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 informed patient

•Knowledge and confidence to recover

•control over their weight loss surgery

ASSESS TEACH EVALUATE

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 is subject to many factors eg ,Pt Engagement/level of understanding,pt knowledge,perioperative Nurse’ knowledge,

• The purpose is to reduce anxiety,provide empowerment,ownership and patient control

Empowerment- Control -Self Belief -Coping Strategies

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

• 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.

EDUCATION SHOULD BE EVERYWHERE

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?

CeQOLCarolina 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

• Surgical Complication

• Unstable Diabetes/Hypertension

• Hypercapnoea

• Pulmonary Embolism-DVT

Preoperative optimisation of Comorbities, reduced readmission rates from 8.5% to 1.7%

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

• Anastomotic leakage

• Wound Infection

• Wound Dehiscence

• Bowel Obstruction

• Respiratory Arrest

• Cardiac Arrest

• PE

• DVT

• 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 issues-unplanned 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 co- morbidities.

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 ceqol@carolinashealthcare.org

• 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