Perioperative medicine training resources: U6M10: Patient wellbeing

The RCA’s rehabilitative care best practice frameworks and post-fall pathways support improved outcomes for community-dwelling older adults.

Abstract
Introduction: The Care Hotel is a virtual medicine hybrid model of care that was implemented at Mayo Clinic in Florida in July of 2020. This temporal accommodation offers patients a comfortable out of hospital environment where they can receive both in-person and virtual care after a surgery or procedure. This study aims to report patient feedback regarding their Care Hotel experience.

Materials and methods: Between July 23, 2020 and June 4, 2021, a satisfaction survey was sent to patients via email after their discharge from the Care Hotel. The survey consisted of 8 Likert questions rating their experience in the model as well as 2 questions where patients describe the positive and negative aspects of their stay. Patient demographics including age, sex, procedure performed, and the surgical/procedural service under which they were admitted to the hotel were also collected.

Results: Out of 182 patients admitted to Care Hotel, 102 answered the survey. Nine surveys were excluded due to missing patient information, and 93 surveys were analyzed. Eighty-seven percent of patients had a positive experience in the Care Hotel model and 94% of patients were likely to recommend the program to others. Positive comments highlighted the ease of use of the technology setups, the low cost of the hotel, the seamless transition of care, and the relief of the burden of care for family members.

Conclusion: The Mayo Clinic hybrid Care Hotel, combining both in-person and virtual modes of medical care, provides a good overall experience for patients following low-risk surgeries and procedures.

Abstract
Background: Rehabilitation interventions are frequently cited as key in supporting frail older people's recovery following periods of decompensation and acute ill-health. Clinicians are required to make decisions about a patient's potential to respond to rehabilitation. 'Rehabilitation potential' decisions can determine access to services. In acute settings clinicians have limited time to assess and work with patients, families and carers. The complexities of ageing, recovery, rehabilitation and frailty may not be fully appreciated. This study aimed to explore multiple perspectives of the concept of rehabilitation potential and how it is assessed in older people living with frailty in the acute healthcare setting.

Methods: Five focus groups with a purposive sample of 28 participants which included clinicians and members of the public were conducted. Analysis comprised a thematic approach using the Framework method.

Results: Rehabilitation potential was found to encapsulate a complex decision-making process where clinicians judged an individual's ability to benefit from and participate in targeted rehabilitation. They asked, "Will it work?", "Is it wanted?" and "Is it available?" In order to predict who would benefit from rehabilitation interventions, clinicians assessed a range of holistic clinical and non-clinical factors. An iterative approach to assessment delivered by a multi-disciplinary team, centred around patient and carer needs and wants was needed to accommodate complexity. Participants believed that everyone had some form of potential but this was dependent on availability of rehabilitation resources and conceptualisations of frailty and rehabilitation. Tensions between iterative approaches to rehabilitation potential assessment and the realities of rapid decision making in the acute hospital setting were found.

Conclusion: Rehabilitation potential decisions involve a complex process of multidisciplinary decision-making and prognostication on the likely outcome and benefit from rehabilitation programmes. These findings lay the foundation for developing structured approaches to rehabilitation potential decision making tools and guidance.

Abstract
Undernutrition is common in patients admitted for surgery and is often unrecognised, untreated and worsens in hospital. The complex synergistic relationship between nutritional status and the physiological responses to surgery puts patients at high nutritional risk. There are clear prospective associations between inadequate nutritional status and the risk of poorer outcomes for surgical patients, including infection, complications and length of stay. However, practically and ethically evidence that nutritional interventions can significantly reduce these poor outcomes is difficult to obtain. Nevertheless health professionals have a duty of care to ensure our patients are properly fed, by whatever means, to meet their physiological requirements.

Abstract
Closing the Aboriginal and Torres Strait Islander mental health gap is an urgent national priority. This commentary provides both an overview of Aboriginal and Torres Strait Islander social and emotional well being and mental health and some of the promising initiatives for restoring wellbeing. Solutions for addressing Aboriginal and Torres Strait islander mental health issues require a “best of both worlds” approach which acknowledges the impact of social and cultural determinants on Aboriginal and Torres Strait Islander wellbeing.

Abstract
Nutritional status is a strong predictor of postoperative outcomes and is recognized as an important component of surgical recovery programs. Adequate nutritional consumption is essential for addressing the surgical stress response and mitigating the loss of muscle mass, strength, and functionality. Especially in older patients, inadequate protein can lead to significant muscle atrophy, leading to a loss of independence and increased mortality risk. Current nutritional recommendations for surgery primarily focus on screening and prevention of malnutrition, pre-surgical fasting protocols, and combating post-surgical insulin resistance, while recommendations regarding macronutrient composition and timing around surgery are less established. The goal of this review is to highlight oral nutrition strategies that can be implemented leading up to and following major surgery to minimize atrophy and the resultant loss of functionality. The role of carbohydrate and especially protein/essential amino acids in combating the surgical stress cascade and supporting recovery are discussed. Practical considerations for nutrient timing to maximize oral nutritional intake, especially during the immediate pre- and post- surgical periods, are also be discussed.

Abstract
Background: Health risk behaviours known to result in poorer outcomes in adulthood are generally established in late childhood and adolescence. These 'risky' behaviours include smoking, alcohol and illicit drug use and sexual risk taking. While the role of social capital in the establishment of health risk behaviours in young people has been explored, to date, no attempt has been made to consolidate the evidence in the form of a review. Thus, this integrative review was undertaken to identify and synthesise research findings on the role and impact of family and community social capital on health risk behaviours in young people and provide a consolidated evidence base to inform multi-sectorial policy and practice.

Methods: Key electronic databases were searched (i.e. ASSIA, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Embase, Medline, PsycINFO, Sociological Abstracts) for relevant studies and this was complemented by hand searching. Inclusion/exclusion criteria were applied and data was extracted from the included studies. Heterogeneity in study design and the outcomes assessed precluded meta-analysis/meta-synthesis; the results are therefore presented in narrative form.

Results: Thirty-four papers satisfied the review inclusion criteria; most were cross-sectional surveys. The majority of the studies were conducted in North America (n=25), with three being conducted in the UK. Sample sizes ranged from 61 to 98,340. The synthesised evidence demonstrates that social capital is an important construct for understanding the establishment of health risk behaviours in young people. The different elements of family and community social capital varied in terms of their saliency within each behavioural domain, with positive parent-child relations, parental monitoring, religiosity and school quality being particularly important in reducing risk.

Conclusions: This review is the first to systematically synthesise research findings about the association between social capital and health risk behaviours in young people. While providing evidence that may inform the development of interventions framed around social capital, the review also highlights key areas where further research is required to provide a fuller account of the nature and role of social capital in influencing the uptake of health risk behaviours.

Abstract
Opioid use and prescribing have become a subject of increasing focus and scrutiny. The ongoing "opioid epidemic" in North America has further increased interest in this area. In patients presenting for surgery, the prescribing of opioids during and following admission to hospital is commonplace and has been identified as a potential contributor to the growing opioid problem in North America. This review aims to present the timeline of the "opioid epidemic" as well as to introduce the concept of a "Transitional Pain Service". The Transitional Pain Service is a multidisciplinary service originating at Toronto General Hospital that employs a multi-faceted approach to monitoring opioid use after discharge from surgery, and aims to safely wean patients from opioids while maintaining effective pain management. This approach and its results will be discussed in this review.

Keywords: CPSP, chronic post-surgical pain; DN4, Douleur Neuropathique 4 questionnaire; GAD-7, General Anxiety Disorder Questionnaire; ICD-11, International Classification of Diseases, Eleventh Revision; NP, neuropathic pain; PHQ-9, Patient Health Questionnaire; QST, Quantitative Sensory Testing; ROC-AUC, area under the receiver operating characteristic; SF-12, Short Form Health Survey-12; chronic post-surgical pain; perioperative pain; risk factors.

Abstract
Background: Holistic biopsychosocial care has been underemphasized in perioperative pathway designs. The importance and a cost-effective way of implementing biopsychosocial care to improve postoperative pain and facilitate surgical convalescence are not well established, despite the recent popularization of Enhanced Recovery After Surgery (ERAS) programs.

Objective: We have explored the evidence and rationale of environmental enrichment (EE) as a complementary multimodal psychosocial care pathway to reduce postoperative pain, optimize patient recovery and improve existing weaknesses in surgical care.

Methods: We conducted a database search to identify and grade potential EE techniques for their evidence quality and consistency in the management of acute postoperative pain, perioperative anxiety and the etiologically comparable acute procedural or experimental pain.

Findings and conclusions: The introduction of music, virtual reality, educational information, mobile apps, or elements of nature into the healthcare environment can likely improve patients' experience of surgery. Compared with traditional psychological interventions, EE modalities are voluntary, therapist-sparing and more economically sustainable. We have also discussed practical strategies to integrate EE within the perioperative workflow. Through a combination of sensory, motor, social and cognitive modalities, EE is an easily implementable patient-centered approach to alleviate pain and anxiety in surgical patients, create a more homelike recovery environment and improve quality of life.