Beyond Pre-Surgery Fasting: Geisinger Boosts Nutrition to Speed Up Recovery

After a successful pilot saw lengths of stay decrease 39% or more, the health system is rolling out its tactics systemwide. Its program will be used in about 15,000 surgery cases annually across 42 surgical procedures.

Surgeons instruct patients to refrain from eating or drinking prior to surgery, as a safety precaution. A recently eaten morsel could easily become a choking hazard in the operating room. But there's also a risk that fasting could inhibit recovery by leaving patients undernourished.

That's one reason why Geisinger launched a quality-improvement project a year ago for its colorectal surgery patients. Rather than being told only what they couldn't eat or drink, patients were told what they should consume.

Pre-surgery instructions are now served with a supply of nutritional drinks.

"[W]e don't send patients starved and dehydrated into surgery, which is different from the traditional approach of fasting beginning the night before," Geisinger Chief Quality Officer Neil Martin, MD, told HealthLeaders in an email via a spokesperson.

Patients are told to consume the immune system–boosting drinks three times per day for the five days leading up to their surgeries. They are allowed to eat a light meal until six hours before surgery and drink clear fluids until two hours before surgery, at which point they are given a carbohydrate drink.

"The drink is absorbed into the body before surgery begins. Although the patient will not have anything in their stomach, they have the nutrients in their system," Martin said. "Having surgery is like entering a marathon. It's important to be fueled and hydrated prior to a race."

From Pilot to Program

This effort to ensure proper nutrition prior to surgery is one of the three key items in Geisinger's ProvenRecovery program, which aims to speed up the healing process and improve pain management while reducing opioid use.

Geisinger launched the program's pilot last year, incorporating colorectal patients in November 2017 then doubling down in April 2018 to include neurosurgery (craniotomy) cases as well. And the results seem to be paying off.

Length of stay for the average neurosurgery patient has dropped 39%, from 4.3 to 2.62 days, according to Martin. For the average colon surgery patient, that figure dropped 44%, from 4.5 days to 2.5 days. These earlier discharges saved more than $4,500 per case for colorectal surgery patients, Geisinger said.

In light of these strong numbers, Geisinger announced this month that it will make the pilot permanent and roll out the ProvenRecovery program systemwide across 42 surgical procedures affecting about 15,000 cases annually. The goal is to have 100 surgical specialties involved by the end of next year.

The Other 2 Prongs

In addition to its focus on pre-surgery nutrition, Geisinger's ProvenRecovery program includes two key post-surgery tactics to improve patient outcomes. One focuses on encouraging early mobility; the other focuses on appropriate pain management.

The mobility item is simple: When patients wake up after surgery, medical staff prompt and help them to move in and around the recovery room bed. The idea is that this accelerates the recovery process.

The pain management component is a bit more complex: Pain is controlled during surgery with a targeted multi-modal combination of non-opioid medications, which can include local anesthesia, over-the-counter drugs such as ibuprofen and acetaminophen, and more.

Geisinger said surgeries can, in many cases, be opioid-free. And it has data to show its care teams have put a dent in their patients' opioid use.

The system has reduced opioid usage by 24% overall since the second half of 2015, and 18% of that decrease is attributable to the ProvenRecovery program, Martin said.