Just as you wouldn’t attempt to run a marathon without training for it, patients need time and help to prepare for surgery. That’s the advice from the co-chair of the Surgical Patient Optimization Collaborative (SPOC), Dr. Kelly Mayson. At a recent SPOC update to VPSA members, she encouraged us to shift the paradigm of “wait times for surgery” to “preparation times for surgery.”
“Our current care pathways don’t always promote patient-centred care,” said Dr. Mayson. “Proceeding to surgery without time to fully optimize fitness and comorbidities can lead to the worst post-op outcomes. Early identification of medium to high-risk patients and understanding their perioperative risk will avoid last minute cancellations and changes of plans. Early review of these patients allows for comorbidity assessment and optimization.”
SPOC is an initiative led by the Specialist Services Committee in partnership with the Shared Care Committee. It has been working to improve surgical care throughout the province since 2019 and Dr. Mayson has been involved since the start. It is a multidisciplinary, structured, personalized program designed to support patients to achieve an improved experience and outcome after surgery.
Optimizing patient pathways includes early physiological evaluations and a prehabilitation personalized care program beginning soon after the decision to proceed with surgery. Components considered for optimization are anemia, smoking cessation, glycemic control, physical activity, nutrition, sleep apnea, pain management, frailty, anxiety/mental health, social support, cardiac, and substance use.
Growth of SPOC
The collaborative began in September 2019 with VGH, St. Paul’s, Royal Jubilee, UHNBC, RIH, and Campbell River Hospital as the pilot sites. Within 6 months, hospitals in Prince Rupert, Trail, Nanaimo, Penticton, Kelowna, and Duncan had signed on, along with the Change Pain Clinic. An additional 13 sites were added in 2022; today over 50 per cent of BC hospitals that provide surgical services now have incorporated an optimization program into their perioperative services. VGH and UBC Hospital initially focused on oncologic gynecologic and urologic patients, but more recently have expanded to lower limb arthroplasty and complex spine instrumentation.
SPOC has developed free online resources for patients including toolkits and passports along with videos (scroll down this webpage to access these materials).
Over 25,000 patients have been screened for optimization; more than 18,000 (75 per cent) required prehabilitation. Of these, close to 17,000 (90 per cent) were prehabilitated prior to surgery. These steps have been popular with patients. More than 75 per cent agreed their overall health improved because of the information and care provided by their surgical preoperative team, while over 91 per cent felt their surgical experience was improved as a result of this care.
The results include a healthier population, lower costs (decreased lengths of stay, morbidity, and cancellations), improved patient experiences, and improved provider experiences.
Reconstructive orthopaedic surgeon Dr. Lisa Howard and spinal surgeon Dr. John Street were on hand to talk about their experiences as part of the Surgical Patient Optimization Collaborative.
“The more fit you are before surgery, the better you will be post-surgery,” said Dr. Howard. “Optimization addresses modifiable risk factors, it decreases medical complications, and it reduces lengths of stay.”
VGH and UBCH have redesigned their pre-admission clinic questionnaires for hip and knee arthroplasty to address frailty, anemia, nutrition, smoking, pain control, and endocrinology. Dr. Howard reviewed each of these and noted how concerns in these areas affect decisions to proceed or delay surgeries. Sixty-four per cent of patients undergoing hip and knee surgeries in VCH optimized in at least one of the components.
“Rather than say no, we say not yet,” said Dr. Howard, “as we want to give patients the motivation to stay the course of optimization.”
Dr. Street was also enthusiastic about SPOC and talked about patient appropriateness and optimization in adult spinal deformity surgery. He, as Drs. Mayson and Howard before him, emphasized that optimization is a team effort.
Dr. Street discussed how elderly patients have the most to gain from spinal deformity surgery, but also potentially the most to lose, as they also get the most adverse events. He and his colleagues have developed a clinically relevant risk threshold, with the optimization of SPOC, that they use to decide if surgery is appropriate. Among the modifiable risk factors are smoking, diabetic control, anemia, pre-operative narcotic use, metal health and BMI. Based on this collaborative multidisciplinary assessment, they will recommend surgery proceeding, waiting for positive results from prehabilitation, or advising that elective surgery be avoided.
Perioperative Clinical Action Network
Geoff Schierbeck, an SSC liaison with Doctors of BC, was the last speaker at the event. He spoke about the Perioperative Clinical Action Network (PCAN). The network unites multidisciplinary surgical team members of all specialties and hospitals across BC to engage in supporting local and regional surgical solutions and quality improvement efforts. SPOC is part of PCAN.
“Network members share information and stay connected,” said Schierbeck. “They have a voice through their advisory committees, and they support innovation improvement.”
Schierbeck spoke about the newly formed Perioperative Care Alignment and Digital Solution Committee (PCADS). It is developing patient screener questions, a preoperative investigations grid, perioperative medication guidelines, and prehabilitation and optimization recommendations.
Watch for more information about PCAN and PCADS as tools are developed.
View the event
The SPOC update was recorded and can be screened here. Family physician Dr. Lesley Wood organized and hosted the event on behalf of VPSA’s Community Building and Wellness Task Group in collaboration with VPSA staff and SPOC.
Feedback from the event
Thirty-three of the 49 VPSA members who attended the SPOC update completed the post-event survey. The vast majority of respondents agreed or strongly agreed that the event was well organized, unbiased, provided a better understanding of surgical optimization, and provided knowledge or insight the respondents will use in their practice. The event earned a 76 per cent net promoter score.
Suggestions for future surgical optimization initiatives included information on the role of nutrition, particularly for patients who cannot afford to follow a good diet, trauma care pathways for frail patients, patient care centres for optimization, and practical office management suggestions for family physicians to help with the optimization components.
Many respondents indicated they are interested in learning more about patient optimization and would like to participate in future surgical optimization working group meetings or initiatives.