Treatment through a preoperative anemia clinic is associated with a reduction in perioperative red blood cell transfusion in patients undergoing orthopedic and gynecologic surgery.

BACKGROUND: Preoperative anemia is associated with increased morbidity, mortality, and risk of transfusion. Treatment through a preoperative anemia clinic (PAC) may improve outcomes. STUDY DESIGN AND METHODS: Adult patients undergoing elective orthopedic and gynecologic surgery with preoperative anemia were identified and referred for hemoglobin optimization with iron and/or erythropoietin from a single-site academic health center. Treated patients were propensity matched to untreated controls and compared on outcomes of erythrocyte transfusion, length of stay (LOS), and readmission. Changes in hemoglobin relative to treatment time before surgery were also measured in the treated cohort. RESULTS: One thousand three hundred thirty-two patients were evaluated between July 2015 and March 2021, of which 161 underwent optimization through the PAC. After propensity matching, 127 (98 orthopedic and 29 gynecology) PAC-treated patients were compared to 127 (98 orthopedic and 29 gynecology) control patients who did not undergo treatment. The primary outcome of perioperative transfusion was significantly lower in treated patients compared with matched controls (12.60% vs. 26.77%, p = .005). A lower LOS was demonstrated in the gynecologic PAC subgroup (2.2 [1.5, 2.4] vs. 3.1 [2.2, 3.4], p = .002). Each day of treatment time before surgery was associated with an increase of 0.040 g/dL hemoglobin (p < .001) until 65 days, after which further time did not increase hemoglobin. CONCLUSION: Treatment through a preoperative anemia clinic is associated with a reduction in perioperative transfusion and possible reduction in LOS and readmission compared with matched controls. Additionally, treatment time before surgery is correlated with a greater increase in hemoglobin up until 2 months prior to surgery.

Roadmap for Transforming Preoperative Assessment to Preoperative Optimization.

Preoperative assessment typically equates to evaluating and accepting the presenting condition of the patient (unless extreme) and commonly occurs only a few days before the planned surgery. While this timing enables a preoperative history and examination and mitigates unexpected findings on the day of surgery that may delay throughput, it does not allow for meaningful preoperative management of modifiable medical conditions. Evidence is limited regarding how best to balance efforts to mitigate modifiable risk factors versus the timing of surgery. Furthermore, while the concept of preoperative risk modification is not novel, evidence is lacking for successful and sustained implementation of such an interdisciplinary, collaborative program. A better understanding of perioperative care coordination and, specifically, implementing a preoperative preparation process can enhance the value of surgery and surgical population health. In this article, we describe the implementation of a collaborative preoperative clinic with the primary goal of improving patient outcomes.

Validation of the perioperative nutrition screen for prediction of postoperative outcomes.

BACKGROUND: Preoperative nutrition risk is often underrecognized and undertreated. The perioperative nutrition screen (PONS) was recently introduced as an efficient tool to rapidly screen for preoperative nutrition risk. The relationship between identification of "nutrition risk" via PONS and adverse postoperative outcomes remains undescribed. METHODS: Preoperative nutrition risk was assessed via PONS from 01/01/2019 to 09/30/2020. Key clinical outcomes were compared with individual and composite PONS components. RESULTS: A total of 3151 patients with PONS evaluations were analyzed. Multivariate regression adjusted for key covariates demonstrated positive responses for specific PONS questions was associated with adverse clinical outcomes as follows. (1) Unplanned weight loss (>10% in 6-months preoperatively) associated with a 22.4% increased length of stay (LOS) (P < 0.0001) and increased 30-day readmission rate (odds ratio [OR], 2.44, 95% CI, 1.73-3.44, P < 0.001). (2) History of <50% of previous oral intake in past week associated with a 25% increased LOS (P < 0.001). (3) Preoperative serum albumin level <3.0 g/L associated with a 29.9% increased LOS (P < 0.001) and increased 30-day readmission rate (OR, 2.66, 95% CI, 1.63-4.35, P < 0.001). (4) Low body mass index was not associated with increased LOS by adjusted analysis although was predictive by univariate analysis. CONCLUSIONS: The PONS and its individual components appear to predict risk of adverse postoperative outcomes, even independent of a validated malnutrition diagnosis. Further studies are needed to assess the impact of specific preoperative nutrition interventions on adverse outcomes predicted by PONS when delivered to patients identified via PONS screen.

Tutorial: Development and Implementation of a Multidisciplinary Preoperative Nutrition Optimization Clinic.

Although much is known about surgical risk, little evidence exists regarding how best to proactively address preoperative risk factors to improve surgical outcomes. Preoperative malnutrition is a widely prevalent and modifiable risk factor in patients undergoing surgery. Malnutrition prior to surgery portends significantly higher postoperative mortality, morbidity, length of stay, readmission rates, and hospital costs. Unfortunately, perioperative malnutrition is poorly screened for and remains largely unrecognized and undertreated-a true "silent epidemic" in surgical care. To better address this silent epidemic of surgical nutrition risk, here we describe the rationalization, development, and implementation of a multidisciplinary, registered dietitian-driven, preoperative nutrition optimization clinic program designed to improve perioperative outcomes and reduce cost. Implementation of this novel Perioperative Enhancement Team (POET) Nutrition Clinic required a collaboration among many disciplines, as well as an identified need for multidimensional scheduling template development, data tracking systems, dashboard development, and integration of electronic health records. A structured malnutrition risk score (Perioperative Nutrition Screen score) was developed and is being validated. A structured malnutrition pathway was developed and is under study. Finally, the POET Nutrition Clinic has established a novel role for a perioperative registered dietitian as the integral point person to deliver perioperative nutrition care. We hope this structured model of perioperative nutrition assessment and optimization will allow for wide implementation and generalizability in other centers worldwide to improve recognition and treatment of perioperative nutrition risk.