• Patient education. Dr. Wahr, vice chair of quality and safety for the department of anesthesiology at the University of Minnesota, says optimizing patients for surgery is at the heart of the increasingly popular Enhanced Recovery
After Surgery (ERAS) programs many facilities have in place. “The entire concept of ERAS is focused on curtailing fasting, reducing opioid use and increasing post-op ambulation,” she explains.
It really frustrates me that some surgeons would choose throughput over allowing the patient to have a better outcome.
— Joyce Wahr, MD, FAHA
Patient education is a core component of the ERAS pathway in place at Pelham Medical Center in Greer, S.C. The facility holds “Joint Camps” for its total joint patients. Prior to the pandemic, the classes were held in-person for
the patient and their significant others, but the camp has since gone virtual.
“We make it a point to educate patients on every aspect of their care, from pre-op to post-op, and address their expectations, wound care requirements and the physical therapy process,” says Lauren Setzer, RN, MSN, Pelham’s
manager of pre-op, PACU and pre-admission testing. “The class lasts around two hours, and patients are enrolled as soon as they schedule their procedure.”
When it comes to patient education, Dr. Wahr urges surgical leaders to be conscious of common biases and misconceptions that may impact outcomes. “If a provider sees a patient who has an A1C of 8.7, they might think, ‘This patient
isn’t taking good care of themselves and will never change,’” she says. “But patients become very motivated when they’re preparing for surgery.”
You can’t achieve the best possible outcome without a motivated and knowledgeable patient. Patients who are informed about the importance of preparing their bodies for the rigors of surgery and who understand that failing to do so increases
the risk of post-op complications usually become willing participants in improving their physical status.
• Pre-op nutrition. Curtailing fasting and traditional NPO restrictions is paramount to patient optimization. Patients should always be given the opportunity to drink clear liquids up until two hours before surgery, says Dr. Wahr,
who points to the significant research that supports the safety of this practice. “Thirst is an incredibly powerful drive that makes patients miserable,” she says. “There’s no reason for patients to arrive in the
OR dehydrated and in need a bolus of salt water.”
Keeping patients properly hydrated and nourished, and having them eat and drink as soon as possible after surgery, helps get them up and walking immediately, which ultimately results in a host of clinical benefits. “It leads to increased
blood flow and cardiac output, better wound healing and a lower risk of pneumonia,” says Dr. Wahr.
If the data is so clear that NPO is generally unnecessary, why do some facilities continue to place this restriction on patients? Dr. Wahr says the issue often comes down to physicians’ desire to move cases as quickly and efficiently
as possible. If a surgery gets cancelled at the last minute, the next patient in line could jump right in if they were on an NPO restriction, she explains. Without the restriction, the surgical team might have to wait 20 or 30 minutes
for the next patient to hit the two-hour threshold since they last drank clear fluids.
“It really frustrates me that some surgeons would choose throughput over allowing the patient to have a better outcome,” she says. “A good friend of mine had cancer surgery, and she was told to be NPO after midnight,”
she recalls. “Her surgery didn’t start until 5 p.m. That’s physician-centered care, not patient-centered care.”
To combat any tendency to perform physician-centered care, Dr. Wahr’s uses dashboards that include surgeons’ names and show which providers are following all process measures that go into its enhanced recovery protocols, says Dr.
Wahr. “The dashboard is never meant for blaming and shaming,” she says. “It’s meant to help correct bad habits that have developed without providers even realizing it.”
An added benefit of the dashboards: They spark some friendly competition. “When surgeons see the dashboard, it becomes obvious that their outcomes are different, and nobody wants to be the outlier,” she says. “Making the
data apparent is really powerful.”
• PONV prophylaxis. Nothing derails a successful outcome and a positive surgical experience like a nauseous patient. To prevent PONV, Dr. Wahr’s facility generally relies on an effective combination of two medications: ondansetron
and dexamethasone. “We strongly suggest that any patient with a risk factor for PONV gets both antiemetics,” she says.
However, because dexamethasone is a steroid, she has found that certain providers balk at giving it to diabetic patients, opting instead to give them only ondansetron, which ultimately hurts the effectiveness of the PONV regimen.
If you find yourself in a similar situation with your providers, Dr. Wahr says giving patients 8 mg of dexamethasone — a measurable but clinically insignificant amount — while pumping glucose is a safe and effective option.
Dr. Wahr acknowledges that PONV prevention is mainly about patient comfort, as serious adverse events don’t generally occur because of nausea or vomiting. But patient comfort is a critical part of optimal outcomes and timely recoveries.
“Clearly, a nauseous patient isn’t able to ambulate soon after surgery,” says Dr. Wahr.
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