Classically, Enhanced Recovery Programs were applied only to patients undergoing high-complexity surgeries with long hospital stays. This article describes the role of the Advanced Practice Nurse (APN) in the implementation process of an Enhanced Recovery Program in Surgery with the purpose of addressing all patients scheduled for surgical intervention and expected hospital admission. The three preoperative areas were identified based on the complexity of the surgery, risk of postoperative complications, and length of hospital stay, and prehabilitation interventions were standardized for each of them. A retrospective analysis was conducted by reviewing data collected through the Electronic Health Record during the period from 2022 to 2023. A total of 8426 participants were included in the program, distributed across three areas: Short Stay Unit (41.95%), Inpatient Unit (41.53%), and Prehabilitation (16.52%). All participants were assessed by the APN, and 6002 positive screenings were detected (2031; 3179; 792 respectively), with proposed referral to the appropriate professional in all cases, with acceptance rates ranging from 12.91% to 98.92%. Thanks to the leadership of the APN throughout the Program, the development and implementation of necessary protocols and interventions to adequately address all surgical patients of the hospital were ensured, detecting their needs and demands early and in a standardized manner before surgery.
Clásicamente los Programas de Recuperación Intensificada se aplicaban solo a pacientes con cirugías de alta complejidad y largas estancias hospitalarias. En el presente artículo se describe el rol de la Enfermera de Práctica Avanzada (EPA) en el proceso de implementación de un Programa de Recuperación Intensificada en la Cirugía con el propósito de abordar a todos los pacientes con intervención quirúrgica programada y con previsión de ingreso hospitalario. Se procedió a identificar los tres ámbitos preoperatorios según el grado de complejidad de la cirugía, riesgo de complicaciones postoperatorias y días de estancia hospitalaria y se estandarizaron las actuaciones de prehabilitación para cada uno de ellos. Se realizó un análisis retrospectivo mediante la revisión de datos recopilados a través de la Historia Clínica Electrónica durante el periodo comprendido entre 2022 y 2023. Se incluyó a 8426 participantes en el programa, repartidos en tres ámbitos: Unidad de Corta Estancia (41,95%), Hospitalización (41,53%) y Prehabilitación (16.52%). Todos los participantes fueron evaluados por la EPA y se detectaron 6002 cribados positivos (2031; 3179; 792 respectivamente), proponiendo, en todos los casos, derivación al profesional oportuno con un porcentaje de aceptación que osciló entre el 12,91% y el 98,92%. Gracias al liderazgo de la EPA durante todo el Programa, se garantizó el desarrollo e implementación de los protocolos e intervenciones necesarios para abordar de forma adecuada a todos los pacientes quirúrgicos del hospital, detectando de forma temprana y estandarizada sus necesidades y demandas antes de la cirugía.
Intensified Recovery Programmes make it possible to standardise the health care provided to surgical patients.1,2 In Spain, these programmes are only applied to patients with highly complex surgeries.2 In 2018, at the Vall d'Hebron University Hospital (HUVH in its Spanish acronym) in Catalonia, the Intensified Recovery in Surgery Programme (PRIC, in its Spanish acronym) was implemented with the purpose of addressing not only patients pending highly complex surgeries, rather all hospital patients with scheduled surgery and expected hospital admission of one or more days. Rehabilitation is part of intensified recovery in surgery and includes all those interventions and strategies designed to improve metabolic and aerobic capacity and eliminate toxic habits in surgery, with the aim of optimising the overall physical condition of the patient before surgery, thus facilitating preoperative preparation.3,4 This article aims to describe PRIC in the preoperative phase, providing data from the years 2022-2023 (during which a total of 8,426 participants were visited) and to identify the roles of the Advanced Practice Nurse (APN).
Methodology and developmentFrom 2018 to 2021, the design and planning of the implementation of PRIC was undertaken, collaborating closely with the Computing Department to include this data in the Electronic Medical Records (EMRs). In 2022, the programme was implemented.
Scope of application and associated interventionsIn line with the existing literature,2,3 the following inclusion criteria were set: patients ≥18 years of age with an indication for scheduled major surgery, regardless of surgical risk and with the patient’s acceptance through informed consent. Major outpatient surgery was excluded. Subsequently, three preoperative areas of application were set, depending on the degree of complexity of the surgery; the risk of postoperative complications; and the days of hospital stay.
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Short stay unit. Expected hospitalisation <72 h. The patient attends an on-site visit with the APN 4−6 weeks before surgery and completes the Holistic Patient Questionnaire (HPQ) (Table 1) in order for specific screening to be run and recommend appropriate referrals where necessary (Fig. 1). The APN explains the surgical process, promotes healthy habits before surgery, and explains end to end care plans (care circuits) to reduce emotional impact and empower the patient.
Table 1.Holistic patient questionnaire.
Rating Scale/test Description Positive screening Referral to Nutritional Malnutrition Universal Screening Tool (MUST) Identification of adults at risk of malnutrition4 ≥2 points Nutrition Functional Fatigue Resistance Aerobic Illness Loss of weight questionnaire (FRAIL) Identification of functional frailty through the following 5 domains: fatiguability, endurance, ambulation, comorbidity and weight loss5 ≥6 points Rehabilitation and physiotherapy Psycholog-ical Patient Health Questionnaire - 4 ítems (PHQ4) Identification of anxiety and/or depression with a numerical result (0−12) to assess emotional state6 ≥3 points Psychology Social Social Risk Indicator Table (SRIT) Assessment of people's social and family situation through 6 items with yes/no answers7 ≥1 positive Social Work Cognitive Question mark 3 items with yes/no answers related to cognitive status8 ≥1 positive Occupational therapy Alcohol consumption Alcohol Use Disorders Identification - C (AUDIT-C) Identification of risky alcohol consumption9 through 3 multiple-choice questions ≥5 points (men) ≥ 4 points (women) Psychology Smoking and/or other toxic use Question mark Yes/no questions to detect consumption10,11 ≥1 positive Preventive Medicine Psychology - •
Hospitalisation ≥72 h and low risk of post-surgical complications. The same visit is carried out, however in the event of a negative screening result, the APN implements an individualised plan that includes: end to end care planning, psycho-emotional support to reduce anxiety, breaking toxic habits, nutritional recommendations to improve healing and muscle gain, instructions on carbohydrate overload, a physical activity programme (aerobic and strength-building) and cognitive stimulation to reduce the risk of delirium. After 15 days, a telematic follow-up visit is conducted to reinforce health education and psycho-emotional support.
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Prehabilitation. Hospitalisation ≥72 h and high risk of post-surgical complications. A multidisciplinary visit with nutrition, physiotherapy, rehabilitation, and psychology is conducted 4−6 weeks before surgery. One day before the visits, the APN reviews and coordinates the care schedule and conducts a telematic assessment of the patient, explaining the itinerary to be followed at the multidisciplinary visit, evaluating their social and family situation, cognitive status and toxic habits, and referring them to the appropriate professionals where necessary. The organisation of all face-to-face visits on the same day and at the same location is beneficial for both the patient and their family members.
PRICs in Spain are usually led by APNs, as they require specialised, trained personnel to take on the following roles: innovation, advanced clinical care, case management, coordination, and teaching and training of professionals.12–14 In addition, the APNs participate in the design and updating of preoperative protocols, standardising care in the three areas, according to evidence-based practice; systematically evaluating the clinical situation and care needs of each patient, with referrals in line with standardised criteria. The APN provides health education to empower the patient in their health care process; leads and coordinates the team; trains the members of the intensified recovery programme, ensuring adherence to protocols based on expert clinical knowledge, and optimises resources through the supervision of health care plans.1,12,15
Results of preliminary implementationA retrospective analysis was run taking data collected through the electronic medical records over the period between 2022 and 2023. Data were obtained from 8,426 PRIC participants; 59.27% were men and most were treated in the short-stay unit (41.95%) or hospitalised (41.53%). The APNs evaluated all participants, detecting 6,002 positive screenings (2,031 in short-stay units, 3,179 hospitalised and 792 in prehabilitation). In all cases, participants with positive screening were proposed referral to the appropriate professionals. The acceptance rate ranged from 12.91% to 98.92% (Fig. 1).
The participation of social workers and occupational therapists in the PRIC programme was key. The majority of patients who lacked social support (1,354) accepted their referral (825 [60.93%]), reducing the hospital stay related to this lack of social support. As for the occupational therapists, out of all the positive screenings (823), the majority accepted the visit (543 [65.99%]), reducing the risk of postoperative delirium. The practice of toxic habits was evident in 22.03% (1,856), with smoking taking a prominent position (1,629 [19.34%]).7
DiscussionIn the short-stay unit, a specific protocol was implemented to address participants’ needs and provide information about the surgical process, reducing emotional stress in line with the existing literature.1,4 In the hospitalisation setting, patients were fully assessed by the APNs and referred to specialists to optimise these altered needs. Patients without any changes in their scales received standardised healthy lifestyle guidelines adapted by the APNs, and follow-up was provided to facilitate adherence to the plan. These two areas represent an innovative feature in the face of current scientific evidence.2,4 Unlike other existing PRICs, the HUVH’s PRIC enables preoperative assessment of any surgical patient, regardless of the complexity of the intervention, through one of the three areas, thus facilitating optimisation of participants’ state of health, which contributed to improving the patient's surgical results. This represents an innovative feature to be incorporated into future revisions.2,12 Regarding the area of prehabilitation, which forms part of most of the PRICs, this represented 16.52% of the total sample, coinciding with the bibliography.2,3 The APN was the key facilitator in the implementation of PRICs, as well as the results obtained.1,12,14
What is more, the role of the social workers and occupational therapists in this programme represented added value since, according to the available scientific evidence, they contributed to the reduction in both hospital stay16 and postoperative delirium,17 which provided an advantage over other models of the PRIC.
The main limitation of the study was the absence of quantitative and qualitative data on outcome indicators in the postoperative period, including complication rates, readmissions, mortality, and patient quality of life. This shortcoming prevents a comprehensive assessment of the programme's effectiveness in short- and long-term recovery and prognosis. Therefore, future research would be required to analyse these parameters and accurately determine the impact of the preoperative model on clinical outcomes.
ConclusionsThe PRIC optimises the preoperative phase for all patients with elective surgery (admission ≥24 h) through standardised screenings and interventions. This enables the entire target population to be systematically assessed and patients with deviations to be referred in a timely manner. In turn, the programme plays a key role in detecting needs, optimising the patient’s circumstances and coordinating their care. The leadership of this programme facilitates navigation through the system, improving interdisciplinary coordination and guaranteeing accompaniment based on scientific evidence.
Ethical considerationsThis study was carried out in accordance with the hospital's ethical and regulatory principles of data protection. Approval was obtained from the HUVH Ethics Committee for data mining and analysis of anonymised data.
FundingNo funding has been received for this study.
The authors declare that they have no conflicts of interest.4
