Your Care Guide for Neurosurgery
When do I call my surgeon? Call if you have any of these symptoms: Severe pain that is not relieved by pain medication Extreme leg swelling, redness or tenderness that does not go away Fever of 101 F (38 C) or higher When do I call 911? Call 911 if you experience any of these symptoms: Chest pain Shortness of breath Unable to walk after a fall Separation of stitches or staples Drainage or pus around your incision site Nausea and vomiting that does not stop Loss of bladder or bowel control Regular clinic hours Monday through Friday, 8 a.m. to 5 p.m. Request medication refills as soon as possible. Medication refills may take up to 24 hours to be approved.
Welcome Thank you for choosing Park Nicollet for your neurosurgical care. Your health and well-being is our top priority and is at the forefront of everything we do. We believe outstanding healthcare is delivered when we merge the science and intellect of medicine with the compassion, spirit and humanity of our hearts. We refer to this as Head + Heart, Together. You may have questions about what to expect during your experience with Park Nicollet Neurosurgery. This care guide provides the information you may need throughout your preparation, surgery and follow-up care. Read this care guide before your surgery to help prepare you and your family members for your hospital stay and recovery. Visit parknicollet.com/neurosurgery for more information. Watch our video, Welcome to Park Nicollet Neurosurgery. You can also watch the video by scanning the QR code at the right. Use a QR app on your smartphone or tablet. Thank you again for allowing us to partner with you and your family in your care to get you back to everything you love. The Park Nicollet Neurosurgery Team 1
Important Telephone Numbers Neurosurgery Neurosurgery Clinic Main Line 952-993-2079 Call to schedule or change appointments, or if you have other questions about your visit. Neurosurgery Clinic Nursing Handout Call the telephone number on the handout provided if you have questions about your surgical procedure, medications or symptoms. After-Hours Emergency Line 952-993-3123 If you need immediate help after regular clinic hours, call this number to page the on-call neurosurgery clinician. If you are having chest pain, shortness of breath or are unable to walk after a fall, call 911. If you have a nonurgent question, call Neurosurgery Clinic Nursing and leave a message. A nurse will return your call during clinic hours. Surgery Coordinator 952-993-7309 The surgery coordinator can help you with the following: Insurance prior authorization Surgery scheduling Pre-operative exam scheduling Follow-up appointment scheduling Questions about the day of surgery Diagnostic Scheduler 952-993-7320 The diagnostic scheduler can help you with scheduling tests such as magnetic resonance imaging (MRI) or computed tomography (CT) scan and scheduling epidural steroid injections. Clinic Manager, Ginny W. Ogle 952-993-7342 Call to provide feedback on a visit or report a concern about your care. 2
Important Telephone Numbers Patient Accounts and Services www.parknicollet.com/patient-accounts-services Methodist Hospital Patient Relations 952-993-5541 Call to provide feedback on a visit or report a concern about your care. Patient Financial Services 952-993-7672 Call if you have questions about billing or financial resources. Park Nicollet Advance Care Planning Help Line 952-993-0190 Advance Care Planning is the process of coming to understand, reflect on, discuss and plan for a time when you may not be able to make your own medical decisions. Call if you have questions about completing a Healthcare Directive or a Living Will or to appoint a healthcare agent. Visit parknicollet.com/healthcaredirectives for more information. 3
Contents Page Welcome...1 Important Telephone Numbers Neurosurgery...2 Important Telephone Numbers Patient Accounts and Services...3 Preparing for Surgery Planning Ahead for Surgery...7 Checklist for planning ahead...7 Stop smoking and using tobacco products...7 Schedule your surgery...8 Complete your pre-operative physical exam... 8 Complete the Pre-admitting Form...8 Pre-admitting Form...9 Check your health insurance coverage...11 Prepare a Healthcare Directive...11 Plan ahead for recovery...11 Preparing for Your Surgery Day...12 Follow eating and drinking guidelines...12 Prepare your skin...12 Decide who may wait with you...12 Manage your medications before surgery...13 Pack for the hospital...14 Understand your role in a safe surgery experience...15 FAQs (frequently asked questions) about Surgical Site Infections...16 Your Surgery Your Surgery Day...19 Directions and parking...19 Checking in...19 In the pre-operative area...19 Getting anesthesia...20 After surgery...20 In the Hospital...21 How do I manage my pain?...21 How do I prevent falls?...21 What can I do to promote a rapid recovery?...21 What about preventing complications?...22 My Notes and Questions for My Care Team...23 Your Recovery When will I leave the hospital?...27 What medications do I stop taking?...27 What about acetaminophen (Tylenol)?...28 4
Preparing for Surgery Page Planning Ahead for Surgery... 7 Checklist for planning ahead... 7 Stop smoking and using tobacco products.... 7 Schedule your surgery... 8 Complete your pre-operative physical exam.... 8 Complete the Pre-admitting Form... 8 Pre-admitting Form... 9 Check your health insurance coverage... 11 Prepare a Healthcare Directive... 11 Plan ahead for recovery... 11 Preparing for Surgery Preparing for Your Surgery Day... 12 Follow eating and drinking guidelines.... 12 Prepare your skin... 12 Decide who may wait with you... 12 Manage your medications before surgery.... 13 Pack for the hospital... 14 Understand your role in a safe surgery experience.... 15 FAQs (frequently asked questions) about Surgical Site Infections... 16 5
Planning Ahead for Surgery You may have a lot of questions as you prepare for surgery. This section of the care guide lets you know what to expect before your surgery. Follow all instructions carefully. As an involved and informed member of your healthcare team, you will be better prepared to help the process go smoothly, make your recovery easier and avoid having your surgery delayed or canceled. Take an active role by asking questions, addressing any fears or anxiety you may have and following these preparation instructions. We encourage you to share this information with any family members, caregivers or friends who will be with you for surgery. Checklist for planning ahead o Stop smoking and using tobacco products o Schedule your surgery o Complete your pre-operative physical exam o Complete the Pre-admitting Form o Check your health insurance coverage o Prepare a Healthcare Directive o Plan ahead for recovery Stop smoking and using tobacco products If you smoke or use tobacco products, stop now. Nicotine decreases the ability of blood vessels to carry oxygen and nutrients to your spine. Nicotine has been shown to cause delayed healing and poor surgical outcomes. Nicotine also can raise your risk for infection and scarring after surgery. For help quitting smoking or using other tobacco products, talk to your primary care provider. You also can visit quitplan.com or call QUITPLAN Services at 888-354-PLAN (7526). 7
Schedule your surgery After you meet with your surgeon, the surgery coordinator will schedule your surgery with you. Leave the entire day of your surgery open. The schedule may change due to emergencies or other scheduling issues. Please contact the surgery coordinator at 952-993-7309 as soon as possible if you need to cancel or change the date or time of your surgery. The surgery coordinator also can answer any questions you may have about insurance coverage, prior authorization or scheduling issues. Watch the Day of Surgery video at parknicollet.com/neurosurgery. A nurse in the Pre-Procedure Assessment Department will call you the day before surgery to confirm arrival and surgery times, review medications and provide final instructions. Your day of surgery Complete your pre-operative physical exam Schedule a pre-operative physical exam with your primary care clinician within 30 days of your scheduled surgery. During this exam, your primary care clinician checks to make sure you are ready for your surgery. Our surgery coordinator can help you set up this appointment. Ask your clinician to print a list of your medications during your pre-operative appointment. Bring this medication list with you to the hospital on the day of your surgery. If you do not have this exam, your surgery may be cancelled. If you do not have a primary care clinician, our surgery coordinator can help you find one. Complete the Pre-admitting Form Complete the Pre-admitting Form on Page 9 and mail or fax it to Park Nicollet Methodist Hospital. Follow all instructions on the form. Visit parknicollet.com/neurosurgery to watch the Day of Surgery video. The video and this care guide help you prepare for your surgery. Scan the QR code to watch the video on your smartphone or tablet. 8
cut here Pre-admitting Form Complete immediately, tear from brochure and either fax to 952-993-6763 or mail by folding twice and taping both corners. If you have any questions about filling out this form, call 952-993-5340. Park Nicollet Methodist Hospital and Park Nicollet Clinic surgery centers Primary MD Surgeon Patient information Last name First name MI Date of birth SS# Home phone ( ) Cell phone ( ) Street address City/State Zip Sex: o Male o Female Marital status: o Married o Single o Widowed o Divorced o Separated o Life Partner Race: o Asian o Black/African Amer. o Caucasian o Hispanic/Latino o Amer. Ind./Alaskan o Multiple Which religion and parish/synagogue would you like listed in your chart? Employer name Phone ( ) Street address City/State Zip Occupation o Full time o Part time o Retired o Disabled Emergency contact/next of kin Last name First name MI Relationship to patient Home phone ( ) Work phone ( ) Street address City/State Zip Employer name o Full time o Part time o Retired o Disabled Insurance information Is surgery due to accident/injury? o Yes o No Is surgery work related? o Yes o No Is surgery auto accident related? o Yes o No Is surgery related to another type of injury? o Yes o No Date of injury/accident Where did injury occur? How did injury occur? Any of the following authorized to pay for surgery? o Black Lung Prog. o VA o Other Government Program Primary insurance company (medical/work. comp/no fault ins.) name Policyholder Relationship to patient Policyholder s date of birth Policyholder s SS# Policyholder s employer Employer phone ( ) Employer s street address City/State Zip Policy/ID# Group# Claim mailing address City/State Zip Customer service phone ( ) Precertification phone ( ) Secondary insurance company name Policyholder Relationship to patient Policyholder s date of birth Policyholder s SS# Policyholder s employer Employer phone ( ) Employer s street address City/State Zip Policy/ID# Group# Claim mailing address City/State Zip Customer service phone ( ) Precertification phone ( ) Additional information Do you have diabetes? o Yes o No Date of surgery: Do you use tobacco products? o Yes o No cut here 9
cut here NO POSTAGE NECESSARY IF MAILED IN THE UNITED STATES BUSINESS REPLY MAIL FIRST-CLASS MAIL PERMIT NO 14392 MINNEAPOLIS MN POSTAGE WILL BE PAID BY ADDRESSEE PARK NICOLLET METHODIST HOSPITAL PREADMISSIONS PO BOX 650 MINNEAPOLIS, MN 55440-9946 fold here and tape both corners fold here and tape both corners 10
Check your health insurance coverage To avoid unnecessary out-of-pocket expenses, contact your health insurance provider to see if precertification, prior authorization, referral or a second opinion is required before your surgery. If you plan to file a claim for workers compensation, contact the insurer who provides the workers compensation coverage (unless your clinician s office has informed you that your claim has been approved). Prepare a Healthcare Directive Advance care planning is the process of coming to understand, discuss and plan for a time when you may not be able to make your own medical decisions. Advance care planning for future healthcare choices is important to do while you are healthy and able to make your own decisions. No matter your age or health, writing your wishes in a Healthcare Directive is important. A Healthcare Directive is your written plan for future medical treatments. A Healthcare Directive also is the document in which you can identify someone to communicate your wishes if you are unable to do so. This person is your healthcare agent. For more information on advance care planning, call the Park Nicollet Advance Care Planning Help Line at 952-993-0190. Plan ahead for recovery Arrange to have an adult drive you to and from the hospital. You will receive medication that makes driving unsafe after surgery for up to 24 hours or longer if you are taking prescription pain medication. Arrange for help at home. You must have a responsible adult stay with you for at least 8 hours after you arrive home from surgery. Many people find that having someone stay overnight is helpful. If possible, arrange for help at home with household tasks, such as cleaning and running errands. Contact appropriate community resources for on-going help at home, if necessary. Talk to your clinician about your needs and for recommendations. Make your home safe in case you are limited in moving around after surgery. For example, clear hallways, remove throw rugs and move items you need to where you can easily reach them. Prepare food ahead of time. Talk to your clinician about any restrictions you may have for eating and drinking after surgery. Develop a pain management plan with your surgeon. Talk to your surgeon about:» What type of pain to expect and for how long» What type of pain relief methods may be used» What degree of relief these methods provide» What has worked well or not so well for you if you have had surgery before 11
Preparing for Your Surgery Day Follow eating and drinking guidelines Do not eat anything after midnight the night before your surgery. You may drink water, Gatorade, tea, and coffee (without cream or milk) up to 4 hours before your surgery. You may take medications your clinician has OK d with a small sip of water. Do not drink alcohol for 24 hours before surgery. Prepare your skin Do not use hair products, makeup or perfume the day of surgery. Your surgeon may ask you to use a skin preparation called Hibiclens before your surgery. If you need to use Hibiclens, follow these instructions: Purchase a 4-ounce bottle of Hibiclens. Shower the morning of surgery. To shower with Hibiclens:» Wash your hair with your regular shampoo. Wash your face with your regular soap or water only. Thoroughly rinse your body with water.» Apply the minimum amount of Hibiclens necessary to cover the skin. Use Hibiclens as you would any other liquid soap. Wash from chin downward. Keep out of eyes, ears and mouth.» Rinse.» Wash a 2nd time from chin downward using Hibiclens. Work up a lather.» Rinse well.» Dry with a clean towel.» Do not apply lotions, deodorants or powders.» Put on clean clothes after showering. Decide who may wait with you Decide which family members or friends you want with you before your surgery. Once your healthcare team has completed preparations for your surgery, you may have 2 people wait with you before going into surgery. Depending on the type of surgery and anesthesia you are having, people may not be able to wait with you. Additional family or friends must wait in the nearby lounge. They can see you after surgery when you are awake and comfortable. 12
Manage your medications before surgery Your primary care clinician will give you instructions before surgery about any medications, supplements or vitamins you take. Please also follow the instructions below. Type of medication Instructions Nonsteroidal anti-inflammatory drugs (NSAIDs), such as: Aspirin (Bufferin, Bayer, Excedrin) Ibuprofen (Advil, Motrin, Nuprin) Stop taking 1 week before surgery. Naproxen (Aleve) Celecoxib (Celebrex) Fish oil or omega-3 supplements Stop taking 1 week before surgery. Acetaminophen (Tylenol) You may take as needed for pain. Oxycodone-acetaminophen (Percocet) You may take as prescribed by your clinician. Hydrocodone-acetaminophen (Vicodin) You may take as prescribed by your clinician. Insulin or oral medication for diabetes Talk with your primary care clinician about how to adjust your doses before clinician. Anticoagulant medications, such as Warfarin (Coumadin) Enoxaparin (Lovenox) Talk with your primary care clinician about when to stop taking these medications. Antiplatelet medications, such as: Clopidogrel bisulfate (Plavix) Cilostazol (Pletal) Talk with your primary care clinician about when to stop taking these medications. 13
Pack for the hospital What to bring to the hospital o Current insurance card and photo ID for when you check in o Money to pay for prescriptions and co-pays» Ask a family member or friend to keep your money safe. o List of all current medications and dosages, including over-the-counter medications and herbal supplements o Any papers your primary care clinician gave you at your pre-operative appointment What to leave at home Please do not bring valuable items to the surgery center or hospital, such as those listed below. Park Nicollet Methodist Hospital and Park Nicollet Clinic are not responsible for lost items. Have family or friends bring you needed items during your hospital stay when they visit. o Wallet or purse o Jewelry o Laptop computer or tablet o Media player o Medications from home, unless your clinician or nurse tells you otherwise o Healthcare Directive or Living Will, if you have one o Eyeglasses and storage case, contact lenses, dentures or hearing aids and batteries, if needed o Comfortable, loose-fitting clothing to wear home o Reading material o This care guide 14
Understand your role in a safe surgery experience Patients involved in decisions about their care are more likely to have good outcomes. Follow these recommendations to take an active role in your care. Understand the informed consent form. Before signing, read the consent form carefully. Confirm your name, type of surgery and that you talked to your surgeon and agreed to the surgery. Ask questions. Keep asking if you do not understand the answers. Answer questions. Medical staff may ask you the same questions numerous times. We check and double-check with you to make sure information is correct. Prevent infections. Read FAQs (frequently asked questions) about Surgical Site Infections on Page 16. See Patient Safety at jointcommission.org for more information. 15
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Your Surgery Page Your Surgery Day... 19 Directions and parking... 19 Checking in... 19 In the pre-operative area.... 19 Getting anesthesia.... 20 After surgery... 20 In the Hospital... 21 How do I manage my pain?... 21 How do I prevent falls?... 21 What can I do to promote a rapid recovery?.... 21 What about preventing complications?... 22 My Notes and Questions for My Care Team... 23 Your Surgery 17
Your Surgery Day On the day of your surgery, we will be with you every step of the way to help make your surgery a success. The following information explains what happens on the day of your surgery. Read this section carefully and share it with your family and friends who will be at the hospital with you. Directions and parking Take Highway 100 to Excelsior Boulevard; go west about ½ mile. Turn right onto the Methodist Hospital campus. Park in the Blue Ramp at the front of the hospital. Enter through the Heart and Vascular Center and follow the signs to the Surgery Center Admitting desk on the 1st floor of Methodist Hospital. Bring your parking ticket with you to be validated for a reduced parking fee. Valet parking is available for a fee at the 6500 Excelsior Boulevard and 3931 Louisiana Avenue entrances. Hours of operation are Monday through Friday, 7 a.m. to 6 p.m. Central Film Library 3930 Louisiana Ave Louisiana Entrance Heart and Vascular Center Orange Ramp Parking Cancer Center Meadowbrook Bldg Methodist Hospital Blue Ramp Parking Excelsior Blvd 3 BLOCKS TO HWY 100 Excelsior Entrance Hwy 100 Checking in Enter the Heart and Vascular Center and follow overhead signs to Surgery Center Admitting on the 1st floor. Check in at the Surgery Center Admitting desk to get your parking ticket validated, a pager and directions to the waiting area for family and friends. During the hospital admitting process, you will sign several documents, including a consent form. This form gives the hospital permission to provide your treatment and care. You will receive an identification bracelet, and you may need to have some final lab tests. After changing into hospital clothing, you will place your clothing and belongings in a bag. A nurse or nursing assistant will return the bag to you after surgery. In the pre-operative area After check-in, you will be taken to the pre-operative area to change into hospital clothing and place your belongings in a garment bag. You will meet with different members of your healthcare team, including nurses, an anesthesia team and your surgeon. A nurse will start an intravenous (IV) line, and your surgeon will answer any remaining questions you may have. 19
Getting anesthesia The type of anesthesia you will have is based on your surgery, medical history, age, personal preference and other factors. Most neurosurgical procedures use general anesthesia, which puts you into a deep sleep for the entire operation. Since the deep level of sleep may affect your breathing, you will need a breathing tube inserted. Side effects of general anesthesia may include sleepiness, nausea, sore throat and muscle aches. You will be carefully monitored throughout your surgery and immediately after in the recovery room. The occurrence of serious problems due to anesthesia is extremely low. After surgery After surgery, you will be taken to a recovery room, known as the Post Anesthesia Care Unit (PACU). In the PACU, nurses monitor you as you wake up. You might not remember this time. Your family or friends will be able to speak with your surgeon immediately after your surgery. If you are going home the same day as your surgery, you will be moved to the observation area where your family or friends can see you. If you are staying overnight, you will be moved to your hospital room once you are fully awake. 20
In the Hospital How do I manage my pain? Surgery is different for everyone. Rating pain also is different for everyone. We partner with you to create a plan for managing pain to make you comfortable and at ease. Pain after surgery can be controlled with a variety of safe options, such as medications you take by mouth or that are given through your IV. Methods other than medication can also help control your pain. These include specific positioning and support of the surgical site, heat and cold therapy, relaxation and positive thinking. You will be asked to rate your pain throughout your hospital stay to determine the amount of medication that is right for your pain level. Nurses will continue to monitor your comfort and work with you to follow your pain management plan. 0 1 2 3 4 5 6 7 8 9 10 No Moderate Worst pain pain pain Rate your pain on a scale from 0 to 10 with 0 being no pain and 10 being the worst pain you have ever had. How do I prevent falls? For your safety, follow the instructions of hospital staff to reduce your risk of falling. Do not get out of bed without help from a member of your care team, even if you feel strong enough to get out of bed by yourself. Most beds at Methodist Hospital are equipped with an alarm system that alerts nursing staff if a patient gets out of bed without help. These alarms are for your safety. Keep items you need within easy reach. Use your call light and wait for staff to help you if you need to get out of bed for any reason. What can I do to promote a rapid recovery? Activity After surgery, start with mild daily activities, such as sitting up and walking as soon as possible. An important part of a healthy recovery is getting up to walk several times a day. Being active as soon as possible after surgery helps prevent a number of complications. Activity promotes good blood circulation, improves how well your lungs and heart work and maintains muscle strength. 21
Eating, drinking and smoking Good nutrition is an important part of your recovery. Having an upset stomach and constipation after surgery is common. You may not feel like eating. Follow the general guidelines below, unless your clinician gives you specific instructions otherwise. Gradually add bland foods to your diet, such as dry toast or crackers. What about preventing complications? Blood clots After surgery, you may be more at risk for developing blood clots. You can help prevent blood clots by walking and doing leg exercises. Do these exercises 4 to 6 times a day. Eat a high-fiber diet to soften bowel movements and prevent constipation. Foods with fiber include fruits, vegetables and grains, such as wheat bran, corn and rye. Eat foods high in protein. Drink lots of liquids. Do not smoke or use tobacco products for 2 weeks after surgery even better, stay smoke-free for life. Not smoking improves healing and reduces the risk of infection or complications in your lungs. Ankle pumps. Bend your feet toward you (use your ankles to flex your feet) and away from you (point your feet). Repeat 10 times. Quad sets. Press the backs of your knees into the bed by tightening the front of your thighs. Hold for 6 seconds and then relax. Repeat 10 times. Pneumonia Too much bed rest after surgery can cause fluid to build up in your lungs, which may cause pneumonia. To help prevent pneumonia, your clinician may recommend you use an incentive spirometer or do deep breathing exercises. 22
My Notes and Questions for My Care Team 23
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Your Recovery Page When will I leave the hospital?... 27 What medications do I stop taking?.... 27 What about acetaminophen (Tylenol)?.... 28 Your Recovery 25
Your Recovery When will I leave the hospital? Your clinician and care team will assess how you are doing after surgery and determine when you can safely leave the hospital. Before going home, you need to have your pain under control and be able to: Walk Use the restroom Swallow medication and food Make sure you ask questions if you do not understand any of your discharge instructions. Tell your care team about any special needs you have before you leave the hospital. What do I do about my medications? Do not take these medications until your surgeon and primary care clinician tell you to start them again. Nonsteroidal anti-inflammatory drugs Nonsteroidal anti-inflammatory drugs (NSAIDs) may cause bleeding around the surgical site. Do not take these medications for 2 weeks after your surgery. Celecoxib (Celebrex) Diclofenac sodium (Voltaren) Indomethacin (Indocin) Meloxicam (Mobic) Sulindac (Clinoril) If you have had spinal fusion surgery, you will need to stop these medications for a longer period of time. Talk to your surgeon. Aspirin Aspirin may cause bleeding around the surgical site. Do not take aspirin (Bufferin, Bayer, Excedrin) for 2 weeks after your surgery. If you have a history of heart problems or your clinician has prescribed aspirin for a serious medical condition, you may be able to start aspirin sooner. Talk to your surgeon. Fish oil or omega-3 supplements Do not take fish oil or omega-3 supplements for 1 week after your surgery. These supplements also may increase your risk for bleeding. Ibuprofen (Advil, Motrin, Nuprin) Naproxen (Aleve) 27
Anticoagulants and antiplatelets You and your care team will work together to come up with a plan for safely restarting these anticoagulant and antiplatelet medications. Warfarin (Coumadin) Clopidogrel (Plavix) Dabigatran etexilate (Pradaxa) Prasugrel (Effient) Enoxaparin (Lovenox) Heparin What about acetaminophen (Tylenol)? Acetaminophen (Tylenol) is not considered an NSAID. Acetaminophen does not increase your risk of bleeding. You may take acetaminophen for mild pain. Keep in mind you may already be taking acetaminophen in another medication, such as oxycodone-acetaminophen (Percocet) or hydrocodone-acetaminophen (Norco). Do not take more than 4,000 milligrams (mg) of acetaminophen in 24 hours from all sources. You may harm your liver if you take more. 28
Park Nicollet Institute 3800 Park Nicollet Boulevard St. Louis Park, MN 55416 952-993-3454 www.parknicollet.com/institute 20981 (6/2014) Your Care Guide to Neurosurgery Copyright 2014 Park Nicollet Institute All rights reserved. No parts of this publication may be reproduced in any manner, mechanical or electronic, without prior permission from the publisher except in brief quotations or summaries in articles or reviews. For additional permissions, contact Park Nicollet Institute. At the time of publication, all facts and figures cited herein are the most current available, all telephone numbers, addresses, website URLs are accurate and active; all publications, organizations, websites and other resources exist as described in this care guide; and all efforts have been made to verify them. Park Nicollet Institute makes no warranty or guarantee concerning the information and materials given out by organizations or content found at websites cited herein, and we are not responsible for changes that occur after this book s publication. If you find an error or believe that a resource listed herein is not as described, please contact Park Nicollet Institute. Park Nicollet Institute 3800 Park Nicollet Boulevard St. Louis Park, MN 55416 952-993-3454 www.parknicollet.com/institute