Before they can move forward with surgery, some patients are learning that they need to make lifestyle changes to help ensure better outcomes. Healthcare providers are finding that improving the patient’s health before surgery reduces the incidence of post-surgical complications, a major driver for readmissions.
In part because hospitals are being hit with stiffer financial penalties from Medicare for preventable readmissions after discharge and legal liability when problems arise, some hospitals are rethinking how they evaluate patients for surgery and taking steps to improve the patient’s health during the crucial preoperative phase.
As a result, some procedures may be delayed for weeks or even months, giving patients with chronic health risks the opportunity to make lifestyle changes to improve their health and their chance for a healthier outcome. Even in some urgent cases, surgeons are taking more time to be sure that their patients are in better shape before they operate.
Assessing Preoperative Risks
Certain health issues may persuade doctors to postpone a surgical procedure. These include:
- nutrition—poor nutrition is linked to post-surgical infections; low levels of serum albumin are associated with higher complication rates
- blood glucose levels—elevated blood glucose levels increase the risk of surgical-site infections and are associated with poor healing
- smoking—smoking increases the incidence of pulmonary complications after anesthesia by as much as six-fold and can complicate lung function, wound healing, and cardiovascular health
- medications—abruptly discontinuing certain medications or continuing others can contribute to postsurgical complications
- history of heart attack—having surgery within two months of a heart attack is associated with an elevated risk of another heart attack and even death
- alcohol consumption—excessive alcohol consumption may lead to postoperative complications and infections
- physical fitness—patients with limited exercise capacity are at higher risks for cardiac complications.
In Washington state, a program called Strong for Surgery has partnered with the American College of Surgeons to help clinicians and patients work together to ensure that patients are optimally prepared for surgery. The program provides preoperative checklists that focus on four areas of lifestyle improvement—smoking cessation, nutrition, blood glucose control, and medication—that can be modified before surgery. Strong for Surgery checklists are reviewed with the patient during an initial consultation. The physician is also provided with educational material for the patient to take home.
New Evidence, New Thinking
As new evidence on best practices regarding surgery risks and health status emerges, other pre-surgery protocols continue to evolve. For example, guidelines for patients who have had previous heart attacks traditionally have suggested a four- to six-week waiting period before any surgery. A study published in Annals of Surgery last year, which followed 600,000 patients, suggests the delay should be at least two months and ideally four to six months or longer. In elective surgeries, traditional thinking dictated that having the patient stop smoking too close to the surgery date would increase coughing, airway secretions, and the risk of pneumonia. A review published last year in the Archives of Internal Medicine found no evidence that quitting shortly before surgery increased postoperative complications, allowing doctors to encourage patients to stop smoking before they undergo surgery.
For healthy patients who are scheduled for procedures that aren’t high risk, hospitals are eliminating some formerly routine tests. Guidelines now call for each patient to have a preoperative evaluation accompanied by a physical examination and medical history but discourage hospitals from performing additional tests, such as chest X-rays, lab tests, electrocardiograms, and stress tests, unless specifically indicated. Some commonplace practices, such as nothing by mouth orders after midnight the day before surgery, are coming under new scrutiny as well. Newer guidelines allow clear fluids up to two hours before surgery. The recommendation is that, rather than taking a one-size-fits-all approach, physicians should be assessing each patient individually and recommending actions to help ensure that the patient is optimally prepared to come through the surgery with the fewest complications.