Surgery
Boosting theatre efficiency with digital prehabilitation
How can we boost theatre efficiency and the health of our population, while relieving pressure on clinicians? Tara Rampal describes how digital prehabilitation (prehab) could provide an effective solution.
Prehab is a peri-operative intervention strategically designed to optimise modifiable risk factors, ultimately aimed at reducing post- operative complications. It’s a multidisciplinary, integrated, personalised intervention with four main pillars – prescribed exercise, nutrition optimisation, tailored psychological support and lifestyle modifications. There is increasing acceptance in the global
clinical community, that prehab reduces post- operative complications, decreases unplanned readmissions and improves patients’ health related quality of life. What’s more, it offers an opportunity to educate and empower patients, and use waiting lists as preparation lists. For example, the Royal College of Anaesthetists believes “fitter patients who are able to improve their health and activity levels recover from surgery more quickly and with fewer complications. What you do in the time leading up to surgery can have a really big impact on your recovery and long-term health.”1
According to the Centre for Peri-Operative
Care, a multidisciplinary initiative working to optimise patient outcomes, a quarter of a million people are at a higher risk from surgery - a number that’s set to rise. Its research highlighted that while 12% of operations result in a complication, being inactive raises this risk four-fold.2 However, preparing in advance of an
operation, and in particular by taking exercise and following nutritional guidance to help build strength and fitness, halves the chances of suffering a complication. The pillars include the following:
Exercise components of prehab are the most studied – it may be aerobic exercise prescription, resistance / strength training or a combination of them all. The most crucial element is the personalisation – tailoring it to a patient’s clinical need such as the planned surgical date, their functional capacity and the time available.
The nutrition optimisation focuses mainly on adequate protein supplementation, deficiency recognition and education. Psychological intervention ranges from talking therapies to cognitive behaviour therapy, focusing on anxiety, depression, acceptance of diagnosis and encouraging adherence to the prescribed exercise. Lifestyle modifications focus on active and empathetic support for smoking cessation, alcohol moderation, involving education and guidance. We know surgery places the body under great
physiological, cognitive and psychological stress (the possible mechanism being neurohumoral pathways, leading to the production of acute phase proteins, whole body protein catabolism and insulin resistance). Increasingly, the number of patients with
frailty, sarcopenia, complex comorbidities and advanced age are being offered surgical interventions. This leaves patients vulnerable to complications, which often translates to increased healthcare costs and utilisation, including total costs, hospital costs, care transition costs, primary care use, dental care use, emergency department use, unplanned hospital readmissions and hospitalisations. Epidemiological evidence demonstrates that higher levels of fitness may offer an advantage post-operatively. The reasons are multitude but may include greater antioxidant capacity and metabolic flexibility. “Pre-operative” time is a motivational opportunity for patients to increase their fitness. All of us when faced with an operation, want a good post-operative outcome with an early return to the baseline if not better. Motivation is a good starting point, but people need support, clear and comprehensive prescription of a tailored programme as every patient takes a different peri-operative journey. Some need support with psychological health and some with physical. The intervention needs to be offered as a whole, integrated intervention as each part complements the other.
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www.clinicalservicesjournal.com I February 2024
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