Want better surgical results? Get patients to step up

Doctors aren’t the only ones who should train for surgery. Hospitals boost results by getting patients prepped with exercise, nutrition, and more.
Staff measure a patient’s gait speed in a Duke University Medical Center program that helps patients gear up for surgery. Credit: Shawn Rocco

Kate Cardwell was anxious about her upcoming surgery for rectal cancer. She wasn't sleeping well and found it tough to focus on the many details of her job in recording industry technical sales. So Cardwell signed up for a Johns Hopkins Medicine program designed to help patients prepare for surgery. There, she learned a visualization technique that had her imagining she’d come through surgery just fine — and was back home in Parkville, Maryland, working in her beloved garden. And she took advantage of other options, like visiting the postoperative suite so she’d know what to expect. 

“On the day of the operation, I was super calm. I felt great,” says Cardwell, 49. “I couldn’t have felt better than I did.”

Such preoperative educational efforts can boost not only patients’ personal experiences, but their physical recovery as well, a growing body of research suggests. As a result, hospitals are working to help patients gear up for surgery by increasing their physical fitness, learning to relax, making smart food choices, and tackling a host of other health-related habits.

“The best analogy is that a two-hour operation is about as hard on your body as running a 5-kilometer race as fast as you can go,” says Michael Englesbe, MD, a transplant surgeon at University of Michigan Medicine. “If you were going to do a 5K, you would train for it. It also makes sense that our patients should train for surgery.” 

“The best analogy is that a two-hour operation is about as hard on your body as running a 5-kilometer race as fast as you can go. If you were going to do a 5K, you would train for it. It also makes sense that our patients should train for surgery.” 

Michael Englesbe, MD
University of Michigan Medicine

Each year, some 10 million invasive, inpatient surgeries are performed in the United States. Most turn out fine, but between 2% and 4% result in complications, according to a 2015 analysis of eight common procedures. And even without complications, a patient’s quality of life and functionality can take a significant hit following major surgery.

But preoperative preparation — sometimes called prehabilitation or perioperative optimization — can affect those outcomes. Take the program Englesbe created at Michigan. It managed to cut postoperative stays by two days and costs by $2,308 per participant, according to an Annals of Surgery study.

Englesbe notes that it’s more than just a matter of numbers. “The way perioperative care is usually done is, I tell a patient in 34 days, I’m going to take out two-thirds of their liver. Then all the patient can do is wait, which can be so challenging psychologically,” he says. “Now we are giving patients something they can do. We empower them to have some ownership over their outcomes. That really changes the mental model they bring into the operating room.”

Here are five primary ways teaching hospitals are getting patients in shape for surgery.

1. Muscling up

Ask patients what they want after surgery, and nearly all say they’d like to head home as soon as possible, says Shelley McDonald, DO, PhD, who spearheads POSH — Perioperative Optimization of Senior Health — at Duke University Medical Center. “We tell patients, the better physical shape you are in going into surgery, the better shape you’ll be in coming out of surgery. Exercise protects everything: your mind, your heart, your muscles.”

POSH, which focuses specifically on geriatric patients because of their increased surgical risks, includes individualized fitness plans in its preoperative efforts.

“For people who don’t have much strength, we start with small steps, such as walking through the house several times a day, and build up from there,” says McDonald. “We want to make a plan that is realistic for them.”

“The better physical shape you are in going into surgery, the better shape you’ll be in coming out of surgery. Exercise protects everything: your mind, your heart, your muscles.”

Shelley McDonald, DO, PhD
Duke University Medical Center

Englesbe’s program, called MSHOP — the Michigan Surgical and Health Optimization Program — distributes pedometers and asks participants to track their steps by logging them into their electronic health record or replying to a reminder text.

“We encourage walking, but not everyone can walk so we provide alternatives like using a stationary bike,” says Englesbe, whose program has trained more than 2,000 patients since 2015. “The average American takes about 7,000 steps a day. The patients we enroll are doing somewhere between 1,000 and 3,000. We take care of a lot of very sick patients, and we need to do all we can to help them get ready for surgery.”

2. Food to fuel healing

A key predictor of surgical success is a patient’s nutritional status, says Strong for Surgery, an initiative hosted by the American College of Surgeons that promotes evidence-based practices to boost preoperative health. And, it notes, malnutrition is prevalent among surgical patients.

To tackle that problem, Indiana University (IU) Health gives patients a special nutritional beverage to drink in the days prior to surgery. The drink is part of a gift bag that includes other supplies, such as an antibacterial cleanser that patients can use preoperatively to reduce infections.

“When severely stressed, your immune system turns off for a period of time, so you risk infection,” says William Wooden, MD, IU director of surgical quality and wellness. “But we can help reverse that by providing nutrients like key amino acids. The drink is as close to magic as I can offer a patient.” 

The IU program, called Preoperative Wellness and Enhanced Rapid Recovery (POWERR), has worked with more than 80,000 patients since its launch about four years ago. "We have dramatically reduced length of stay and readmissions. Surgical site infections have dropped by 59% in the user group, and cost of care for these patients is down by $3,300 to $5,500 per case," Wooden says.

At Duke, the Perioperative Enhancement Team (POET) project — the center’s program for presurgery optimization — includes nutritional care that covers concerns like blood sugar control. That’s in part because hyperglycemia is a common cause of postponed surgeries. All POET patients are screened for diabetes as well as malnutrition and anemia, explains Solomon Aronson, MD, the program’s medical director.

“One of the most rewarding things about our program is that close to 50% of patients we screen are not even aware that they have diabetes,” says Aronson. “If these patients weren’t plugged into the system because of surgery, they might miss this opportunity to improve their health.”  

3. Don’t forget to breathe

One common tool in the battle against postoperative complications looks a lot like a child’s cheap plastic toy. It’s an incentive spirometer, a handheld device with a breathing tube and a floating ball that measures how deeply the user inhales. 

At IU, patients receive the device in their preoperative roller bag. Wooden says using it in the weeks before surgery may improve lung capacity — plus, it gets patients ready to use the contraption postoperatively. “We teach them to use it when they’re fully awake, when they don’t hurt, and aren’t just coming out of surgery,” says Wooden. “That’s very effective.”

McDonald’s team teaches patients a few deep breathing exercises and makes sure they understand the purpose behind the practice. “We tell them it helps reduce postoperative pain and anxiety,” she explains. “Once people hear that, they say, ‘Oh, I can do the exercises.”

“No one wants surgery, so we certainly have their attention. Let’s use this opportunity to really drive health for them and their families.”

William Wooden, MD
Indiana University Health

For some patients, breathing well also means quitting or cutting back on smoking. But squelching the habit doesn’t just boost lung function. It also enhances wound healing and helps prevent infection, explains POET’s Aronson.

POET recently launched one of the nation’s most in-depth preoperative smoking cessation programs. “We use specially trained providers and life coaches and provide personalized attentiveness to a person’s reasons for smoking,” says Aronson. “Then we also follow up to ensure compliance.” 

4. Don’t worry, be happy

Anxiety brews a dangerous biochemical soup, notes Roseanne Sheinberg, MD, who runs the Pre-Operative Mind-Body Program at Johns Hopkins Medicine. 

“From the moment a patient hears they’re having surgery, they’re anxious, and that has neuro- hormonal consequences,” she says. “Your body squirts out all these chemicals that cause inflammation. But if you practice relaxation, you’re getting your body’s hormonal chemical milieu in an optimized state, which sets you up for success after surgery.”

“From the moment a patient hears they’re having surgery, they’re anxious, and that has neuro-hormonal consequences.”

Roseanne Sheinberg, MD
Johns Hopkins Medicine

Sheinberg teaches a relaxing visualization technique from a program called Prepare for Surgery, Heal Faster. She says her role is to help patients immerse themselves in their imagined peaceful place.

“They can’t just think, ‘I’m sitting on the beach.’ They have to feel their toes digging into the sand, smell the salty air, use all their senses. When you imagine something in-depth like that, the body doesn’t know the difference between what you’re just imagining and what’s really happening — and that causes measurable physiologic changes.”

At MSHOP, patients get simple, do-it-yourself relaxation tips: take a soothing bath, pet your pet, and plan to do something uplifting every week before surgery. And the program points out that relaxation may help cut postoperative pain.

Other programs also address patients’ worries about pain. At Johns Hopkins, the Perioperative Pain Clinic helps patients better understand and manage pain starting weeks before surgery. In an effort to avoid opioid dependence, the clinic offers a panoply of tools, including psychiatry and physical therapy.

POSH’s McDonald says some patients definitely worry about postoperative addiction. “We counsel them on multimodal pain control, including topicals and thermal modalities. Many times, it’s such a relief for them knowing their pain will be controlled with the safest approaches possible.”

5. Planning ahead

Many preoperative programs focus on helping patients plan for what awaits after surgery.

“People worry how they’ll go to the bathroom, pay their bills, let the dog out. A lot of times they don’t want to inconvenience their families,” says Englesbe. “So we work on care planning and other logistics so they can relax and not perseverate over details.” 

And as patients look ahead to their lives postsurgery, preop programs can set them up for a lifetime of success, notes Wooden. “Let’s take this adverse event in this person’s life and use it to educate them on healthy living. No one wants surgery, so we certainly have their attention,” he says. “Let’s use this opportunity to really drive health for them and their families.”