9/3/19 1 Optimizing patients for surgery The Experience in a Level 1 County Hospital Diane St Pierre, APRN, ACNP-BC, CTTS Certified Tobacco Treatment Specialist Disclosures ´ I have nothing to disclose. Objectives ´ Describe the need for surgical optimization in the outpatient surgery clinic ´ Describe the methods used to improve overall patient health prior to elective surgery ´ Discuss the impact on patient care and same day cancellations in the OR Why do we need surgical optimization? ´ The risk for negative outcomes in elective surgery has been shown to be reduced when preoperative optimization is performed ´ Smoking cessation ´ Weight loss ´ Nutrition support ´ Glycemic control ´ Optimization of medications ´ Delirium ´ Prehabilitation ´ Patient directives Why do we need surgical optimization? ´ In 2016, our county hospital had an estimated 23,847 minutes of operating room underutilization. Depending on the type of surgery, the first 30 minutes of OR time costs $4,272 - $7,508, each minute after that costs $23. This translated into $1,716,984 in lost revenue. ´ Updated current OR costs: $3,885-$9,345 for the first half hour. $17.53-$21 per minute. ´ Postoperative Respiratory complications can add an additional $52,000 dollars to the cost of hospitalization. ´ Surgical site infection rate prolongs hospitalization and impacts reimbursement Why do we need surgical optimization? ´Common reasons for same day cancellations ´ Uncontrolled HTN ´ Uncontrolled DM ´ Poor nutritional status ´BMI too high ´Low albumin ´ Need for cardiac or pulmonary risk stratification ´ Need for medical risk stratification
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9/3/19
1
Optimizing patients for surgeryThe Experience in a Level 1 County Hospital
Diane St Pierre, APRN, ACNP-BC, CTTSCertified Tobacco Treatment Specialist
Disclosures
´ I have nothing to disclose.
Objectives
´ Describe the need for surgical optimization in the outpatient surgery clinic
´ Describe the methods used to improve overall patient health prior to elective surgery
´ Discuss the impact on patient care and same day cancellations in the OR
Why do we need surgical optimization?´ The risk for negative outcomes in elective surgery has been shown to be
reduced when preoperative optimization is performed
´ Smoking cessation
´ Weight loss
´ Nutrition support
´ Glycemic control
´ Optimization of medications
´ Delirium
´ Prehabilitation
´ Patient directives
Why do we need surgical optimization?
´ In 2016, our county hospital had an estimated 23,847 minutes of operating room underutilization. Depending on the type of surgery, the first 30 minutes of OR time costs $4,272 - $7,508, each minute after that costs $23. This translated into $1,716,984 in lost revenue.´ Updated current OR costs: $3,885-$9,345 for the first half hour. $17.53-$21 per
minute.
´ Postoperative Respiratory complications can add an additional $52,000 dollars to the cost of hospitalization.
´ Surgical site infection rate prolongs hospitalization and impacts reimbursement
Why do we need surgical optimization?
´Common reasons for same day cancellations´ Uncontrolled HTN´ Uncontrolled DM
´ Poor nutritional status´BMI too high
´Low albumin´ Need for cardiac or pulmonary risk stratification
´ Need for medical risk stratification
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Why do we need surgical optimization?´ These delays can postpone elective surgery upwards of
4-6 months. Family Practice clinics are so overburdened that a patient request for an appointment can take 3 months to be scheduled. ´ High provider turnover rates (residents) can result in patients not having
an assigned primary care provider. One byproduct of this is lack of appropriate medication refills, leading to uncontrolled hypertension and diabetes as well as other medical conditions.
´ There is additional burden placed on the UCC/ED for medication refill visits.
Why do we need surgical optimization?
Common preventable postoperative complications which may be prevented by optimization
´ Pneumonia
´ Superficial and deep wound infection
´ Myocardial Infarction
´ Arrhythmia
´ Severe pain
´ Pulmonary Embolism
´ Acute Kidney Injury
´ CVA
´ Respiratory failure
´ Acute confusion/delirium
´ Cardiac arrest
´ Need for transfusion
ASA Classification METS – metabolic equivalent of task
One MET is defined as the amount of oxygen consumed while sitting at rest and is equal to 3.5 ml of O² per kg body weight, per minute.Evaluates the functional capacity or exercise tolerance of an individual
AHA/ACC Guidelines 2017
´ For patients with history of CAD without symptoms and without risk factors, no additional cardiac testing is indicated prior to surgery.´ Risk factors:
´ Sex Fam ily history of heart d isease
´ Sm oking Uncontrolled stress/anxiety
´ Elevated LDL Alcohol use
´ Uncontrolled diabetes Physical inactivity
´ Obesity Elevated CRP
´ Uncontrolled HTN
Risk stratification – case study
´ 58 yo woman PMH COPD, CHF, HTN, GERD, DM
´ FH CAD, CVA
´ Saw PCP 5/31
´ Ortho 6/27 – needs rotator cuff repair
´ SOP 7/2 - Exertional chest pain relieved with rest
´ 7/10 – DSE
´ 7/18 – LHC w/ DES x3 (RCA, LAD, LCX 80% not amenable to PCI)
´ Smoking has been shown to increase the risk of postoperative complications´ Respiratory
´ Pneum onia
´ Difficulty weaning
´ Reintubation
´ Increased m ortality
´ Infection
´ Increased risk for SSI
´ Increased M RSA drug resistance
´ Wound healing
´ CV complications
Smoking Cessation
´ Medicare Part A and B cover individual counseling for smoking cessation´ Counseling is a covered benefit without regard for signs or symptoms of
tobacco related disease´ Can be individual, group, phone counseling
´ Two quit attempts per year are covered ´ 4 counseling sessions per each quit attem pt
´ Part D covers NRT (inhaler or nasal spray), bupropion, varenicline´ OTC not covered
´ Patch, gum , lozenge
Smoking Cessation´ Affordable Care Act Coverage´ Tobacco cessation interventions for adults have an “A” rating by the U.S. Preventive Services Task
Force (USPSTF), m andating coverage of tobacco cessation treatm ent. This applies to both federal and state run m arketplace plans.
´ Coverage includes both counseling and m edications without cost-sharing (out of pocket expense to the patient). For those using tobacco products, at least 2 quit attem pts per year are covered.
´ This includes:
´ Four tobacco cessation counseling sessions of at least 10 m inutes each (individual, phone, or group) w ithout prior authorization
´ 90 days of any FDA-approved tobacco cessation m edication when prescribed by a healthcare provider w ithout prior authorization
´ The 7 FDA-approved cessation m edications include: N icotine patch, gum , lozenge, nasal spray, inhaler, bupropion, and varenicline.
´ These recom m endations are based on the 2008 Update of the Clinical Practice Guideline:Treating Tobacco Use and Dependence (PHS)
ACA plans which do not provide this coverage are out of com pliance
´ https://attud.org/aca.php
Smoking Cessation
´ Counseling´ Readiness to quit
´ Previous quit attempts
´ Quit plan
´ Quit date
´ Barriers to quitting
´ Plan for triggers, stressors´ Slips vs relapse
´ Smoking cessation apps
´ Smoking cessation classes
´ Empower the patient´ M otivational interview ing
´ Shared decision m aking This Photo by Unknown Author is licensed under CC BY-NC
´ Surgery August 8 with successful TAR´ PRS performed panniculectomy´ Surgery follow up 8/29 – 37.02 (209 lb)´ No medications used.
This Photo by Unknown Author is licensed under CC BY-NC-ND
Nutrition support´ 25-40% of patients admitted are malnourished
´ Albumin <3 associated with increased rate of post op complication
´ Optimizing protein improves wound healing´ BMI <20 would benefit from supplements
´ Post procedure, eat 3 meals per day ´ Protein shake to replace if not hungry/able to eat
´ Protein rich foods to help with healing´ Fish, poultry, eggs, beans, cheese, nuts, tofu, protein drinks
´ Stay well hydrated´ Meet with RD if needed
´ Immune modulating supplements
Glycemic control
´ Uncontrolled diabetes can double the risk of SSI
´ Patients without diagnosis of diabetes with perioperative glucose >124 had higher incidence of infection
´ Glycemic control prior to elective surgery decreases the risk of hyper/hypoglycemia perioperatively
´ Perioperative physiological stress can increase BG
´ 25% of people with Type 2 DM are undiagnosed
´ Hispanic and Asian population 50% have not been diagnosed
´ Most prediabetic patients are undiagnosed
Glycemic Control´ Type 1 Diabetes
´ Autoimmune disease
´ Previously called Juvenile Diabetes
´ Genetic risk factors
´ Parent or first degree relative with Type 1
´ Ethnic risk factors
´ In the US, predominately seen in whites more than Latino or African American
´ Outside the US, China has the lowest incidence
´ 10-20 times less than Europe, North America and Australia combined
´ Finland has the highest incidence
´ 60 in 100,000 people
´ Three times US average
Glycemic control
´ Type 2 Diabetes´ The body either is resistant to insulin or produces an inadequate
amount. ´ Symptoms
´Polydipsia´Polyphagia
´Polyuria´Fatigtue
´Visual changes´None
Glycemic control´ Screening for Type 2 diabetes
´ Not autoimmune´ Risk factors include
´ Family history of diabetes (1st or 2n d degree relative)´ Personal history of GDM´ Maternal history of GDM´ Ethnicity´ Characteristics of insulin resistance
´ Acanthosis nigricans´ PCOS´ HTN´ Dyslipidemia
´ Small for gestational agehttps://derm101.com/clinical-atlas/acanthosis-nigricans/
´ Ethic groups at risk for diabetes´ More likely to be overweight with hypertension and type 2 diabetes
´ African Americans
´ Mexican Americans
´ American Indians
´ Native Hawaiians
´ Pacific Islanders
´ Asian Americans
w w w .D ia b e te s.o rg
Glycemic Control
´ Evaluate HbA1c as well as SMBG logs every visit
´ HbA1c reflects average SBG for the last 12 weeks
´ Heavily weighted on the last 4 weeks
´ Can be checked q one m onth when titrating m edications
´ 5.8-6.4 is prediabetes
´ 6.5 is diabetes
´ >10 associated with increased infection risk
´ “double digits”
Glycemic control – case study
´ 49 year old man with PMH DM, CHF, AF on apixaban, HTN, CKD, Charcot foot. Morbidly obese BMI 63.34 (416 lb)´ Initial visit on Levemir 127 units bid and Humalog 70 units ac
tid´Issues with portion control, OMAD
´ A1c 10.2 (246)´ Rx Toujeo (U300 glargine), liraglutide (Victoza) and glipizide´ RTC after 4 weeks - weight 434´ 4 weeks later – weight 420 SMBG 83-438 A1c 8.6´ 6 week follow up – weight 409 SMBG 130-199 am 100-155 pm
´A1c 6.8
Glycemic control
´ Education, education, education!´ Patient engagement´ Dietary modification´ Optimizing medical management´ Overcoming clinical inertia´ Acknowledging improvement ´ Evaluating barriers to self care (no blame)´ Close follow-up
Glycemic Control
´ Lifestyle modifications´ Diet
´ Exercise
´ Good sleep hygiene
´ Stress management´ Cortisol levels
This Photo by Unknown Author is licensed under CC BY-NC-ND
This Photo by Unknown Author is licensed under CC BY-NC-ND
This Photo by Unknown Author is licensed under CC BY-SA-NC
´ Helps to improve recovery time´ Reduces LOS both hospital and rehab
´ Reduces morbidity and mortality´ Enhance physical conditioning to help mitigate physiological
stressors of surgery
´Incentive spirometry´Daily walks
´Lean proteins´Maximize nutrition
´Reduce risk for delirium
Prehabilitation
´Frailty assessment´Timed get up and go
´Time to rise from sitting, walk 3 meters, turn, walk backand sit down with usual aids
´ >=13s predicts falls´ >=30s corresponds to functional dependence
´ Referral to PT if indicated
This Photo by Unknown Author is licensed under CC BY-NC-ND
Enhanced Recovery after Surgery
´ ERAS is a series of protocols that has been shown to reduce infections, decrease LOS and improve outcomes
´ Limit perioperative fluids and opioids´ Reduce physiologic stressors´ Regional or local blocks´ Maintain normothermia´ Early mobilization´ Early oral intake´ Clear liquids up to two hours before surgery time
Enhanced Recovery after Surgery
´Meds for PONV given in OR´Tight glycemic control´Preop patient education´Preop nutrition shakes 5 days prior´Presurgery drinks (3)
Pain management plan
´ Early education about the pain management plan and medications for pain relief´ Multimodal pain protocol
´ Continue home pain med regimen
´ IV lidocaine 1.5mg/kg, max 200mg (anti-inflammatory)
´ Support from management´ Proactive boss with good ideas
´ Surgeon champion´ Surgeon buy-in
´ Resident buy-in´ Support staff
´ Clinic management and staff buy-in´ Space
´ Collaboration with dietician and social work´ Patient buy-in
´ Invested practitioners
How did that work out?´ Decreased same day cancellations from 9% to 6%´ Decreased wait time for surgery clearance´ SSI impact
This Photo by Unknown Author is licensed under CC BY-SA-NC
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2013 2014 2015 2016 2017 2018 2019
superficial deep organ
Surgical Site Infection Incidence
Acknowledgements
´ Claudette Cook, APRN, AGACNP – partner in crime, sounding board, all around amazing provider.
´ Elizabeth Smith, DNP, APRN, CNS, CCRN – Worked to conceptualize what optimization would look like at JPS, and then let us run with it. Chief supporter and cheerleader!
´ Ashley Conn, LCSW – without whom we would be lost. Provides guidance and support for our patients, connecting them to needed resources.
´ Our surgeons – who respect and support the clinic and celebrate our successes with us.
´ Gan, T. J., Thacker, J. K., Miller, T. E., Scott, M. J., & Holubar, S. D. (Eds.). (2016). Protocols. Enhanced Recovery for Major Abdominopelvic Surgery (1st ed., pp. 333-361). West Islip, New York: Professional Communications, Inc.
´ Howard, R., Yin, Y. S., McCandless, L., Wang, S., Englesbe, M., & Machado-Aranda, D. (2018). Taking control of your surgery: Impact of a prehabilitationprogram on major abdominal surgery. American College of Surgeons, 228(1), 72-80.
´ Wolpert, H. (Ed.). (2016). Diabetes Self-Management Support and Education. Intensive Diabetes Management (6th ed., pp. 23-32). Alexandria, Virginia: American Diabetes Association.