? Prehab, immunonutrition. Safe surgical principles. Optimizing Preoperative Evaluation

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1 Optimizing Preoperative Evaluation Timothy Geiger, MD, MMHC Associate Professor of Surgery Executive Medical Director, Surgery Patient Care Center Chief, Division of General Surgery Director, Colon and Rectal Surgery The process to maximizing outcomes? Prehab, immunonutrition Pre-op risk mitigation Standard processes Safe surgical principles The bottom of the pyramid does not fix everyone Concept of how population wide interventions may leave at risk groups behind American Journal of Public Health, Feb

2 Shifting the mean While we achieve the goal of shifting the mean- Infections LOS QOL There is always a group left behind Going up the pyramid decreases the tail at risk? Prehab, immunonutrition Pre-op risk mitigation Standard processes Safe surgical principles Getting ready for surgery Prehabilitation Immunonutrition Preoperative risk stratification 2

3 Getting ready for surgery I think this is part of the new frontier in patient care Low cost, high yield care Generates patient and family buy in Surgery now becomes active and not passive for the patient and family NSQIP risk calculator- patients can visually see how their health effects their risks Prehabilitation Getting in shape for surgery Loss of 20-40% functional capacity after surgery Increased LOS, more likely to discharge to rehab or SNF Increased DVT, PE, infections, Ileus? At 8 weeks post surgery- prehab group statistically higher walking test, and more patients reported being at or above pre-op levels Estimating the risk Consent process originated in 1914 Part of the shared decision making process Problem- we have a knowledge advantage ACS NSQIP surgical risk calculator was developed to help quantify the risks for an individual patient Shared decision making Visually see the risk 3

4 Percentage of Patients Who Underestimated Their Risk Enhanced Recovery After Surgery: What do patients think Prospective, cohort study of 150 patients undergoing any surgery included in the ACS NSQIP calculator Primary aim-see if patients felt use of the calculator was informative and assisted in decision making Baseline survey- goals of surgery, and perception of patients own risk Assessed patient own risk calculation vs the ACS NSQIP calculator results ACS NSQIP results were reviewed with patient and the impact of the calculator was assessed. Raymond et al. submitted for publication, Annals of surgery, 2017 What do patients think Results- 0% knew of the ACS NSQIP calculator or were shown it during the consent process 81% of patients expressed they would have wanted to know High risk patients were twice as likely to underestimate their risk of death (compared to low risk) High risk patients were three times more likely to underestimate their risk of any complication, and length of stay 70% of high risk patients stated they would consider participating in a pre-habiliation program to decrease their risks 39% said they would be willing to delay their surgery in order to decrease their risks Raymond et al. submitted for publication, Annals of surgery, 2017 Percentage of Patients Who Underestimated Their Risk Compared to ACS NSQIP Calculator s Predictions 100% 90% 80% 70% Low Risk Patients (personal calculated risk median) High Risk Patients (personal calculated risk 2x median) ** * ** * *p < compared to low risk **p <0.01 compared to low risk * 60% * 50% ** 40% 30% 20% 10% 0% n=79 n=28 n=76 n=29 n=84 n=63 n=76 n=20 n=76 n=74 n=76 n=53 n=83 n=34 Serious Complication Any Complication Kidney Failure Discharge to Readmission Death Length of Stay Nursing Facility 4

5 Reduction of modifiable risk factors We already look at some risk factors DM, Smoking, HTN, polypharmacy EKG, albumin, electrolytes, hemoglobin The Big 5 Plus Big 5 complications Delirium Major Adverse Cardiac Events (MACE) Postoperative pulmonary complications Acute kidney injury Hyperglycemia 800Lb Gorilla Frailty This accounts for those left behind Preoperative risk management and prevention Simple concept- Identify the high risk patients, make an intervention prior to surgery Complex follow through What risks need modifying Cardiac? Pulmonary? Nutrition? Smoking? What is the intervention? How long can surgery be delayed? Cancer vs. polyp? Nearly-obstructing- how nearly? 5

6 Pre-op clinic Vanderbilt Preoperative Evaluation Clinic (VPEC) Anesthesia run program to ensure patients are healthy enough for surgery Pt seen in surgery clinic then VPEC appointment is coordinated if surgery is planned VPEC guidelines Simple list meant to catch at risk patients Hi-RiSE Program High Risk Surgical Encounter Pathway for those who meet big 5 risk criteria Creation of a preoperative team to manage all aspect of the workup Will then continue care though the operating room and hospitalization Matt McEvoy 6

7 Normal vs. High risk Two pathways Normal risk, major procedure- NP clinic with MD oversight High risk, major procedure- MD review and recommend Well defined best practice pathways and check lists The pathway is built on standard principles Any patient who does not get checked off then goes for manual review by an MD MD can notify surgeon and schedule consultations Patient identified as Hi-RiSE candidate The assigned Perioperative Consult Service (PCS) attending (anesthesiologist) coordinates care with specialist(s), collects data and communicates effectively with OR teams and the perioperative rounding service Creates a true perioperative surgical home Only needed by a small percentage of patients 7

8 VPEC clinic feedback loop Results: Increase in the proportion of cancelled cases reviewed from 17.3% (34 of 196) to 95.6% (194 of 203) (p<0.001). After implementation, changes were reported in - the number of cases reviewed by each resident (p<0.0001) - perceived importance of review (p=0.03), - ease of review (p=0.03). What does it mean? The VPEC clinic has created a program that allows the surgeon to do what he/she does bestdiagnosis and operate on a specific problem The initial MD visit helps identify which pathway to send the patient, based on surgery type or patient risks Once in the pathway, a series of best practices is applied to help minimize any co-morbid risks to surgery A constant feedback loop helps to make changes and avoid errors. How does it work in the real world? (Sept 2017) 89 year old female presents with synchronous colon cancers after recovering from a CVA. PMHx: CHF, A Fib, mitral regurg, pulmonary HTN, DM, HTN Pt seen by CRS: cardiology consultation for surgical risk stratification Cards- continue HTN meds, hold eliquis 48hrs prior to surgery, acceptable risk Pt seen in VPEC- noted to have increased pedal edema and new SOB - MD evaluated Pt had medication change 3 days prior. Cardiology contact, labs and echo obtained - CHF Admitted for observation Anesthesia team collaborated with cardiology through the hospitalization and subsequent outpatient workup. It was decided to delay the OR for 2 weeks for optimization Milestones were set and relayed to OR anesthesia team and surgeon until deemed safe for surgery Pt underwent a lap subtotal with ileosigmoid and was discharged POD#5 with no MACE, PPC, Delirium, AKI, or glycemic control issues; no PONV; almost zero opioids 8

9 What does it take to work? Established model of care with known transitions best practice parameters Feedback mechanisms Communication is the key Image- Austin County News Online Why does preoperative evaluation matter? 39% of patients said they would be willing to delay their surgery in order to decrease their risks 100% of patients don t want a complication (assumption) If we can make changes prior to surgery that will reduce the risk- we should 9