Transcription:

Melanie Cole, MS (Host): UAB Medcast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA Category 1 credit. To collect credit, please visit uabmedicine.org/Medcast and complete the episode’s post-test.

Welcome. Today we’re talking about perioperative medicine, and specifically preoperative optimization. My guest is Dr. Jeffrey Simmons. He’s an associate professor of anesthesiology at UAB Medicine. Dr. Simmons, I'm so glad to have you joining us today. This is a really great and very important topic. Start by telling us what is perioperative medicine and how is it different than regular medicine?

Jeffrey Simmons MD (Guest): Well Melanie, one, thanks for having me on today. Perioperative medicine is all the care that a patient is gonna get from the time that they schedule a surgery until they're fully recovered. That’s going to include nursing, surgery, anesthesia. It may involve hospitalist medicine, intensive care units, pain medicine. So there’s a full scope of what perioperative medicine can be. What I was hoping to focus on today is this idea of preoperative optimization. That is where we look at modifiable conditions that a patient has before surgery, and then we attempt to pre-habilitate them or modify those risk factors in an attempt to improve that patient’s outcomes after surgery.

Host: So then is this similar to ERAS except for an extended version of it because it starts before, when they first schedule it, all the way ‘till they're recovery?

Dr. Simmons:   Yes. Enhanced recovery is very important. It’s service line specific. So if you had colorectal surgery or if you had some kind of surgical oncology surgery or spine surgery, those are gonna be surgery line specific things that you can do to improve a patient’s outcome. Where preoperative optimization comes into play is this is gonna be universal for all patients coming through regardless of the type of surgery. So if you are malnourished or you are anemic or you have risk factors because of your advanced age, these are all different things that we can optimize prior to surgery that really is universal to all different service lines. In modifying those risk factors, we can enhance enhanced recovery because we are still improving outcomes after that surgery’s over.

Host: So then let’s talk about some of those conditions that can realistically be optimized before surgery. Tell us about some of the modifiable preoperative conditions that if a patient improves upon can increase their chances of having better outcomes.

Dr. Simmons:    So the list is pretty extensive. But if you look at some of the ones that we are actively working on at UAB, malnutrition tops the list. Smoking cessation, anemia, elder care planning. We look at screening for patients that do not know they have sleep apnea. We look at hyperglycemia control. We are screening patients that are at high risk for DVTs or venous thromboembolism or blood clots people would say. We are looking at opioid reduction strategies and ways to prevent adverse outcomes after surgery. When you combine all of these things into one overall kind of guideline or risk assessment, we are doing this for our orthopedic surgery patients in total. Like we’re looking at all of these things and kind of bundling them for our orthopedic surgery patients and then specifically any of our patients who are coming through our preoperative assessment clinic. So the list is very long, but each of these conditions significantly impacts a patient’s post-operative outcome.

So, for example, if a patient is anemic. Traditionally that patient comes into the hospital anemic and they're not identified as being anemic and nothing was done to treat them. That anemia may go unrecognized or even underappreciated, which is most likely what happens. Really it’s underappreciation of the significance of the disease. If that patient then comes in and becomes hypotensive during surgery, for example, and then they get transfused with blood products, well there's risk involved with the risk of transfusion. There's hospital resources that are being used maybe when it could have been prevented. Anemia in and of itself is a pretty profound multiplier of risk to other conditions like heart failure or kidney disease.

So even if we can reduce the amount of transfusions that are done, reduce the risk of that blood transfusion to the patient, reduce the risk of anemia being a multiplier of other problems, we can improve that patient’s outcomes. We can do that very easily through identifying that patient and treating them before surgery. That sounds like something that should have been and could have been done forever. The medical community as a whole has really not delved into optimization. UAB is really on the forefront of this of what is becoming the next step in surgical care. Not so much looking at intraoperative and post-operative, but really starting to see how can we optimize the patient’s presurgical condition to improve their outcomes?

Host: I certainly agree with you. As you said, it should have been done and it would make common sense that this would have been the concept for so many years. Do you feel that other facilities are recognizing this as well? While you're speaking about that, Dr. Simmons, how is UAB equipped to manage this type of optimization? What are you doing from that time ‘till the time of recovery to really help a patient through this—all of it—and the support systems needed.

Dr. Simmons:  Yeah, that’s a great question. We are part of a large community. When you look at national societies that are being designed around perioperative management of a patient, I would say that the United States, as a whole, really got on board with this—I would say—probably five to eight years ago as enhanced recovery became the biggest thing in surgery. Everybody wanted to do enhanced recovery. They were really looking at the time that the patient came into the hospital until afterwards. There are many national organizations that are completely focused on perioperative improvement.

We are equipped at UAB—and I think this is a natural progression of how we are caring for patients now as we are really focusing on quality and providing quality of care over quantity of care, right? We have to make sure that we’re providing the best quality of care for the best value. We are really now focusing on things that patients, I think, want us to focus on. We’re looking at patient satisfaction. We’re looking out comes that are very important to the patient. For example, how fast were they able to return to work? Were they discharged to a nursing home or were they discharged home? What was their cognitive performance like afterwards? So we are not just looking at the traditional hospital and clinical outcomes like length of stay or transfusion risk. We really want to be patient focused and provide quality of care over quantity of care.

UAB is incredibly equipped to do this. We have two locations at UAB. We will see over 120 patients a day, which is roughly around 78 to 80% of our entire surgical population when you look at that over the course of the year. So we’ll do right around 36,000 surgeries. We’re seeing almost 30,000 of those patients in our preoperative clinic. With those two different clinics, we also have a core faculty of anesthesiologists that are assigned to those facilities everyday who are managing and screening those patients, reviewing their records, with the addition of a very robust staff of nurse practitioners.

As a team, we are seeing those patients and not only doing the traditional anesthesia preoperative assessment, but we are screening those patients for all of the modifiable risk factors that we can pre-habilitate over time. We have gotten some really amazing traction. Our surgeons are very onboard. The surgeons are taking our suggestions and saying, “Okay. Let’s make this happen because we want the patients to do better.” Certain things like smoking cessation, for example—which is one of the things that we’re screening for and offering cessation medications for, that’s just good public health in general. So we are really trying to look at the patient as a whole. We have great surgical buy in, and we are really well equipped from the staffing standpoint to be able to see all these patients.

Host: It’s really amazing. As I said before, what an interesting topic. As we wrap up Dr. Simmons, where do you see this going? Do you think it’s going to become standard of care across the board? What would you like surgeons about finding additional information on optimization? Really what you see happening and that you’d like them to know what you're doing at UAB Medicine.

Dr. Simmons:   I think the most important thing is to know that they’ve got an ally in the patient’s health. When it comes to how you go about optimizing a patient, you cannot do it alone. You cannot be one person trying to move the mountain. This only works through a large collaborative effort. As we see improvements from what we’re doing with patients and we’re seeing increased patient satisfaction and we’re getting those success stories of the patient that didn’t get transfused when they probably otherwise would have. We get the phone call back from a patient that says, “I was able to stop smoking because you guys were the very first people to give me the medications or the counselling that I needed to be able to stop smoking. I knew how important it was from what you guys told me because I didn’t want to get that surgical site infection and that really prompted me to stop.” So we’re getting the patient buy-in. As we get a larger collaborative effort from the surgeons and the anesthesia group, this is where it’s really gonna take off.

Our mission in our division is to improve surgical readiness to promote the best possible outcomes. So when we are looking at a patient in the pre-operative clinic, that patient is the most important person to us at that time. So who is in front of us that we can improve, that we can educate, that we can make sure that a condition that they have that could have been improved upon is improved upon before surgery. We communicate that to the surgery team, and then we develop a plan. An individualized plan for that patient so that they can do better afterwards. So that’s really where I'm hoping to get to on a 100% scale, not just patients that are enhanced recovery patients. We want to do this on all patients.

Host: So well put, Dr. Simmons. Great information and a great topic. Thank you for coming on and sharing your expertise in this important topic for other providers. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. That wraps up this episode of UAB Medcast. For more information on resources available at UAB Medicine, you can head on over to our website at uabmedicine.org/physician. If you as a provider found this podcast as informative as I did, please share with other providers because that’s how we all learn from the experts at UAB Medicine together. What a great topic and something so important that you spread this around. Be sure not to miss all the other fascinating podcasts in our library. Until next time, I'm Melanie Cole.