patients about temporarily quitting smoking or losing weight, it’s important that we do so without judgment or sounding like we’re lecturing them. Rather than sounding like we’re on a high horse, we discuss the matters in terms of how the work we’re asking them to put in will benefit them.

We explain that quitting smoking for 30 days or losing 30 pounds will make their surgeries as safe as they are for non-smokers who are at healthy weights. We ask them if they’d like to lower their chances of post-surgery pneumonia or if they’d like to avoid having an infected wound packed with gauze every day for a month. Those conversations work better when it doesn’t seem like you’re angry with them and you’re honestly explaining how they can impact their results by doing their part.

Thankfully, the days of purely doctor-driven care are a thing of the past. Successful surgery is truly a shared experience, and we need to explain to patients that saying that isn’t merely lip service. They need to understand that technological advances and surgical skill are two of the components that allow for successful outpatient procedures, but that surgery is more than just operating on them.

The patients’ preparation beforehand and rehabilitation afterward is equally important. Good processes at top-notch facilities are successful in part because they’re good at getting patients to understand they have a lot of power when it comes to what kind of outcome they’ll have.

If it takes a few appointments and a few awkward conversations before a passive patient becomes an engaged one and you can achieve that shared view, it’s worth it. OSM