Us­ing nu­tri­tion coun­sel­ing to help prep surgery pa­tients for bet­ter out­comes

Modern Healthcare - - BEST PRACTICES - By Maria Castel­lucci

Marathon run­ners know to carbo-load the night be­fore a big run and the im­por­tance of re­plen­ish­ing elec­trolytes as they tick off miles. Be­ing at­tuned to their bod­ies, ex­er­cise en­thu­si­asts do what they can to min­i­mize the phys­i­cal stress they’ll un­dergo dur­ing an event.

Pre­par­ing for surgery should be no dif­fer­ent, ar­gues Dr. Paul Wis­chmeyer, an anes­the­si­ol­o­gist at Duke Univer­sity Hospi­tal in Durham, N.C. Yet, pa­tients are told to es­sen­tially starve them­selves be­fore­hand. “Why are we do­ing this?” he asked. For starters, habit. Telling pa­tients to forgo eat­ing or drink­ing be­fore surgery has be­come com­mon­place and it is a hard pat­tern to break. The other is­sue is that nu­tri­tion just isn’t top of mind for doc­tors when their pa­tients go into surgery. Most physi­cians only took one class dur­ing med­i­cal school on the im­por­tance of nu­tri­tion. But it’s closely re­lated to how a pa­tient will re­cover af­ter a pro­ce­dure, ac­cord­ing to Wis­chmeyer.

Stud­ies show that a well-nour­ished in­di­vid­ual is more likely to sur­vive and is quicker to re­cover from many kinds of surgery, es­pe­cially ab­dom­i­nal and vas­cu­lar pro­ce­dures. De­spite this, an es­ti­mated 30% of pa­tients are mal­nour­ished be­fore surgery.

Duke Univer­sity Hospi­tal is part of a grow­ing move­ment tack­ling mal­nu­tri­tion for sur­gi­cal pa­tients. Called En­hanced Re­cov­ery Af­ter Surgery, it mim­ics com­mon prac­tices in Europe that en­cour­age food be­fore and af­ter pro­ce­dures to im­prove out­comes.

Some stud­ies have shown that these in­ter­ven­tions can re­duce in­fec­tion rates by 40% and shorten length of stay by two days, Wis­chmeyer said.

Duke re­cently es­tab­lished a clinic fo­cused on help­ing pa­tients im­prove their nu­tri­tional health be­fore they un­dergo pro­ce­dures. Pa­tients are re­ferred to the Pe­ri­op­er­a­tive Screen­ing Clinic if they are found to be mal­nour­ished right be­fore a non-emer­gency surgery.

A clin­i­cal de­ci­sion-sup­port func­tion was added to the elec­tronic health record to help physi­cians iden­tify mal­nour­ished sur­gi­cal pa­tients. The EHR prompts physi­cians to com­plete three steps to de­ter­mine if their pa­tient is un­der­nour­ished be­fore a sched­uled pro­ce­dure.

Weigh the pa­tient to know if his or her body mass in­dex is too low for their height and age.

Ask the pa­tient if he or she has lost more than 10% of their weight in the past six months.

Ask if the pa­tient has been eat­ing less than 50% of their nor­mal diet in the past week.

Pa­tients with an ab­nor­mally low BMI score or who re­spond af­fir­ma­tively to ei­ther ques­tion are re­ferred to the nu­tri­tion clinic and surgery is post­poned. “We know that if you have low mus­cle mass in your body, and you un­dergo chemo­ther­apy or surgery, your chances of dy­ing are much, much higher,” Wis­chmeyer said.

Duke also plans to start screen­ing pa­tients for vi­ta­min D de­fi­ciency since it’s an ef­fec­tive way to know if pa­tients suf­fer from weak bone mass, which also can af­fect sur­gi­cal out­comes.

At the clinic, the pa­tient typ­i­cally meets with a di­eti­tian for about a month to get healthy. A big part of the meet­ings are fo­cused on nu­tri­tional education. The di­eti­tian will rec­om­mend high-pro­tein foods to eat be­fore and af­ter their surgery. Pro­tein sup­ple­ments are also ad­min­is­tered. Once it has been de­ter­mined the pa­tient is healthy enough to un­dergo surgery, the pro­ce­dure is resched­uled.

All sur­gi­cal pa­tients at Duke are told to have a liq­uid sup­ple­ment loaded with car­bo­hy­drates two hours be­fore their surgery. This goes against com­mon prac­tice at most U.S. hos­pi­tals, which usu­ally tell pa­tients not to eat or drink any­thing eight hours be­fore a pro­ce­dure.

Af­ter they awake from surgery, they are again given an­other pro­tein sup­ple­ment. A pa­tient usu­ally isn’t hun­gry shortly af­ter surgery, but it’s im­por­tant to en­cour­age pa­tients to have nu­tri­ents in their body to im­prove their like­li­hood of a speedy re­cov­ery, Wis­chmeyer said. A di­eti­tian will also call the pa­tient about a month af­ter their surgery to ask about their eat­ing habits and if they have lost or gained weight since the pro­ce­dure.

So far, physi­cians at Duke have been re­cep­tive to the pro­gram, Wis­chmeyer said. “They want to bet­ter serve their pa­tients,” he said.

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