Avoid complications by making sure patients are Strong for Surgery

A patient’s risk of negative outcomes often is predetermined based on their risk characteristics, but also potentially modifiable in the days and weeks preceding an operation, according to David R. Flum, MD, MPH, FACS, director, UW Medicine’s Surgical Outcomes Research Center and professor of surgery and adjunct professor, health services and pharmacy, University of Washington, Seattle. The American College of Surgeons (ACS) sponsors the Strong for Surgery campaign to help surgeons guide their patients in modifying the behaviors that put them at risk of negative outcomes, added Dr. Flum, medical director of the Surgical Care and Outcomes Assessment Program Comparative Effectiveness Research Translation Network.

“We are so much better than we were 20 years ago,” in terms of delivering better quality and safer care in the operating room (OR), Dr. Flum said. “Now we need to move beyond the OR and start focusing on who we pick to go to the OR. Optimizing the patient for surgery—that’s what Strong for Surgery is all about.”

Strong for Surgery codifies the steps surgeons should take to ensure patients are healthy and strong enough for surgery. “It’s a complement to the National Surgical Quality Improvement Program (ACS NSQIP®) and part of the College’s overall effort to improve surgical quality across the entire continuum of care,” starting with Strong for Surgery in the preoperative stage. The focus is on deciding, “Is this the right operation for the patient, and is this the right patient for the operation?”

Rachel R. Kelz, MD, MSCE, MBA, FACS, professor of surgery, Hospital of the University of Pennsylvania, Philadelphia, described how hospitals can build a foundation for implementing a Strong for Surgery program, emphasizing the importance of the preoperative optimization phase of care as defined in the ACS Red Book, Optimal Resources for Surgical Quality and Safety. The Red Book “provides a common language” that all stakeholders in patient care—including hospital administrators, other health care professionals, and patients and their families—can use throughout the surgical care journey.

“You can’t possibly do this yourself,” Dr. Kelz said. “In the preoperative phase, you want to get all the caregivers together” to establish the best possible plan for the patient’s care and what steps the patient needs to take to preoperatively to be ready for surgery.

She noted that Strong for Surgery, at present, focuses on smoking cessation, nutrition, glycemic control, and medications. “There are really compelling data coming out that show that people who stop smoking before an operation stay nonsmokers for five years after recovery.” Thus, Strong for Surgery may result in not only better episodic outcomes, but improved overall health, she added.

“Implementation of a Strong for Surgery program is not an event. It’s a process,” Dr. Kelz said. This process occurs over four phases: exploration—learning the benefits of implementing the program; installation of the resources needed toward implementation; initial implementation—a “soft launch” or pilot program; and full implementation.

Thomas K. Varghese, Jr., MD, MS, FACS, is leading the College’s Strong for Surgery campaign. Dr. Varghese is chief value officer, Huntsman Cancer Institute; head, section of general thoracic surgery; and program director, cardiothoracic surgery fellowship, University of Utah, Salt Lake City. He is also associate professor, department of surgery, University of Utah School of Medicine. He noted four new checklists are in development, which will focus on delirium, prehabilitation, patient directives, and safe and effective pain control. To develop the checklists, a group of stakeholders was assembled to discuss how to address these issues using checklists, he said.

“Does Strong for Surgery work?” he asked. In Washington State, where the concept originated, the model was used to prepare 85.4 percent of colorectal patients undergoing specific procedures at participating hospitals. Some common complications from these operations dropped from nearly 10 percent before implementation to approximately 7 percent, Dr. Varghese said. The Strong for Surgery program is now being used at 150 sites in the Upper Northwest, four national sites, and 36 sites have accessed the Strong for Surgery toolkits.

Starting in 2019, surgeons will be able to incorporate Strong for Surgery checklists into their use of the ACS NSQIP Risk Calculator, he said. “We are hoping to eventually have one centralized checklist,” Dr. Varghese added.

Margaret L. Schwarze, MD, MPP, FACS, assistant professor of surgery and endowed professor, Morgridge Professorship in Vascular Surgery, division of vascular surgery, University of Wisconsin-Madison, spoke on patient directives, emphasizing that patients and their families should be well-informed about best-case and worst-case consequences of an operation.

“Informed consent doesn’t help us as much as we would like to think it does,” Dr. Schwarze said. “At the end of the day, we don’t provide the information families need to know to make informed decisions.”

Surgeons often are trained to think that a worst-case situation involves a patient dying in the OR—a relatively rare event these days. “A worst-case scenario is a patient who has complication after complication and the family decides to withdraw life support,” Dr. Schwarze said.

To avoid these situations, Dr. Schwarze recommended that surgeons provide patients and their caregivers with a more comprehensive snapshot of what the patient will experience given their health status preoperatively. “Set the stage,” she said. “Break the bad news. It’s important to say, ‘I’m worried,’” about the outcome of a procedure.

Dr. Schwarze also suggested using a graphic aid to show the best-case and worst-case scenarios for an operation versus of comfort care. Then, “tell a story,” about previous experiences with patients. Finally, elicit the preferences of patients and their families. Ask them, “‘What is important to you?’” she said. “Make recommendations based on patient values.”