It's no secret that malnourished patients tend to have bad outcomes after surgery, but that's not your problem, right? When patients arrive at your facility, you're more concerned with their high deductibles than with their low albumin levels. While you're hardly alone in overlooking your patients' nutritional status, what if I told you it's easy to get your patients in the best possible nutritional shape for surgery — as easy as completing a 4-question checklist to identify those who are malnourished?

Here's the thing: You're perfectly positioned to help. Because outpatient facilities have the luxury of time, you can use the checklist to screen patients from the time they schedule surgery to the day they show up for their procedure. Yes, it requires coordination among your facility, your surgeons, and local dietitians or nutrition experts, but pre-op nutrition screening can lead to happier, healthier patients.

A bit of background: A few years ago, a few physicians and I developed Strong for Surgery (S4S), a public health campaign that engages patients and their surgeons to improve overall health and increase the likelihood of a positive surgical outcome (osmag.net/t8mFKX). The free program targets 4 areas that are known to be highly influential determinants of surgical outcomes: nutrition, glycemic control, medication management and smoking cessation. Today we'll focus on surgical nutrition.

Nutrition screening checklist

You can screen for malnutrition in 60 seconds. The Strong for Surgery nutrition screening checklist asks patients 4 questions to determine if the patient is malnourished. If the patient answers "YES" to any of them, you should refer her to a registered dietitian for nutritional assessment and intervention to improve the patient's condition before surgery.

• Is BMI less than 19?
• Has the patient had unintentional weight loss of over 8 pounds in the last 3 months?
• Has the patient had a poor appetite — eating less than half of his meals or fewer than 2 meals per day?
• Is the patient unable to take food orally (dysphagia or vomiting, for example)?

Additionally, for inpatient procedures, the checklist also suggests testing the patient's albumin level to ensure it's not less than 3.0 g/dL. (Historically, we have used low albumin as an indicator of malnutrition, but relying on albumin levels alone may falsely diagnose patients as malnourished.) For complex GI surgeries, the checklist also suggests giving the patient evidence-based immune modulating supplementation.

Optimizing nutrition before surgery

You can optimize nutrition in the 3 to 4 weeks between when the patient is scheduled for surgery and they arrive at your facility. Once you run through the screening process, if you determine the patient is nutritionally at risk, then you want to work with a nutrition specialist or dietitian to provide guidance to get the patient the proper diet in the weeks leading up to surgery. The exact guidance to improve the patient's condition can vary greatly, depending on the factors contributing to malnourishment. Regardless, the goal is to get the patient in the best possible shape for surgery.

Keep in mind that sometimes the patient's condition will handcuff the amount of improvement. For example, if you have a patient with ulcerative colitis, you may need to improve his malnourished condition before the scheduled surgery. You can likely improve it, but you may not get the patient to 100% before surgery.

And for all patients, don't forget about the importance of nutrition in the hours leading up to surgery. Though historically we have told patients that they cannot have anything to eat or drink after midnight the night before the procedure, recent literature has shown that it is not necessarily a good thing to have patients arriving at your center dehydrated and in starvation mode. Instead, consider letting them take liquids up to 2 hours before surgery. Supplementing with a high-carbohydrate liquid has been shown to improve surgical outcomes and improve the mood of patients heading into procedures, while keeping risk of aspiration low.

Tips for successful implementation

The process sounds simple enough: Screen patients before scheduling their surgery and then work with a registered dietitian or nutritional specialist to ensure they are no longer malnourished when they arrive at your center. On the day of the procedure, let the patient have a carbohydrate-rich drink up to 2 hours before surgery. The actual implementation of this, however, can be difficult. Here are some tips for a successful nutrition-screening program:

1. Don't make it a burden for surgeons. When I work with facilities to implement the Strong for Surgery program, one challenge is integrating the screening into the workflow. Start by identifying who will be part of the nutrition screening process. In most outpatient facilities, this will require a strong relationship with your surgeons and their offices. Share the checklist with your surgeons and tell them how you want patients screened for nutrition, but make sure you're being fair with what you're asking. If your surgeons are seeing 30 patients a day, and you're asking them to come up with an intervention that adds 5 minutes per patient, right there you've already failed because it will take away too much time. Maybe a nurse educator can do the screening instead of the physician? Can the patient be screened during a pre-op phone call?

2. Find a nutritional expert to partner with. If your facility has worked with one in the past, it may be a matter of reestablishing that relationship. Or, you may have no idea who your healthcare network's dietitian is, or you might not have one at all. If you don't have a dietitian on hand, look to the local community to identify the resources and establish a partnership before implementing the nutrition screening. As a facility leader, you should know the local healthcare community and can identify potential partners.

3. Focus on one initiative at a time. To be successful, you don't want another initiative happening at the same time — if your focus is nutrition, you don't want staff to also be worrying about a recent acquisition or EMR rollout.

4. Have experience with QI efforts. If your facility regularly holds quality improvement efforts, such as hand hygiene or infection prevention campaigns, your staff are likely already open to change and you have the infrastructure in place to form a multidisciplinary team to look at nutrition screening and treatment.

5. Activate the power of one. For those resistant to change, look to the power of one. Who will be the champion — the one surgeon, the one nurse, the one anesthesia provider — who is willing to do whatever it takes to make sure patient care is the best it can be?

6. Start small. Start practicing nutritional surveillance and fore-going NPO with just one set of procedures or one willing surgical team. Once others see the success of that one team or department, we're all competitive by nature and others will be drawn in.

Patients taking charge

All of us are wired to prepare ourselves before undergoing something major, like running a race, taking a long trip or having surgery. A patient's risk of negative outcomes from an operation is often both predetermined and modifiable before entering the operating room. Yet for decades, we've been telling patients to just sign the paper and show up on the day of their procedure. Instead, patients are asking what they can do to get ahead of surgical intervention, and we've found that providers who teach their patients what to do before surgery are having better outcomes and higher patient satisfaction. OSM