The preoperative work-up
The Origins of ERASThe concept of Enhanced Recovery (ER) within Perioperative Medicine has been an integral part of the patients journey through elective surgery for over a decade. Pioneered in Denmark, the Enhanced Recovery Pathway (ERP) has been adopted on a global scale. In the UK it has been championed by the Department of Health (DOH) since 2002 and advocated by three of the royal medical colleges (anaesthetists/general practitioners/surgeons) helping patients ”to get better sooner” since 2012.The success of the pathway is dependent on the commitment and expertise of all members of the multidisciplinary team who are involved in the patients journey – from GP referral, preoperative assessment, theatres and surgery through to ward based care and a well coordinated discharge back into primary care.A full circle of clinicians should be available to help optimise your health, relieve your fears, use new and innovative techniques, control your pain, manage your nutrition, plan your discharge and set your expectations to get you up and out of hospital, back home with a plan of action and ‘fighting fit’.
PHEW! Is it that simple?The Royal College of Anaesthetists Perioperative Medicine vision document  aims to create a dedicated perioperative team of clinicians to help ensure that patients receive ongoing care and communication before and well after discharge. This is to help prevent re-admission to hospital, but also to equip patients, their family and their carers with the skills to help them return to ‘normal’ or even better health post surgery.ER uses a proactive rather than a reactive approach. It requires the skills and dedication of the all the clinical teams to inform, guide and structure each component of the patients care pathway to allow for careful planning, opportune moments and prediction of outcome pre and post surgery. The ownership is meant to be largely on the patient themselves through shared decision-making, setting realistic goals and being well informed about expectations through the surgical process.Patients are the key to optimal recovery in the absence of any complications.
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So… Is standardisation always right?Or should we still use an ‘Enhanced Recovery approach’ but individualise it to our patients physical and psychological needs at the point of surgical referral?Preoperative assessment is the official starting point of ER. Most hospitals now run nurse led preoperative assessment units successfully with respect to clinical testing, patient information and a triage system for access to Consultant Anaesthetists for patients who are deemed high risk.That said, there is more to preassessment than just the ‘obs and swabs!’. In a population that is now surrounded by social media, internet and TV with an expectation to conform, there is a growing culture of both positive and negative lifestyle advice that is confusing and poorly delivered, potentially causing a detrimental effect on our patients’ perceptions of what is the ‘right thing to do’.I’m having surgery in 4 weeks – should I stop smoking? I’ve heard it can make you put on weight and make your chest worse? – How many times have we as professionals heard that?
So what’s right?Smokers have a substantially increased risk of postoperative complications. Preoperative smoking intervention can be effective in decreasing this incidence, and surgery may constitute a unique opportunity for smoking cessation interventions. One initiative taken by Newcastle Upon Tyne NHS Foundation Trust (2016) was to coordinate with public health services within the North Eastern area to help streamline the smoking cessation pathway. Despite an intensive smoking referral process, the footfall of patients who were referred into public health was minimal. In one of the largest preassessment care units (estimated 28,000 patients per year), a simple change to the preoperative questionnaire was implemented raising an ‘opt out’ choice rather than ‘opt in’ to smoking cessation services. In 3 months (May – July 2016), over 150 patients were referred into the services with positive outcomes in reducing and stopping smoking in the perioperative period.It is this point about ‘opportune’ moments that changes the thought process, not only of the clinical teams but also for our patients’, promoting good interventions and an informed decision about improving their health in preparation for surgery.Preventative medicine isn’t always factual, and its relevance is sometimes questioned because there are limits to measurable outcomes. There are numerous pieces of evidence and reports to show that positive lifestyle changes such as good diet/reduction in smoking and alcohol can benefit our long term health. However, there is not as much data to show that adopting these lifestyle choices prior to surgery actually improves postoperative outcomes.One review looked at both unpublished and published evidence of trials to show a link between getting fitter and improved postoperative outcomes with reduction in morbidity and hospital stay.  There are however still a very limited number of studies in this area.What we can do is take the evidence that is out there and use it to help educate our patients to make good choices before surgery, give them a better understanding, improve their mind set as to the responsibility they have in their surgical preparation and care and give them the evidence to show the benefits. We can still streamline some aspects of care as mentioned to compliment an ER pathway, but to deliver a truly patient-centred apporach in preoperative care an individual plan should be made with trained staff to try and improve preoperative fitness and instigate appropriate lifestyle changes.
But how do we engage patients in getting fitter?In 2016, The University Hospital of Southampton (UHS) launched ‘surgery school’. The movement of patients into a classroom based session allowed health professionals to educate and motivate patients to improve a number of lifestyle factors. Nutrition, exercise, alcohol and smoking are discussed to help patients understand how improvements in these areas can help to reduce post operative complications and reduce length of stay in hospital. As well as the obvious health benefits, the overall impact has huge cost efficiencies for the NHS. ‘Fixing dad’ was aired on TV in 2016. It was made by the sons of a man with diabetes and showcased his journey to improve his lifestyle. The film was an inspiring look at both the physical and psychological benefits of improving health through diet and exercise with an end outcome of preventing or curing type 2 diabetes. Part way through filming a CT scan to look at fat percentage, this gentleman was diagnosed with a renal cell tumour. The health benefits he had already seen, undoubtedly gave him a clearer mindset and focus on his surgical journey and his outcome and recovery was uncomplicated. 
SummaryPrehabilitation, optimisation, and ER are all familiar terms within our perioperative medicine disciplines. The benefits of engaging and educating our wider MDT teams, and more importantly, our aging, frail population in prevention rather than cure is still a minefield of uncertainty and limited studies.At a time when health services are stretched and with limited resources, and a population who should have a choice in their care, our job for the future is to try and promote what we believe is right at the beginning of the surgical pathway and unite primary and secondary care. The evidence of ER protocols proven to have positive outcomes in length of stay and rehabilitation should be coupled with individualised care and realistic goals and expectations. Clichéd it may be, but all of this should surround the main philosophy and value that represents ourselves as healthcare professionals – putting patients at the heart of everything we do.What experiences have you had in delivering enhanced recovery services? Do you have ideas on how to balance the compromise between standardisation and personalisation of care? Write your view in the comments, and hear about other peoples experiences in delivering enhanced recovery schemes.
- Royal College of Anaesthetists Perioperative Medicine Vision Document
- Thomsen, T., Villebro, N., Moller, A.M. (2010). A Review of Interventions for Preoperative Smoking Cessation. The Cochrane Collaboration
- Perry, R. et al (2016. Pre-admission interventions to improve outcome after elective surgery – protocol for a systematic review. Syst Rev. 5:88
- University of Southampton – A team of medical researcher develop “surgery school” to get patients fit
- Fixing Dad – a project to prevent or reverse type 2 diabetes
Perioperative Medicine in Action
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