I learned a new word yesterday – Prehabilitiation (my spell-checker doesn’t like it). I found it in an article about improving patient fitness for surgery. “‘Prehabilitation’ is a broad term that applies to any intervention administered before surgery which aims to improve a patient’s health and fitness in order to reduce surgery-related morbidity, decrease the length of hospital stay and facilitate the patient’s return to normal. Incorporating such interventions within standard ERAS (Enhanced Recovery After Surgery) programs may further improve outcomes for surgical patients”(1).
That’s a mouthful, but it basically describes my mission with Post-Op Provisions. Patients can be prepared more effectively for their procedure(s). Prepared physically, mentally, and provisionally. Most of the focus in the Enhanced Recovery After Surgery movement has been on optimization of co-morbid medical conditions and improving fitness and nutrition (rightfully so). But – each ERAS or Prehabilitation protocol I’ve read stops at the door. There is no continuation or standardization of care after the patient goes home.
That troubles me. The majority of surgical recovery happens at home in 2017. Criteria to go home include the patient’s ability to maintain their own hydration (no IV fluids), control their pain (without IV pain medications), and have someone at least nearby to keep an eye on them for 24 hours (and a ride). That’s it. There is nothing in these criteria that assesses the patient’s ability to care for themselves. The decision to leave the terribly expensive hospital or outpatient surgical facility is based on physiology alone.
That said, most people prefer to be at home if they can. Their beds are undoubtedly more comfortable that those in hospitals, there is less noise, fewer interruptions of sleep… What there usually isn’t at home, however, is help with care.
We can do better. Surgical care needs to extend beyond the facility door. Discharge instructions as a groggy patient and overwhelmed caregiver roll out aren’t enough. Planning for even the simplest surgical recovery should begin preoperatively with detailed discussions about what postoperative care will entail, and patients should be provided or at least directed toward supplies they’ll need.
Why doesn’t this happen; and I know it still doesn’t happen – I’ve yet to talk to a patient who said they were given / told / directed towards everything they needed – the most common comment is, in fact, “They send you home with nothing!”? It doesn’t happen because no one gets paid for it. The facility can’t get reimbursed for supplies given to patients for postoperative care, the surgeon doesn’t get paid any more to give thorough perioperative instructions, and patients don’t know to demand it. For most patients, their interaction with the surgical world is blissfully brief, and it’s a planet they never want to return to.
Prehabilitation and ERAS protocols substantiate that prevention of postoperative complications begins pre-op. Optimizing a patient’s physical status before a procedure is essential but isn’t it also essential to facilitate a smooth transition from facility to outpatient care? Providing supplies for outpatient procedural recovery may seem like a small thing but it undoubtedly reduces stress, improves independence, and expedites functional recovery. And, truth be told, most of the small, seemingly inconsequential items included in POP Boxes aren’t readily available over the counter. I’ve looked, A LOT.
So, should everyone get a POP Box before surgery? Of course my answer is yes; but POP Box or no, post-procedural care at home can definitely be improved. However we do it, prehab is a good thing.
1. Pre-admission interventions to improve outcome after elective surgery – protocol for a systematic review. Perry et al. Systematic Reviews (2016) 5:88 DOI 10.1186/s13643-016-0266-9.