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Patient Prep Powers Successful Surgeries

By Don Sadler

One of the biggest keys to successful surgical outcomes is thorough patient prep before the surgery. There are many different components to effective preoperative patient prep, with the most important usually being clear communication between the patient and the preadmission team.

What is Preoperative Patient Prep?

Alexander Hannenberg, M.D., a perioperative safety consultant and co-founder of ORDxRx Solutions for Surgical Safety, refers to preoperative patient prep as “a process to address modifiable risks that contribute to patient complications or impaired recovery.”

Failure to do preop patient prep thoroughly and effectively can potentially lead to a number of negative outcomes. “These include prolonged hospital stays, returns to acute care, poor healing, infections and cardiovascular or respiratory complications,” says Hannenberg.

Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, the director of evidence-based perioperative practice for the Association of periOperative Registered Nurses (AORN), concurs. She emphasizes the importance of effective patient prep in minimizing the risk of surgical site infections (SSIs).

“Preoperative patient skin antisepsis reduces the patient’s risk of developing an SSI by removing soil and transient microorganisms at the surgical site,” says Spruce. “Reducing the number of bacteria on the skin near the surgical incision lowers the risk of contaminating the surgical incision site.”

Preoperative decolonization, preoperative bathing and hair management at the surgical site are all part of preparing the skin for antisepsis. “This contributes to a reduction of microorganisms on the skin,” says Spruce.

David Shapiro, M.D., an anesthesiologist at Red Hills Surgical Center in Tallahassee, Florida, believes that the biggest benefit of a rigorous preop evaluation is determining the most appropriate setting for a patient to undergo a specific procedure at a specific time.

“A thorough preop evaluation should be structured to assist clinicians in their decisions regarding how to deliver the most appropriate care to each of their patients,” says Shapiro. “From the patient’s perspective, having these determinations made prior to the immediate preoperative timeframe goes a long way toward avoiding the possibility of a same-day cancellation.”

“As surgical professionals, we often forget to appreciate how upsetting cancellations can be for our patients,” Shapiro adds.

Keys to Effective Preoperative Prep

Spruce offers the following tips for effective preoperative patient prep:

  • • Preop skin care – “For optimal effectiveness of the antiseptic, it is necessary to adhere to the time allotment for application before the surgical procedure as outlined in manufacturer’s instructions and perform a standardized surgical site preparation protocol,” says Spruce. “This includes site preparation before application of the skin antiseptic, application of the antiseptic using sterile technique and safety measures to prevent patient injury related to antiseptic use.”
  • • Fasting protocols – While the fasting guidelines of various anesthesia societies support allowing clear fluids up to two hours and solid food up to six hours before anesthesia, Spruce notes that many patients receive instructions to not eat or drink anything after midnight before the day of their procedure.
  • • Antibiotic protocols – Preoperative antibiotic selection to help reduce the risk of postop infection is based on the type of surgical procedure. “Surgeons will select antibiotics for patients based on numerous factors such as cost, safety, ease of administration, pharmacokinetic profile, bactericidal activity and hospital resistance patterns,” says Spruce.
  • • Decolonization program – Spruce says it’s important for facilities to convene an interdisciplinary team to determine the need to implement a preoperative decolonization program for Staphylococcus aureus. “Prophylaxis for staph local epidemiology, patient risk factors, health care resources and operative or invasive procedure risk factors are key considerations for development of an optimal decolonization program,” says Spruce.
  • • Diabetic, radiology and pregnancy testing – These tests should be completed before the day of surgery so delays aren’t encountered. “Anesthesia providers may order additional tests based on the patient’s condition and these should also be completed prior to the patient’s arrival for surgery,” says Spruce.

Preoperative Patient Interviews

Preoperative interviews are important when it comes to identifying patients in need of prehabilitation, says Hannenberg. “These interviews are part of multifaceted triage that can include questionnaires, manual or automated extraction of data from the EHR and clinician application of screening algorithms,” he says.

Doing preop interviews by telephone or virtually via Zoom calls has become more common during the pandemic.

“Virtual preoperative visits eliminate the need for some patients to come to the facility for interviews and testing, which reduces potential exposure to COVID-19 from other patients and community members,” says Spruce. “Patients can be screened for medical optimization and given preop instructions over a Zoom call.”

Regardless of how the preop interview is conducted, patients should be given clear, standardized instructions for preoperative bathing and other interventions and allowed the opportunity to ask questions. “Make sure patients understand the rationale behind the instructions so they know the importance of following them,” says Spruce.

Shapiro stresses the importance of setting expectations during the preop interview. “Often, there are tasks or protocols that are required of patients to optimize their presurgical status,” he says. Examples include discontinuance of medications or the addition of measures like skin antisepsis that can contribute to a successful episode of care.

“This teaching should not only provide reassurance to the patient, but it should also reinforce what the outcomes and timeframe of the procedure are expected to be,” says Shapiro.

Shapiro believes that the preop interview should be customized to account for whatever level of understanding the patient may bring to the conversation. “Each patient should be given the opportunity to clarify instructions and voice questions and concerns,” he says.

“It’s so important that patients arrive at the facility knowing there are compassionate and caring health care professionals who will be managing their care on their behalf,” Shapiro adds. “This dynamic starts with the preoperative communication and can chart the course toward the optimal outcome that we desire and the patient both expects and deserves.”

Hannenberg recommends a deliberate and stepwise implementation plan for going beyond patient assessment to preop patient optimization. “The work can be thought of in several dimensions including disease condition or patient population stratified by age, surgical case type or even specific surgical practice,” he says.

“There are few, if any, institutions that can integrate their entire surgical population into a comprehensive assessment-optimization process, so an incremental approach makes the most sense,” Hannenberg adds. “There will be crosscutting lessons learned with implementation for a particular patient cohort that will make the expansion of scope smoother and more successful.”

Surgical Scheduling and ERAS

Of course, scheduling is an important part of the patient preadmission process. “This is the first place where critical patient information is captured and relayed to the surgical team,” says Spruce. “Surgical schedulers should be sure to relay critical information to the preoperative team.”

This critical information typically includes:

  • The correct patient and procedure, including site and side
  • Completion of the patient history and physical
  • Completion of required consultations
  • Informed consent
  • Preoperative orders
  • Anesthesia consult as needed
  • Implant, instrumentation and equipment needs
  • The name of the patient’s caregiver who will be present at the preoperative visit

Enhanced Recovery After Surgery (or ERAS) programs can go a long way toward helping patients improve their surgical recovery. First developed in Europe, ERAS has been touted as the evidence-based new paradigm of perioperative care.

There are five consensus practical care components of ERAS:

  1. Preoperative carbohydrate loading
  2. Interactive patient notification technology
  3. Early resumption of diet
  4. Setting pain management expectations
  5. Early mobility

Among the measurable benefits of ERAS programs at Scripps Memorial Hospital, which participated in a collaboration in 2021 with Cardinal Health and ClearFast Inc., were:

  • A 50% reduction in patient length of stay
  • A roughly two-thirds reduction in the use of opioids among surgical patients
  • A statistically significant reduction in SSIs
  • A statistically significant reduction in surgical patient readmissions

“ERAS programs are a new way of thinking about the entire perioperative setting and how the process impacts patients, as well as how patients can impact their own recovery,” says Spruce. “There are specific detailed protocols to use in specific patients, but all patients can benefit from ERAS programs.”

For example, patients can improve their nutrition and physical fitness prior to surgery to help diminish the impact of the stress of the procedure on their bodies and promote faster recovery.

ERAS Protocols for Carbohydrate Loading

Carbohydrate loading prior to surgery can be accomplished by consuming preoperative beverages like ClearFast, an iso-osmolar, complex carbohydrate-rich beverage that contains neither fat nor protein. According to ClearFast Inc. founder M. Lou Marsh, MD, the full ERAS protocol calls for two to three 12-ounce servings of the beverage during the 12 hours prior to surgery.

“Not only are these patients more comfortable, hydrated and nourished going into surgery, but the ERAS literature strongly suggests a reduction in the incidences of de novo postop insulin resistance and the attendant hyperglycemia it causes,” says Marsh. “This metabolic aberration often leads to surgical site infections that are responsible for prolonged hospital lengths of stay.”

According to Marsh, preop carbohydrate loading remains one of the few integral parts of most, if not all, ongoing ERAS programs nationally. “And ClearFast appears to be the beverage of choice,” she says. “Today, ClearFast is euphemistically referred to as the ‘Beverage of ERAS.’ ”

Anecdotally and in published studies, patients who consumed ClearFast before surgery have overwhelmingly said they felt neither hungry nor thirsty during the immediate preop period.

“This translates into fewer incidences of patients breaking the requisite preop fasting from all solids and other non-clear liquids before their scheduled surgeries,” says Marsh. “This results in a significant reduction in the number of delayed or canceled procedures due to failure by patients to fast.”

Why Patient Education is Critical

Beverly Kirchner, BSN, RN, CNOR, CNAMB, stresses the importance of patient education when it comes to successful preoperative prep.

“Education is critical to ensuring that patients get the most benefit from their surgery,” she says.

“Suppose you stick to the preadmission calls and physical prep like anesthesia NPO,” says Kirchner. “You would not discuss the preoperative education or the nursing history and physical, which are critical to ensuring that the patient meets the admission criteria.”

The bottom line, says Kirchner, is that patients can’t be compliant if they don’t understand the instructions provided during preoperative prep. “And this may lead to poor surgical outcomes,” she says.

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