Essential Keys To Managing The High-Risk Patient Undergoing Elective Surgery
In addition to optimal medical management, thorough preoperative preparation is the fundamental key to success in the surgical management of high-risk patients, such as those with diabetes. I have witnessed avoidable complications that have occurred due to a lack of attention in areas that may be mistakenly perceived as inconsequential.
During my fellowship, I learned several fundamental keys to success that minimize potential complications, increase patient satisfaction and foster the surgeon-patient relationship.
Informed consent occurs over several clinic visits and includes the patient’s support network. True informed consent should be an exchange of information over a period of time as opposed to a single event in time in which the patient signs a consent form. Studies have shown that patient expectations and postoperative outcomes are enhanced when informed consent occurs in this fashion.1,2 This is due to enhanced patient understanding of the procedure, potential risks and complications as well as an understanding of the expected postoperative recovery course.
It is valuable to reiterate the planned procedure, the most common potential risks, complications and their management should they occur, and the expected postoperative recovery course. Multiple visits give the patients time to process this information, ask questions and get answers to their satisfaction.
One or more of these visits should involve the patient’s support network that will be aiding during the postoperative recovery. Involving the patient’s support network is beneficial to the patient by having another person who can raise additional questions the patient may not have considered. It is beneficial to the surgeon to have another person who can provide insight into the patient’s expectations and ensure an understanding of what is required for an uncomplicated recovery. This person may also shed light on potential areas of non-adherent behavior.3 The patient should review the consent form and sign it during a separate dedicated visit to serve as a final review of the information presented over time.
Assessing The Patient’s Capacity For Postoperative Adherence
Involving other specialties preoperatively will be critical during the postoperative period. A thorough history and physical should include questions concerning the patient’s home environment. Does the patient live in a single story or multi-level home? Are there steps for entry and exit into the house? Is the patient’s house wheelchair accessible? These are important variables to consider, especially for patients who will require strict non-weightbearing for an extended period of time. Knowing this information will dictate what durable medical equipment they will require postoperatively.
Also consider a preoperative referral to physical therapy as physical therapists can simulate situations that the patient will encounter postoperatively, such as using a commode, getting in and out of a car, and going up and down steps. Physical therapists can determine if the patient is able to perform these activities while maintaining weightbearing restriction. This information may dictate the necessity of adjunctive surgical procedures such as the use of external fixation for “weight sharing” if the patient is incapable of remaining strictly non-weightbearing.4
The inability of the patient to perform these activities may also dictate the need for postoperative placement in a skilled nursing or acute rehabilitation facility. If one determines this to be a potential need, consultation to a social worker may be beneficial.