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Optimizing patients for surgeryThe Experience in a Level 1 County Hospital

Diane St Pierre, APRN, ACNP-BC, CTTSCertified Tobacco Treatment Specialist

Disclosures

´ I have nothing to disclose.

Objectives

´ Describe the need for surgical optimization in the outpatient surgery clinic

´ Describe the methods used to improve overall patient health prior to elective surgery

´ Discuss the impact on patient care and same day cancellations in the OR

Why do we need surgical optimization?´ The risk for negative outcomes in elective surgery has been shown to be

reduced when preoperative optimization is performed

´ Smoking cessation

´ Weight loss

´ Nutrition support

´ Glycemic control

´ Optimization of medications

´ Delirium

´ Prehabilitation

´ Patient directives

Why do we need surgical optimization?

´ In 2016, our county hospital had an estimated 23,847 minutes of operating room underutilization. Depending on the type of surgery, the first 30 minutes of OR time costs $4,272 - $7,508, each minute after that costs $23. This translated into $1,716,984 in lost revenue.´ Updated current OR costs: $3,885-$9,345 for the first half hour. $17.53-$21 per

minute.

´ Postoperative Respiratory complications can add an additional $52,000 dollars to the cost of hospitalization.

´ Surgical site infection rate prolongs hospitalization and impacts reimbursement

Why do we need surgical optimization?

´Common reasons for same day cancellations´ Uncontrolled HTN´ Uncontrolled DM

´ Poor nutritional status´BMI too high

´Low albumin´ Need for cardiac or pulmonary risk stratification

´ Need for medical risk stratification

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Why do we need surgical optimization?´ These delays can postpone elective surgery upwards of

4-6 months. Family Practice clinics are so overburdened that a patient request for an appointment can take 3 months to be scheduled. ´ High provider turnover rates (residents) can result in patients not having

an assigned primary care provider. One byproduct of this is lack of appropriate medication refills, leading to uncontrolled hypertension and diabetes as well as other medical conditions.

´ There is additional burden placed on the UCC/ED for medication refill visits.

Why do we need surgical optimization?

Common preventable postoperative complications which may be prevented by optimization

´ Pneumonia

´ Superficial and deep wound infection

´ Myocardial Infarction

´ Arrhythmia

´ Severe pain

´ Pulmonary Embolism

´ Acute Kidney Injury

´ CVA

´ Respiratory failure

´ Acute confusion/delirium

´ Cardiac arrest

´ Need for transfusion

ASA Classification METS – metabolic equivalent of task

One MET is defined as the amount of oxygen consumed while sitting at rest and is equal to 3.5 ml of O² per kg body weight, per minute.Evaluates the functional capacity or exercise tolerance of an individual

AHA/ACC Guidelines 2017

´ For patients with history of CAD without symptoms and without risk factors, no additional cardiac testing is indicated prior to surgery.´ Risk factors:

´ Sex Fam ily history of heart d isease

´ Sm oking Uncontrolled stress/anxiety

´ Elevated LDL Alcohol use

´ Uncontrolled diabetes Physical inactivity

´ Obesity Elevated CRP

´ Uncontrolled HTN

Risk stratification – case study

´ 58 yo woman PMH COPD, CHF, HTN, GERD, DM

´ FH CAD, CVA

´ Saw PCP 5/31

´ Ortho 6/27 – needs rotator cuff repair

´ SOP 7/2 - Exertional chest pain relieved with rest

´ 7/10 – DSE

´ 7/18 – LHC w/ DES x3 (RCA, LAD, LCX 80% not amenable to PCI)

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Surgery – specific risk

´ HIGHER

´ LOWER

•Aortic•Non-Carotid Peripheral Vascular•Major Thoracic

•Major Abdominal•Carotid•Head/Neck•Orthopedic

•Breast•Eye/Skin

Smoking cessation

´ Smoking has been shown to increase the risk of postoperative complications´ Respiratory

´ Pneum onia

´ Difficulty weaning

´ Reintubation

´ Increased m ortality

´ Infection

´ Increased risk for SSI

´ Increased M RSA drug resistance

´ Wound healing

´ CV complications

Smoking Cessation

´ Medicare Part A and B cover individual counseling for smoking cessation´ Counseling is a covered benefit without regard for signs or symptoms of

tobacco related disease´ Can be individual, group, phone counseling

´ Two quit attempts per year are covered ´ 4 counseling sessions per each quit attem pt

´ Part D covers NRT (inhaler or nasal spray), bupropion, varenicline´ OTC not covered

´ Patch, gum , lozenge

Smoking Cessation´ Affordable Care Act Coverage´ Tobacco cessation interventions for adults have an “A” rating by the U.S. Preventive Services Task

Force (USPSTF), m andating coverage of tobacco cessation treatm ent. This applies to both federal and state run m arketplace plans.

´ Coverage includes both counseling and m edications without cost-sharing (out of pocket expense to the patient). For those using tobacco products, at least 2 quit attem pts per year are covered.

´ This includes:

´ Four tobacco cessation counseling sessions of at least 10 m inutes each (individual, phone, or group) w ithout prior authorization

´ 90 days of any FDA-approved tobacco cessation m edication when prescribed by a healthcare provider w ithout prior authorization

´ The 7 FDA-approved cessation m edications include: N icotine patch, gum , lozenge, nasal spray, inhaler, bupropion, and varenicline.

´ These recom m endations are based on the 2008 Update of the Clinical Practice Guideline:Treating Tobacco Use and Dependence (PHS)

ACA plans which do not provide this coverage are out of com pliance

´ https://attud.org/aca.php

Smoking Cessation

´ Counseling´ Readiness to quit

´ Previous quit attempts

´ Quit plan

´ Quit date

´ Barriers to quitting

´ Plan for triggers, stressors´ Slips vs relapse

´ Smoking cessation apps

´ Smoking cessation classes

´ Empower the patient´ M otivational interview ing

´ Shared decision m aking This Photo by Unknown Author is licensed under CC BY-NC

Smoking Cessation

´ Behavior modifications´ Placebo

´ Oral hygiene

´ Water

´ Delay response to crave

´ Inconvenient placement of tobacco product

´ No smoking indoors

´ Refocus

´ Puzzles, gam es, reading, take a walk

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Smoking Cessation

´ Prescription medication

´ NRT

´ Inhaler, nasal spray

´ Patches can be prescribed

´ Buproprion (Wellbutrin)

´ Can be once or twice daily dosing

´ Also helpful for anxiety, weight loss

´ Varenicline (Chantix)

´ Titrate up dose

´ Twice daily dosing

´ Take with food/full glass of water

This Photo by Unknown Author is licensed under CC BY-SA

This Photo by Unknown Author is licensed under CC BY-NC-ND

This Photo by Unknown Author is licensed under CC BY-SA-NC

Smoking Cessation

´ Combination therapy

´ NRT with concurrent smoking

´ NRT with buproprion or varenicline

´ NRT with buproprion and varenicline

´ Buproprion with varenicline

´ Completion of cessation therapy testing

´ Nicotine/cotinine

´ Cotinine <2 tobacco free

´ Cotinine <8 passive exposure

Weight loss

´ Underweight patients have a higher mortality while overweight patients have a higher morbidity

´ Increased BMI increases surgical complication potential

´ BMI >40 ASA III – severe systemic disease

´ Difficult intubation

´ IV access

´ BMI >35

´ Increased risk of infection

´ W ound dehiscence or delayed wound healing in abdom inal surgeries

´ Increased length of surgery

´ Increased potentia l for respiratory com plications

Weight loss

´ Discuss options for weight loss strategies

´ Patient engagement and buy-in

´ Limiting unhealthy carbohydrates and processed food

´ Increasing physical activity

´ Pool aerobics

´ Daily walking

´ Chair exercises

´ Psychological support

´ Close follow-up

´ Small, focused attainable goals

Weight loss

´ Try to individualize for patient preference

´ Low carb

´ Mediterranean diet´ MyPlate

´ Portion control

´ Diabetic diet

´ Standard American Diet (SAD)

´ Coaching, not lecturing´ Celebrate every victory

S h o p a n a t o m ic a l .c o m

Weight loss case study

´ 58 y/o woman with large ventral hernia sent to clinic 2/2019 for weight loss. Target for weight loss BMI <40. Current BMI 45.17 (255 lb).

´ March 11 - 43.74 (257 lb)´ April 9 – 41.81 (236 lb)´ May 8 - 41.1 (232 lb)´ June 19 – 38.83 (219 lb)´ July 17 – 38.09 (215 lb)

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Weight loss case study

´ Surgery August 8 with successful TAR´ PRS performed panniculectomy´ Surgery follow up 8/29 – 37.02 (209 lb)´ No medications used.

This Photo by Unknown Author is licensed under CC BY-NC-ND

Nutrition support´ 25-40% of patients admitted are malnourished

´ Albumin <3 associated with increased rate of post op complication

´ Optimizing protein improves wound healing´ BMI <20 would benefit from supplements

´ Post procedure, eat 3 meals per day ´ Protein shake to replace if not hungry/able to eat

´ Protein rich foods to help with healing´ Fish, poultry, eggs, beans, cheese, nuts, tofu, protein drinks

´ Stay well hydrated´ Meet with RD if needed

´ Immune modulating supplements

Glycemic control

´ Uncontrolled diabetes can double the risk of SSI

´ Patients without diagnosis of diabetes with perioperative glucose >124 had higher incidence of infection

´ Glycemic control prior to elective surgery decreases the risk of hyper/hypoglycemia perioperatively

´ Perioperative physiological stress can increase BG

´ 25% of people with Type 2 DM are undiagnosed

´ Hispanic and Asian population 50% have not been diagnosed

´ Most prediabetic patients are undiagnosed

Glycemic Control´ Type 1 Diabetes

´ Autoimmune disease

´ Previously called Juvenile Diabetes

´ Genetic risk factors

´ Parent or first degree relative with Type 1

´ Ethnic risk factors

´ In the US, predominately seen in whites more than Latino or African American

´ Outside the US, China has the lowest incidence

´ 10-20 times less than Europe, North America and Australia combined

´ Finland has the highest incidence

´ 60 in 100,000 people

´ Three times US average

Glycemic control

´ Type 2 Diabetes´ The body either is resistant to insulin or produces an inadequate

amount. ´ Symptoms

´Polydipsia´Polyphagia

´Polyuria´Fatigtue

´Visual changes´None

Glycemic control´ Screening for Type 2 diabetes

´ Not autoimmune´ Risk factors include

´ Family history of diabetes (1st or 2n d degree relative)´ Personal history of GDM´ Maternal history of GDM´ Ethnicity´ Characteristics of insulin resistance

´ Acanthosis nigricans´ PCOS´ HTN´ Dyslipidemia

´ Small for gestational agehttps://derm101.com/clinical-atlas/acanthosis-nigricans/

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Glycemic Control

´ Ethic groups at risk for diabetes´ More likely to be overweight with hypertension and type 2 diabetes

´ African Americans

´ Mexican Americans

´ American Indians

´ Native Hawaiians

´ Pacific Islanders

´ Asian Americans

w w w .D ia b e te s.o rg

Glycemic Control

´ Evaluate HbA1c as well as SMBG logs every visit

´ HbA1c reflects average SBG for the last 12 weeks

´ Heavily weighted on the last 4 weeks

´ Can be checked q one m onth when titrating m edications

´ 5.8-6.4 is prediabetes

´ 6.5 is diabetes

´ >10 associated with increased infection risk

´ “double digits”

Glycemic control – case study

´ 49 year old man with PMH DM, CHF, AF on apixaban, HTN, CKD, Charcot foot. Morbidly obese BMI 63.34 (416 lb)´ Initial visit on Levemir 127 units bid and Humalog 70 units ac

tid´Issues with portion control, OMAD

´ A1c 10.2 (246)´ Rx Toujeo (U300 glargine), liraglutide (Victoza) and glipizide´ RTC after 4 weeks - weight 434´ 4 weeks later – weight 420 SMBG 83-438 A1c 8.6´ 6 week follow up – weight 409 SMBG 130-199 am 100-155 pm

´A1c 6.8

Glycemic control

´ Education, education, education!´ Patient engagement´ Dietary modification´ Optimizing medical management´ Overcoming clinical inertia´ Acknowledging improvement ´ Evaluating barriers to self care (no blame)´ Close follow-up

Glycemic Control

´ Lifestyle modifications´ Diet

´ Exercise

´ Good sleep hygiene

´ Stress management´ Cortisol levels

This Photo by Unknown Author is licensed under CC BY-NC-ND

This Photo by Unknown Author is licensed under CC BY-NC-ND

This Photo by Unknown Author is licensed under CC BY-SA-NC

Glycemic Control

´ Medication´ Biguanides

´ Sulfonylureas

´ SGLT2 inhibitor

´ GLP1

´ DPP4 inhibitors

´ Thiazolidinediones´ Glucosidase inhibitors

´ Bile Acid Sequestrants

´ Insulins

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Glycemic Control

´ Biguanides´ Metformin

´ Reduces the am ount of glucose secreted by the liver

´ Does not cause weight gain

´ Does not cause hypoglycem ia

´ Helps reduce cholesterol

´ Lowers A1c by 1-2%

´ G I side effects m ost com m on but less w ith XR

´ Take with meals

´ M onitor B12, G FR

´ Available in liquid form , extended release form

This Photo by Unknown Author is licensed under CC BY-SA-NC

Glycemic Control

´Sulfonylureas´Glipizide, glyburide, glimepiride

´Stimulates beta cell insulin release

´Glyburide has highest risk of hypoglycemia, but all have the potential

´Can cause weight gain, so caution in obese patients

´Reduces A1c 1-2%´Take with meals

This Photo by Unknown Author is licensed under CC BY

Glycemic Control

´ SGLT2 inhibitors´ These are the “glucoretics” “Flozins”

´ Canagliflozin (Invokana) – increased risk of am putation, CV death reduction

´ Dapagliflozin (Farxiga) – avoid w ith hx bladder cancer

´ Newly approved generic

´ Em pagliflozin (Jardiance) – CV death reduction´ Ertugliflozin (Steglatro)

´ No weight gain (mild weight loss)´ No hypoglycemia´ Reduces A1c 1-2%´ UTI/gangrene risk

Glycemic Control´ DPP-4 Inhibitors

´ Incretin Enhancers

´ Sitagliptin (Januvia)

´ Saxagliptin (Onglyza) – increased HF risk´ Linagliptin (Tradjenta)

´ Alogliptin (Nesina) – increased HF risk

´ Delayed gastric emptying´ Increased action of gut hormones

´ Increased secretion of insulin´ Can cause joint pain, pancreatitis,

dyspnea and edema´ Reduces A1c 0.6-0.8%

This Photo by Unknown Author is licensed under CC BY-SA

Glycemic Control

´ Thiazolidinediones´ TZDs – increase sensitivity to insulin

´ Pioglitazone (Actos)

´ Rosiglitazone (Avandia)

´ Can worsen or even induce congestive heart failure

´ Caution in macular edema

´ Monitor for weight gain

´ Reduces A1c 0.5-1%

Glycemic Control´ Other options´ Glucosidase Inhibitors

´ Acarbose (Precose)

´ M iglitol (G lyset)´ Delays absorption of carbohydrates

´ Reduces A1c 0.5-1%´ Can cause hypoglycemia, avoid with Cr >2

´ Meglitinides´ Repaglinide (Prandin)

´ Nateglinide (Starlix)´ Stimulates insulin burst with meals´ Can cause hypoglycemia and weight gain

´ Reduces A1c 1-2%

´ Bile Acid Sequestrants´ Colesevelam (W elchol)

´ Reduces A1c 0.5%´ Lowers LDL 15-30%

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Glycemic Control - Injectables

´ GLP-1 RA´ Exenatide (Byetta) – bid dosing

´ Exenatide XR (Bydureon) - weekly´ Liraglutide (Victoza) – daily. Shown to reduce CV risk

´ Dulaglutide (Trulicity) - weekly´ Semaglutide (Ozempic) – weekly

´ Delays gastric emptying

´ Increases insulin secretion

´ Promotes satiety

´ Glucagon suppression

´ Reduces A1c 05.-1.6%

´ Weight loss 1.6-6kg

´ Not with history of Thyroid Cancer (personal or family history)

´ Watch for symptoms of pancreatitis This Photo by Unknown Author is licensed under CC BY

Glycemic Control - Insulins´ Basal

´ NPH´ Intermediate, lasts 10-16 hrs

´ Detemir (Levemir)´ Glargine (Lantus or Basaglar)

´ Degludec (Tresiba)

´ Bolus

´ Aspart (Novolog, Fiasp) ´ Fiasp has more rapid onset of action

´ Lispro (Humalog)

´ Glulisine (Apidra)

´ Basal/bolus

´ NPH + short or rapid acting insulin

Commons.Wikimedia.org

Glycemic Control – other insulins

´ Afrezza – inhaled regular human insulin

´ Duration 3 hours

´ Assess lung function

´ Can cause bronchospasm

´ Tresiba – U200

´ Toujeo – U300

´ Humalog U200

´ Humulin Regular U 500

´ For patients requiring >200 units insulin daily

Optimization of medication

´ Review all medications including herbals and OTC supplements

´ Taking correctly?

´ Medications/supplements that increase bleeding risk

´ Medications that may interfere with anesthesia plan

´ Illicit drugs that can interfere with anesthesia and pain plan

´ Daily marijuana use

´ Hypocoagulable state w ith synthetics

´ Management of holding parameters for anticoagulation/antiplatelets

Delirium

´ Postoperative delirium is linked with poor outcomes

´Increased LOS´Functional decline´Institutionalization´Increased costs´Increased mortality

Delirium risk factors

´Age´Alcohol/substance abuse´Physically deconditioned´Impaired cognition´Abnormal labs

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Prehabilitation

´ Helps to improve recovery time´ Reduces LOS both hospital and rehab

´ Reduces morbidity and mortality´ Enhance physical conditioning to help mitigate physiological

stressors of surgery

´Incentive spirometry´Daily walks

´Lean proteins´Maximize nutrition

´Reduce risk for delirium

Prehabilitation

´Frailty assessment´Timed get up and go

´Time to rise from sitting, walk 3 meters, turn, walk backand sit down with usual aids

´ >=13s predicts falls´ >=30s corresponds to functional dependence

´ Referral to PT if indicated

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Enhanced Recovery after Surgery

´ ERAS is a series of protocols that has been shown to reduce infections, decrease LOS and improve outcomes

´ Limit perioperative fluids and opioids´ Reduce physiologic stressors´ Regional or local blocks´ Maintain normothermia´ Early mobilization´ Early oral intake´ Clear liquids up to two hours before surgery time

Enhanced Recovery after Surgery

´Meds for PONV given in OR´Tight glycemic control´Preop patient education´Preop nutrition shakes 5 days prior´Presurgery drinks (3)

Pain management plan

´ Early education about the pain management plan and medications for pain relief´ Multimodal pain protocol

´ Continue home pain med regimen

´ IV lidocaine 1.5mg/kg, max 200mg (anti-inflammatory)

´ Acetaminophen 650mg q 6o scheduled

´ Celebrex 200mg q 12o scheduled (or Naproxen 500mg)

´ Gabapentin 300mg q 8o scheduled (or Pregabalin 50mg q 12)

´ Muscle relaxant scheduled

´ Analgesic – Ketamine prn moderate pain

´ 2nd line medications – Oxycodone, morphine q 4-6 prn, or hydromorphone

´ 3rd line medications – Oxycodone 10mg q 12 scheduled

´ Analgesic effect 1.5 x greater when acetaminophen added to oxycodone

´ Still not at goal, pain consult

Pain management

´ Set realistic goals for pain management in clinic and during perioperative period

´ Decrease opioid use postop

´ Complications r/t opioid use

´ Respiratory depression

´ Increased fall risk

´ Urinary retention

´ Nausea/vomiting

´ Constipation/ileus

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Patient directives

´ Discuss financial burden

´ Post op pain

´ Surgical risks

´ Need for surgery

´ Reduce anxiety

´ Meet with LMSW, financial counselor

´ Advanced directive/living will

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Postoperatively

´ Can see 1-2 times after surgery to facilitate getting back in with PCP´Partnering with PCP for continuity of care

´ Continue management of uncontrolled conditions´ Smoking cessation´ Monitor nutrition

´ Monitor glycemic control´Higher risk for SSI with perioperative hyperglycemic in

non diabetic patients

Reducing ED/UC visits

´Medication refills for patients who cannot get in to see their PCP´Typically sent from Preadmission Testing to

avoid UCC visit´Uncontrolled HTN´Asthma/COPD´Diabetes

Referral sources

Surgery44%

Orthopaedics23%

Podiatry19%

Oral Surgery4%

Other4%

GYN4%

Neurosurgery2%

SURGICAL OPTIMIZATION REFERRING DEPARTMENTS

SurgeryOrthopaedicsPodiatryOral S urgeryOtherGYNNeurosurgery

Clinic growth October 2016 - June 2019

11

70

87

72

102

101

72

96

104

94

152

139

172

152

124

175

152 15

9

160

141 144

135

200

185

240

254

195

265

257

243

236

252

229

1 0 1 1 1 2 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 2 3 4 5 6 5 1 7 0

2 0 1 6 2 0 1 7 2 0 1 8 2 0 1 9 T O T A L

TOTAL

Tot a l

Optimization Clinic Growth

´ In October 2016, 11 patients were seen´ In October 2017, 172 patients were seen

´ In October 2018, 240 patients were seen´ January 2019, 265 patients were seen

´ As of June 30, 2019, 5170 patients have been seen´ A second FTE for nurse practitioner was added in April 2018

´ A third FTE for nurse practitioner was approved May 2019´ Starts 9/9/19

´ There is already talk of a fourth practitioner!

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What is needed for success

´ Support from management´ Proactive boss with good ideas

´ Surgeon champion´ Surgeon buy-in

´ Resident buy-in´ Support staff

´ Clinic management and staff buy-in´ Space

´ Collaboration with dietician and social work´ Patient buy-in

´ Invested practitioners

How did that work out?´ Decreased same day cancellations from 9% to 6%´ Decreased wait time for surgery clearance´ SSI impact

This Photo by Unknown Author is licensed under CC BY-SA-NC

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2013 2014 2015 2016 2017 2018 2019

superficial deep organ

Surgical Site Infection Incidence

Acknowledgements

´ Claudette Cook, APRN, AGACNP – partner in crime, sounding board, all around amazing provider.

´ Elizabeth Smith, DNP, APRN, CNS, CCRN – Worked to conceptualize what optimization would look like at JPS, and then let us run with it. Chief supporter and cheerleader!

´ Ashley Conn, LCSW – without whom we would be lost. Provides guidance and support for our patients, connecting them to needed resources.

´ Our surgeons – who respect and support the clinic and celebrate our successes with us.

Questions?

´ Thanks for listening!

´ Diane St Pierre, APRN, ACNP-BC, CTTS

´ dstpierre@jpshealth.org

References

´ diabetesed.net. (n.d.). www.diabetesed.net

´ Gan, T. J., Thacker, J. K., Miller, T. E., Scott, M. J., & Holubar, S. D. (Eds.). (2016). Protocols. Enhanced Recovery for Major Abdominopelvic Surgery (1st ed., pp. 333-361). West Islip, New York: Professional Communications, Inc.

´ Howard, R., Yin, Y. S., McCandless, L., Wang, S., Englesbe, M., & Machado-Aranda, D. (2018). Taking control of your surgery: Impact of a prehabilitationprogram on major abdominal surgery. American College of Surgeons, 228(1), 72-80.

´ Wolpert, H. (Ed.). (2016). Diabetes Self-Management Support and Education. Intensive Diabetes Management (6th ed., pp. 23-32). Alexandria, Virginia: American Diabetes Association.

´ https://www.diabetes.org/resources/statistics/statistics-about-diabetes

´ http://www.diabetesforecast.org/2017/nov-dec/race-and-type-1-diabetes

´ https://attud.org/aca.php