New Hanover Regional Medical Center’s Perioperative medicine team at the NHRMC Surgery Navigation Center helps patients optimize their health prior to surgery to ensure patients can undergo surgical procedures more safely and reduce their risks for complications.
Part of doing that includes scheduling appointments before surgery with the team at the Surgery Navigation Center, which welcomes patients in the NHRMC Medical Mall. These appointments allow patients to have lab work and consultations with nurses and, if needed, also Perioperative hospitalists for more complex cases. If a health issue requiring immediate attention is discovered during a pre-operative visit, by using a fast-track referral system NHRMC’s Perioperative medicine team can send patients to specialists quickly for evaluation and needed treatment. Quick referrals can prevent postponement of surgery or help shorten the amount of time a surgery may need to be delayed.
Detecting heart-related problems and addressing other health risks that could cause a patient to have complications during and after surgery is an important part of what NHRMC’s perioperative medicine team does for patients. According to Carla Hupert, PA-C, MPAS, Perioperative Physician Assistant at NHRMC Surgery Navigation Center, without preoperative appointments some serious issues would likely be undetected until the day of surgery causing the procedure to be cancelled on that day.
Hupert said pre-operative appointments have played a role in helping some patients scheduled for elective surgery discover they needed cardiac care and ultimately needed to postpone a back surgery to undergo heart bypass surgery. In another example, Hupert said when a Surgery Navigation Center nurse found an undiagnosed irregular heartbeat in a patient scheduled for a knee replacement, the patient was seen by the Perioperative hospitalist and a referral was fast-tracked to a cardiologist at Cape Fear Heart Associates. The patient was quickly evaluated and treated, and the surgery date was pushed back for only a few weeks. “This helped to optimize the patient’s cardiac health, and it potentially prevented the patient from having a major cardiac event,” said Hupert.
It’s not just heart-related issues that preoperative medicine helps patients address before surgery but also issues such as diabetes and stroke. “We talk to patients who have had a stroke in the recent past about their increased stroke risk, and depending on the timing of their stroke and what type of surgery they are having, we may recommend they delay a surgery for a few weeks or few months.” Hupert said. “We also work with endocrinologists and have a fast-track way to get our diabetic patients to certified diabetes educators to help them get their hemoglobin A1C down into the goal range, which for joint surgery is less than 7.5 percent in order to help them decrease their risk of post operative joint infection.”
Scope of Services
About 4,000 patients having elective surgeries are seen by NHRMC’s Perioperative medicine team each year. Hupert said a scoring tool and point system are used to determine which patients will need Perioperative medicine services. Some factors considered include how long a patient will be under anesthesia in the operating room, the complexity of the surgical procedure, the patient’s medical risks, such as does the patient have heart disease, lung disease, diabetes, and if the patient has had any strokes, heart attacks or blood clots. Hupert said a patient’s medications are also considered, such as if the patient is taking blood thinner or immunosuppressant.
Hupert said NHRMC Perioperative services typically sees patients after a surgeon has set an appointment date for a surgery. After being notified of surgery date, a nurse at the Surgery Navigation Center reaches out to the patient for a telephone interview and schedules an appointment for lab testing and a visit to see to see a nurse and/or hospitalist when necessary.
In some cases, surgeons request Perioperative services for a patient before a date is set for a patient surgery. “For example, some of our patients get preoperative anemia treatment,” Hupert said. “We want to make sure the patient’s anemia is resolved before surgery; so, we’re seeing some patients before they schedule a surgery date.”
Testing is an important part of pre-operative visits. “Our rule is to perform the right testing for the right patient, and we follow evidence-based Perioperative medicine and Anesthesia guidelines as well as Choosing Wisely criteria to determine which blood tests and other evaluations are needed for patients based on their medical history and information received from the patient’s care team members.”
Nutrition is also important to surgical recovery. Hupert said, “We offer a nutritional supplementation through an Enhanced Recovery After Surgery (ERAS) program to improve patients’ immediate preoperative nutrition and hydration status,” she said. “That’s been shown to significantly decrease patients’ rates of dehydration preoperatively and decrease rates of infection and wound healing issues.”
Benefits of Perioperative Medicine
Hupert said she and her Perioperative medicine colleague Dr. Hollis Ray see their roles as Perioperative hospitalists as a “bridge to their primary care provider” for patients planning for surgery. “Patients’ primary care providers take care of them all of the time, but as the Perioperative hospitalists we become the bridge medical provider during the time immediately prior to their surgery and during their hospitalization and then return them to their primary care providers to resume general health maintenance goals once they are back home after surgery .
Hupert said over recent years there’s been a bigger push for patients to be evaluated prior to surgery, and that NHRMC Perioperative medicine has been shown to have a positive impact. “Twenty years ago, a patient typically wouldn’t be evaluated by their anesthesiologist or hospitalist until the day of their surgery, but now if it’s an elective surgery we are hoping to see them ideally three to four weeks before their surgery so that if there is anything that needs to be done to get them healthier for surgery we can do that in the month before their surgery and avoid delaying their surgery if possible,” said Hupert. “That’s why we have these fast-track referral processes in place because our goal is to not delay surgery when possible and to not let a patient get to the morning of surgery only to be told that their surgery must be cancelled due to a problem.”
“Dr. Ray and I are there to help the patient be in the best health possible before surgery,” said Hupert. “Our whole goal is to get the patient safely to the operating room, decrease the risks of complications while they are in the hospital and decrease complications post operatively so that they also do well after surgery.”