Primed for Success

Ever think of all you can do to optimize your patients' experience and improve their surgical outcomes — before they even step foot into your facility? Here are 5 easy ways to improve your pre-operative protocol.

A malnourished patient is likely to have bad outcomes. Thomas K. Varghese, Jr., MD, MS, head of the section of general thoracic surgery at the University of Utah, and a team of doctors created a simple checklist to screen for malnutrition.

The Strong for Surgery checklist asks patients 4 key questions to determine if the patient is malnourished. Refer the patient to work with a nutritionist or dietician in advance of surgery if the patient answers yes to any of these questions:

• BMI less than 19;
• unintentional weight loss over 8 pounds in the last 3 months;
• poor appetite (eats less than half of meals or fewer than 2 meals per day); and
• unable to take food orally.

As more facilities start to move to Enhanced Recovery After Surgery (ERAS) protocols, pre-op nutrition will become even more important for successful surgery, says Robyn Washington, MBA, BSN, RN, CNOR, a clinical nurse III at Houston Methodist at the Texas Medical Center. NPO after midnight has long been the standard, but ERAS encourages patients to drink clear liquids up to 2 hours before surgery and stop solid foods before midnight, says Ms. Washington. Houston Methodist encourages patients to drink apple juice — preferably a low-sugar brand — 2 hours before arriving at the facility.

It's been a slow process to get both surgeons and patients on board, says Ms. Washington, but education has been a huge help. The hospital worked first with the surgeons' offices to get them up to speed on ERAS and the role nutrition plays in patient outcomes. The hospital supplies surgeons' offices with brochures that patients receive when they schedule their surgery. Having doctors champion the cause — especially the hospital's medical director, surgical director and members of the anesthesia team — helped ease fears among hesitant doctors.

"We have found that having other physicians discuss it with them directly has made a difference," says Ms. Washington. "They just want to know if it works, if it will delay their cases and what the benefits really are. Having their peers be the ones to answer their questions helps their offices accept this new way of thinking."

Adding a few steps pre-operatively can make a big difference in your surgical site infection prevention efforts. Take pre-op CHG bathing, for example. Denice Morrison, MSN, RN-BC, CNOR, perioperative education coordinator at North Kansas Hospital, notes that her facility has seen an improvement by implementing a protocol requiring pre-op CHG bathing for patients.

"The biggest benefit we have seen is a reduction in bacteria on the patient's skin prior to the surgical prep that has resulted in fewer surgical site infections," says Ms. Morrison. "Our procedure population includes a large number of total joint replacements; and we want to ensure that they are protected as much as possible from an SSI."

The hospital's surgical services department instructs patients to take a CHG bath before coming to the hospital for their procedure. But because the facility "cannot control whether a patient follows the request to complete a CHG bath," Ms. Morrison notes that it was important they had backup procedures in place. Staff ask patients on the day of surgery if they've completed the pre-surgery bath. If not, then a pre-op nurse uses a CHG wipe to cleanse them.

Key to making pre-op bathing work is educating both staff and patients, says Ms. Morrison. She notes that the hospital completed a "performance improvement project" that provided in-house education to nurses on the importance of not only the CHG bath itself, but also proper documentation and patient education. "We found that with proper education, compliance increased," she says.

Patients receive a brochure on the importance of CHG bathing at the surgeon's office. Plus, patients scheduled for joint replacement surgery learn about the benefits of compliance with the CHG bathing regimen at a total joint seminar.

"Our surgeons and their staff are very good about explaining the improved outcomes we've seen when using a CHG bathing regimen," says Ms. Morrison.

New apps and online portals make pre-operative communication a snap for facilities. The St. Louis Children's Specialty Care Center created an app to suit the needs of their patients. Vicki Rhomberg, MSN, RN, program manager, explains how it works.

The facility first calls the patient's family a week before the procedure to notify them that they'll be receiving a text message that has a link to download the app and log in. Once the patient's parents download and log into the app, it uses the case number to know what type of procedure the patient is receiving. To stay HIPPA-compliant, no patient-specific information is stored on the app, says Emily Pharr, BSN, RN, staff nurse at the center. Instead, the videos, checklists and other information is purely based on the case number and type of surgery the patient is receiving.

The app includes everything and anything the patient may need to prepare for surgery. That includes a video that gives patients a tour of the hospital from "the time they walk through the doors of the facility all the way to the waiting room and through care at home," says Ms. Rhomberg. It also has a checklist that parents can use to prepare their children the night before, and videos that demonstrate the surgical experience from a child's perspective. It even has GPS directions built into the app, with information telling patients exactly where to park and enter the facility so they don't get lost.

"The night before the scheduled procedure, parents who have downloaded the app will get their NPO time texted to them," says Beth Smith, MSN, RN, staff nurse at the center. "It has the time they need to stop solids, when to stop clear liquid and what a clear liquid even is."

This app is making a big difference not only in patient satisfaction, but also in NPO compliance, says Ms. Smith, who notes that a surgeon at the center recently performed an informal analysis and found a decrease in same-day cancellations — including those due to NPO violations — attributed to communication failures. Parents tell staff that they most appreciated the NPO text that reminds them when to stop feeding their child.

"Most of the time when we were doing a pre-operative phone call, we were reaching people on their cell phone, and it would be inconvenient for them to stop whatever they were doing to write down the information," says Ms. Rhomberg. "This puts that information right at their fingertips."

Using pre-admission software helps get important information about your patient to the facility ahead of time, says Rena Carney, RN, BSN, director of nursing at Dublin Surgery Center. "Over the past few years, we have worked hard to get our patients and physicians on board with using the pre-admission software," she says. "We currently have about 80% to 90% of our patients using the software to fill out necessary forms prior to arriving at our center on the day of surgery."

At her center, as soon as patients get on the surgery schedule, they receive an automated phone call that's sent through the pre-admission software that directs the patient to go to the website and fill out the forms online. If they don't fill out the forms as it gets closer to the surgery date, then the system will send out another pre-op reminder phone call. A pre-op nurse will call to assist those patients having trouble completing the online forms, says Ms. Carney.