Use of Prepare for Surgery, Heal Faster in Oncology Surgical Patients

Roger Maris Cancer Center, Fargo, ND

Cheryl Hysjulien, RN, PsyD and Andrea Paradis, 500 ERYT, AYS, CRMT, LR

Background

  • Surgery is stressful. (Ramsay, 1972) With the addition of a cancer diagnosis, stress grows exponentially. Prepare for Surgery, Heal Faster (PSHF) is a five-step program developed by Peggy Huddleston to prepare patients for the stress of surgery using mind-body techniques of relaxation, healing imagery and hypnotic statements. Additionally, it incorporates the use of community support. PSHF is an evidence based program that decreases pain, need for pain medications, surgical complications and promotes quicker recovery.
  • Enhanced Recovery After Surgery (ERAS) is a multi-modal, evidence based treatment program to improve outcomes for surgical patients. “Central to this mission is a culture of inclusivity and the recognition of the importance of multi-professional and multi-disciplinarian collaboration.” (ERAS USA, 2019) PSHF is qualified to be part of the Pre-Operative portion (patient counseling) of ERAS.
  • Purpose: the purpose of this poster is to provide information on implementing an evidence-based, stress reduction program to be used to assist surgical patients in healing and decrease narcotic use and complications. It will demonstrate the importance of interdisciplinary cooperation to improve perioperative care and enhance post-operative recovery.

Methods

Recruitment: Purposeful sampling through regional Sanford facility. Participants were self-selected after being approached.

Participants: Cancer patients, prior to receiving cancer related surgery.

Protocol:
Two staff members trained under Peggy Huddleston and provided individual patient instruction.

Interested breast cancer surgeon collaborated in pilot program.

Initiated group class for breast surgery patients.

Formalized the process for referral and monitoring outcomes.

Created intentional relationship with Nurse Navigators to grow referrals to group class as well as private instruction.

Positive patient report to anesthesia generated initial discussions between ERAS and PSHF groups.

Education and demonstration for staff.

Patients’ level of stress was measured at: pre/post class instruction and immediately prior to surgery.

Outcomes

• Even though this study had limitations (ie. no post-op data, lack of understanding of importance of stress reduction before surgery, etc) results show increase of patient referrals and decrease of patient stress/anxiety. Furthermore we were able to identify barriers and solutions to implementing this integrative program within a hospital. Much of the growth hinged on collaboration between teams, staff education and awareness of expansion opportunities.

• The program grew exponentially with the PSHF and ERAS teams working together. Referrals grew by an estimated 150% due to assistance from Nurse Navigators and surgeon’s nurses. Through the positive outcomes from breast surgical patients, the Head and Neck team at RMCC approached the PSHF team to begin implementing the program with their surgical patients.

• Our data demonstrates significant improvement in patient stress/anxiety measures pre and post the PSHF class. This shows the importance of continuing to nurture collaboration and implement this program with all oncology patients requiring surgery.

Implications

Implications for patients: Reduces stress and anxiety associated with surgery. Increased comfort to adhere to steps of program due to interdisciplinary support. Anecdotal evidence shows increase of patient satisfaction through surgical process.

Implications for professionals: Skillful negotiation with multidisciplinary team members is essential to the success of the implementation of this program. More group collaboration and efficient communication is necessary to improve outcomes. Anecdotally systematic and cultural factors affected fulfillment of outcome measures. Moving forward, addressing these systematic and cultural factors will be critical for success and program growth. Interdisciplinary collaboration demonstrated an increase in referrals.

Barriers and Resolutions

Physician

  • Unfamiliarity with research behind mind body techniques and positive impact on pain management, stress, surgical recovery, etc.
  • A number of surgeons were reluctant to “make” patients attend classes.
  • Initially educate and work with one breast surgeon.
  • Expand the program to all breast surgeons via education.
  • Talk about the benefits for patients at case conference presentations.
  • Receive patient to physician endorsements.

Nursing

  • May be hesitant to support patients’ participation in PSHF and data collection for PSHF.
  • Lack of knowledge and understanding of the importance of the impact of the mental state going into surgery.
  • Provide multiple opportunities for staff to learn about PSHF, including demonstrations of PSHF sessions.
  • Regularly assess compliance of referrals from surgeons’ nurses.
  • Design an online survey for postoperative data collection for future use.

Anesthesia department

  • Some anesthesiologists and nurse anesthetists were reluctant to participate in the portion of PSHF that involved them reading the patients statements due stated time constraint.
  • Engage physician champion (i.e. professional ally) in anesthesia.
  • Empower patients during PSHF class to request statements to be read while under anesthesia.
  • Statements can be read by CNAs, Nurses or any member of the surgical team.

Enhanced Recover After Surgery (ERAS) Protocol

Pre-operative Phase

•Patient counseling

•Avoid bowl preparation

• Minimize fasting

• Pre-medications

Intra-operative phase

  • Avoid NG tubes
  • Short acting anesthetics
  • Intra-operative analgesia
  • Goal directed fluids
  • Avoid drains
  • Intra-operative warming
  • Post-operative care pathways
  • Non-opiod analgesic
  • PONV protocol

Post-operative phase

• Early mobilization

• Early catheter removal

• Early oral feeding

• Audit

• Follow up

Prepare for Surgery, Heal Faster (PSHF) Protocol

Step 1

Relax to Feel Peaceful

  • Patients are taught the importance of stress reduction on the outcomes of surgery.

Step 2

Visualize Healing

  • With the help of class leader, patient creates three distinct imageries related to the healing process;
    1. Immediately after surgery.
    2. Intermediate healing.
    3. Complete recovery.
  • Patient is provided a CD to listen to a relaxation track twice a day which includes progressive muscle relaxation, safe place imagery and their personalized recovery imagery.

Step 3

Organize a Support Group

  • Patient organizes a support group within their own community and asks them to send them a personalized version of positive thoughts (blanket of love, prayers, positive thoughts, etc) 30 minutes before their surgery.

Step 4

Healing Statements

  • The patient personalizes healing statements that will be read by a surgical team member as they go under anesthesia and at the end of surgery.

Step 5

Meet the Surgical Team

  • Prompt patient to create relationships with their surgical team prior to surgery.