Preoperative Education
What works?
What doesn’t?
What is the evidence?
Shirley Lockie
ABOUT ME
•
Diploma of Practice Management
•
15 years in the OR
•
PNSA
•
MClin Sci specializing OBESITY
•
Executive member of OSSANZ
•
PNAQ (ACORN QLD ) education
•
AANSA Secretary
•
Fully credentialled PNSA at 4 hospitals
Perioperative Nurse
Surgical Assistant
•
Initial patient assessment, physical exam, medical history
and coordination of pre surgery tests in collaboration with
the surgeon.
•
Patient education during the pre-surgery, intra operative
and post-surgery phases of the patients episode of care.
PERIOPERATIVE
SERVICES
•
From a perioperative point of view -
•
“what if......we were able to identify and measure
key points before bariatric surgery, to provide an
enhanced recovery and ultimately influence long
term results?”
Why do we educate ?
• Better
ASSESS
informed patient
• Knowledge
TEACH
EVALUATE
and confidence to
recover
• control
over their weight loss
surgery
Preoperative Education
•
Hayward 1975: pts given preop information required
less analgesia and had faster recovery.
•
Lookinland and Pool 1998 demonstrated that a
structured preoperative education program improved
clinical outcomes, gave better patient satisfaction and
faster recovery, as compared to unstructured post op
education.
•
Goldstein and Hadidi 2010: Demonstrated that pt who
attended a bariatric preoperative education class had
higher levels of knowledge and post operative
satisfaction.
Practice Audit
•
In my practice we discovered 90% of our patients
had unidentified comorbidities:-
•
Obstructive Sleep Apnoea (OSA)
•
Diabetes
•
Hypertension
•
Hiatus Hernia/GERD
What is Preoperative education?
• Preoperative
patient education is a common and
important intervention in surgical nursing, yet there is
very limited systematic evidence on its precise role.
• It Empowermentis subject to many
factors
,Pt
Control
-Selfeg
Belief
Engagement/level
-Coping Strategies
of understanding,pt knowledge,perioperative Nurse’
knowledge,
• The
purpose is to reduce anxiety,provide
empowerment,ownership and patient control
Hospital Preoperative Clinics
•
Physical health questionnaire only: few days
before or on the day of surgery.
•
Research shows often the information gathered is
inconsequential,often not passed to medical staff,
not factually correct (pt perception “ I don’t
snore”)
HOW?
•
LEAFLETS
•
DOCUMENTS
•
IPAD PROGRAMS
•
APPS
•
VIDEOS (pts may re-watch several times )
WHEN and WHERE?
•
SURGEON’S OFFICE
•
STRUCTURED PROGRAM
EDUCATION SHOULD BE EVERYWHERE
•
WITH PERIOPERATIVE SUPPORT
•
DISCUSSIONS AND TIME TO TEACH
•
A discrepancy between nurses' perceptions and practice in relation to the
provision of preoperative information was found. Limited teaching aids,
tight operation schedules and language barriers affected the delivery of
preoperative information to ambulatory surgical patients.
WHAT IS ALREADY
HAPPENING
•
YOUTUBE
•
FORUMS
•
GOOGLE/BLOGS
•
FACEBOOK/WEB CHAT-SUPPORT GROUPS
•
COSMOPOLITAN/magazines/advertising
•
Media -Talking Point-BIG MEDICINE
Trust me, I am a website!
•
Nichols and Oermann 2005:
•
evaluated 40 websites
•
75% had evidence of commercial promotion
•
62.5% biased
•
Only 37.5% recently updated
What are we measuring ?
•
Measuring long term results ?
•
Weight loss ,Quality of Life ?
•
Resolve of comorbidities?
CeQOL
Carolina Equation for Quality of Life
•
Focus on Inguinal Hernia Repair -Based on mesh
repair patient outcomes had been significantly
improved
•
Quality of Life measurements focussed on pain,
mobility and % chance of discomfort 1 year after
surgery
•
Realistic expectations are explained via data
collection and via the algorithm.
•
The patient can see the likely results taking control of
their potential outcome.
CeDAR Carolina’s Equation for
Determining Associated Risks
•
•
Diagnosis and stabilization of
Diabetes,Reducing BMI and
ceasing smoking
•
Reduces the complication rate
68%-23%
•
Cost economics in some USA
healthfunds are using this tool to
charge patients less with specific
surgeons and pathways which
advocate preoptimization
Blackstone and Cortes
SORD 2010
• age
• body
mass index
• history
of deep venous thrombosis or pulmonary embolism
• severity
of sleep apnea
• diabetes
• hypertension
• mobility
• cardiac
status
• psychological
classification.
Readmission Variables
•
Nausea, vomiting, and dehydration (26%),
•
Abdominal pain (20%) ? Constipation?
•
Wound issues (8%)
•
Respiratory
Preoperative optimisation of Comorbities,
•
reduced
readmission rates from 8.5% to 1.7%
Surgical
Complication
•
Unstable Diabetes/Hypertension
•
Hypercapnoea
•
Pulmonary Embolism-DVT
Establishing pathways
•
Experience
•
Literature
•
Trial and error pathways
•
Development of pathways
•
Analysing complications and readmissions
Introducing a dedicated bariatric
program
•
During an episode of surgical care, adverse
outcomes and therefore patient safety are
primarily determined by the quality of the systems
of care –National Surgical Quality Improvement
Program
•
Surgeons qualifications contribute to the system
•
However there is much importance on
communication, coordination and teamwork in
achieving quality surgical care.
Dumon et al
SORD 2011
•
Studied outcome and quality indicators over a 6 yr
period.
•
1886 Gastric bypass procedures, involving 2
surgeons.
•
Team approach: surgeons, bariatric coordinator,
dedicated anaesthetists, dietician, phyios, mental
health specialists and bariatric nurses.
•
Establish clinical pathways including perioperative
workup and education.
Preoperative work up
•
Initial Consult-Office visit with Surgeon
•
Evaluation Blood work,HBA1C TSH FBC Complete Metabolic
Panel
•
Pulmonary Function Tests
•
ECG
•
Chest Radiograph (Chest X Ray )
•
Upper GI Study
•
Sleep study
Perioperative Pathways
DVT prophylaxis
Incentive Spirometry
Hydration program
Restricted post operative diet
Thorough post operative visit and follow up schedule
Ancillary Evaluation
•
Endocrinology consult if history of disease
•
Pulmonary consult if history of disease
•
Cardiology if hypertensive BMI >50 age>50
•
Diabetic or hypertensive
Complications
•
GI bleeding
•
Respiratory Arrest
•
Anastomotic leakage
•
Cardiac Arrest
•
Wound Infection
•
PE
•
Wound Dehiscence
•
DVT
•
Bowel Obstruction
•
UTI Dehydration
Results
•
Reduction overall complication rate 18.6% to
4.8%
•
Reduction in overall length of stay: 6.7 days to
3.2 days
•
Reduction in 30 day readmission rates 15.7% to
8.1%
Evidence
•
Underlying systems and processes
•
Direct effect of bariatric programs
•
Direct effect on patient care
•
Surgeons experience and volume
Implementing
Perioperative Pathways
Team communication
Time to provide the teaching skills and literature
Reinforcement of the processes via eg support
group
Related Facts!
•
60% pts with hypertension, BMI>35 will have OSA.
•
Undiagnosed OSA can lead to extubation issuesunplanned ICU admission.
•
Risks of respiratory complications, haematoma, infection,
return to theatre, poor post operative coping skills.
Multidisciplinary Approach
•
Multidisciplinary teams work because they:-
•
All talk the same language information from a
specific expert opinion eg psychology,dietitian
•
Continually reinforce the need to know and how to
make the operation work on a one to one basis and
Patient to team relationship
•
Individual programs per patient analysing pt
specifics eg blood deficiencies,Rx and monitoring
pt outcomes
What Doesn’t Work
(as well)
•
Last Minute Dot Com
•
Drive Through
•
What is the long term result
Preoperatively
•
“At the Cleveland Clinic Bariatric and Metabolic
Institute, we believe that optimal teaching about
readmission prevention should be completed 1–2
weeks before admission.
Karen Schulz
Cleveland Clinic
•
Has a dedicated nurse who calls patients 1–2 days after
discharge to review questions regarding potential
complications.
•
Patients are educated preoperatively regarding the 24-hour on
call phone service.
•
Patients are also informed about a hydration clinic that is
available for individuals who fall behind in their fluid intake.
•
After surgery, individuals are encouraged to visit their primary
care provider 1–2 weeks after surgery to assist in monitoring of
blood pressure, blood sugar, and any other medical comorbidities.
Professional Responsibility
•
As a perioperative Nurse I see the benefits of
patients on the program in my practice
•
We have a duty of care to at least try to provide
the preoperative service knowing that this DOES
influence long term outcomes
•
To initiate proactive treatment for best long term
outcomes
REFERENCES
•
“Nurses' perceptions of preoperative teaching for ambulatory surgical patients.”J Adv Nurs. 2008
Sep;63(6):619-25. doi: 10.1111/j.1365-2648.2008.04744.x.
•
B Todd Heniford, MD, FACS, et al. Comparison of Generic Versus Specific Quality-of-Life Scales for
Mesh Hernia Repairs. J Am Coll Surg 2008;206:638–644.
•
CeQOL [email protected]
•
CeDAR.
•
Budak et al. Patient education: Effective methods of content delivery. Bariatric Nursing and Surgical
Patient Care Vol 3 Number 4 2008
•
Hunt et al. “Safe Passage “ A Team Approach to Positive Outcomes for Bariatric Patients MedSurg
Nursing Vol 3 Number 4 2008
•
Olaithe M; Bucks RS. Executive dysfunction in OSA before and after treatment: a meta-analysis. SLEEP
2013;36(9):1297-1305.
•
Chaar et al 2010. Does patient compliance with preoperative bariatric office visits affect post operative
excess weight loss. SORD 7 (2011) 743-748
•
Moon RC et al. Treatment of Weight Regain Following Roux-en-Y Gastric bypass,Revision of
pouch,Creation of new Gastrojejunostomy and placement of Proximal pericardial patch. Obesity Surgery
Journal Vol 24 No 6 2014
References
•
Blackstone RP, Cortes MC. Metabolic acuity score: effect on major complications after bariatric
surgery. SORD 2010;6(3):267–73.
•
Blackstone RP, Cortes MC, Messer LB, et al. Psychological classification as a communication
and management tool in obese patients undergoing bariatric surgery. SORD 2010;6(3):274–81.
•
Kellogg TA, Swan T, Leslie DA, et al. Patterns of readmission and reoperation within 90 days
after Roux-en-Y gastric bypass. SORD 2009;5(4):416–23.
•
Cottingham K, McCarty T, Arnold D, et al. Preoperative vs postoperative administration of low
molecular weight heparin for laparoscopic gastric bypass. Oral presentation, 21st Annual
Meeting of the American Society for Bariatric Surgery; San Diego, California; 2004.
•
Hyatt et al. The effects of sleeve gastectomy on gastro-esophageal reflux and gastro-esophageal
motility Expert Rev. Gastroenterol. Hepatol. 8(4), 445–452 (2014)
•
Karen Schulz, M.S.N., C.N.S., C.B.N. Decreasing bariatric surgery: Readmissions with preoperative
education. SORD 10 (2010): 387-388
•
Dumon KR et al: Implementation of designated bariatric surgery program leads to improved clinical
outcomes. SORD 7 (2011): 271-276