After learning that he needed surgery to remove a golf-ball size tumor in his lung, 67-year-old Doug Rice expected to go under the knife right away. But his doctor told him he’d have to make an important change first: Quit smoking for 2½ weeks to reduce the chance of dangerous complications.
Hospitals are taking steps to improve the outcomes for patients undergoing surgery—starting with the crucial preoperative period that can make the difference between a successful procedure and a poor or even deadly result. Doctors are finding more evidence of the benefits of boosting a patient’s health before surgery, and post-surgical complications are a major reason that patients end up back in the hospital.
Hospitals also are facing more financial penalties from Medicare for preventable readmissions after discharge, as well as legal liabilities when things go wrong.
For patients like Mr. Rice, who also suffers from emphysema and high blood pressure, that might mean delaying procedures for weeks or even months to strengthen health, tinker with medical regimens or encourage lifestyle changes. Even in more urgent cases, surgeons are taking extra time to ensure patients are in better shape. At the same time, for healthy patients undergoing procedures that aren’t high risk, hospitals are eliminating unnecessary tests and precautions that add costs, don’t help and may cause harm such as X-rays that expose patients to extra radiation.
Mr. Rice’s surgeon, Thomas Varghese, is medical director of a program in Washington state, Strong for Surgery, which has joined with partners including the American College of Surgeons to provide preoperative checklists focusing on risk factors that can be modified before surgery.
Often patients may only get a sheet of instructions a day or two before surgery on how to prepare for the procedure. Strong for Surgery checklists are meant to be reviewed much earlier—in an initial consultation between the doctor and patient, who also is provided a packet of educational materials to take home.
“This is an opportunity to engage patients in the process of asking important questions, rather than passively moving through the system,” says Dr. Varghese, director of thoracic surgery at the University of Washington’s Harborview Medical Center in Seattle.
The checklist focuses on four issues: smoking, nutrition, blood sugar control and medication. Smoking, for example, can impair the ability to withstand anesthesia, increase the risk of respiratory complications after surgery such as pneumonia and interfere with wound healing.
New evidence continues to emerge regarding surgery risks and health status. For example, for patients who have had previous heart attacks, guidelines have suggested a four- to six-week delay before any kind of surgery. But a study of nearly 600,000 patients published last year in the journal Annals of Surgery suggested the delay should be at least two months and ideally four to six months, if not longer, for these patients to avoid another heart attack.
Guidelines from several of groups including the Bloomington, Minn.-based Institute for Clinical Systems Improvement call for each patient to have a preoperative evaluation with a physical examination and medical history, but discourage hospitals from automatically performing chest X-rays, lab tests, electrocardiograms and stress tests.
In part, hospitals perform extra tests to protect themselves from liability, but that can cut both ways. For example, if a patient in good health had a heart attack after surgery, it might raise questions if no ECG was ordered before. But hospitals also may face problems if they routinely order stress tests—even though guidelines on their use are more restrictive—and then a patient’s death is linked to such a test.
Some time-honored practices are being challenged. For example, newer anesthesiology guidelines say most patients may have clear fluids up to two hours before surgery, a departure from the traditional order to take nothing by mouth after midnight the night before. Rather than protect patients from breathing fluid into their lungs while under anesthesia, as long feared, withholding fluids leaves patients “miserable and dehydrated before surgery,” says Karen Mauck, a physician at the Mayo Clinic in Rochester, Minn., who specializes in perioperative medicine, the term for care given before, during and after surgery.
Hospitals are also more carefully evaluating non-cardiac patients before surgery to determine their risks of a heart attack or other issues. Doctors at Mayo are testing a new cardiac-risk calculator, based on data published last year in the journal Circulation, which uses five factors including a patient’s age, physical condition and the type of procedure.
Rather than take a “one-size-fits-all approach,” Dr. Mauck says, “in the 30 days before surgery, we should be looking at each patient, assessing their individual risks and making recommendations to get them through the period 30 days after surgery with the fewest complications.”
In elective surgeries, doctors may ask patients to stop smoking for several months. It was long thought that stopping smoking too close to surgery would increase coughing and airway secretions and raise the risk of pneumonia. But a review last year in the Archives of Internal Medicine found no evidence that quitting shortly before surgery increased postoperative complications and concluded advice and help quitting can be provided any time before surgery.
When he was diagnosed with non-small cell lung cancer in 2010, Mr. Rice, a retiree in Lynwood, Wash., had just suffered a bout of pneumonia, and Dr. Varghese explained that even a couple of weeks smoke-free would help optimize his health. “I had a half a pack on me at his office and I handed them to my wife and went cold turkey after smoking 50-plus years,” says Mr. Rice. (Mr. Rice’s surgery was a success and he says he hasn’t resumed smoking, he exercises and takes better care of himself).
The Strong for Surgery checklist also suggests that patients who are poorly nourished can benefit from a nutrition formula, sold by Nestlé SA and others. It can be provided for five days before a procedure, boosting the immune system to fight off bugs. It can reduce infectious complications by 40% to 60%, according to Dr. Varghese. Patients who haven’t had much of an appetite or haven’t been able to eat well should receive a simple blood test that can check levels of albumin, a protein found in blood. In addition to checking diabetes patients’ blood-sugar control, checking blood sugar for those over 45, or less than 45 with a high body mass index is recommended so any needed treatment can be started before a procedure.
The Strong for Surgery checklist also includes a recommendation that patients and doctors review all medications, including herbal remedies that patients may not think to disclose. Ginkgo biloba for instance, can cause bleeding problems and hormone therapy can increase the risk of blood clots after surgery.
Morrie Johnson, a general surgeon in Mount Vernon, Wash., says he is using the Strong for Surgery checklist in his practice. “This is another way of educating surgeons about changes that can make a real impact to prevent complications and reduce costs,” Dr. Johnson says.
This article originally appeared in the October 23, 2012 edition of the Wall Street Journal.