Perioperative Medicine at HSS: A Guide for Inpatient Surgical Patients

Patients who are scheduled to undergo a surgical procedure often have a number of questions and concerns, as well as some degree of anxiety about this experience and their upcoming hospitalization. At the Hospital for Special Surgery, all patients are supported by an institution-wide commitment to safety and comfort. In addition, every individual scheduled for an inpatient procedure and some select ambulatory surgery patients, meets with and is evaluated by an HSS-affiliated internal medicine physician in collaboration with the Division of Perioperative Medicine. The focus of perioperative medicine is to optimize the health of all HSS patients.

• The Role of the Perioperative Physician
• Preparing for Surgery
• The Morning of Surgery
• Anesthesia
• The Operating and Recovery Room
• Recovering in the Hospital
• Pain Control
• Specialty Nurse Practitioners and Consultants
• Preparing to Leave the Hospital

The Role of the Perioperative Physician

Physicians in the Division of Perioperative Medicine are HSS internists who place special emphasis on evaluating the patient’s health status prior to surgery, developing a “risk assessment” based on his or her medical history, and monitoring the patient’s progress before and after surgery. A comprehensive plan is developed for each patient to ensure that surgery is appropriately timed and that risk is minimized. Practitioners of perioperative medicine are also attuned to individual patient needs before, during, and after surgery. (For more information on how risk is assessed, please refer to Understanding Perioperative Care.)

In addition, the Perioperative Medical team works with colleagues throughout the hospital to ensure that all medical needs are addressed and that discharge from the hospital is safe and smooth. The physicians in the Division of Perioperative Medicine, in addition to some rheumatologists within the Department of Medicine, have a full-time commitment to working within HSS and do not have an independent practice outside of HSS. Essential team members also include nurse practitioners, who have specialized experience in areas such as endocrinology and cardiology, nutritionists, physical therapists, and medical specialists.

Preparing for Surgery

When scheduling a procedure with a surgeon, patients are advised to obtain an estimate of how long you will be in the hospital. This will vary depending on the nature of the surgery and anticipated recovery time. Make sure to plan accordingly, considering work schedules, holidays, and upcoming family plans. It’s also helpful to expect that the following issues will be reviewed during the weeks and days leading up to surgery

• Readiness for Surgery: As noted, if you have been scheduled for an inpatient procedure, or in some select ambulatory cases, a physician affiliated with the Hospital for Special Surgery will evaluate your readiness for surgery. This will include a medical history and physical exam as well as laboratory tests. Depending on your overall health and the type of surgery planned, tests may include, labs, an EKG or a chest x-ray; some patients need additional testing such as a cardiac stress test. The Perioperative Medical team is committed to scheduling patients only for those tests that are deemed medically necessary and to minimizing the risk that any such tests would entail, such as exposure to radiation.
• Autologous Blood Donation: Some patients may require a blood transfusion during hospitalization. If this need is anticipated, you can donate your own blood for this purpose.
• Medications: You may be instructed by your HSS internist and/or surgeon to stop certain medications (such as strong blood thinners like Plavix or Coumadin) several days to a week before your surgery. In addition, you may be instructed to take some of your medications the morning of surgery even though you won't be able to eat that morning. It is important for you to bring a list (or a bag of pill bottles) including all your medications to your medical evaluation appointment, including vitamins, over-the-counter medications, and supplements (a number of medications and supplements may interact with medications you might receive after surgery).
• Care and Cleaning of the Skin: At the end of your last bath or shower before surgery (within 24 hours of the procedure), the surgical area should be washed with antiseptic soap solution The soap solution should be thoroughly rinsed and removed after application to the surgical site. Do not shave your legs during this last shower. The nurses will use special scissors to remove hair from the surgical site before your procedure.
• You will receive more specific instructions regarding skin preparation for your type of surgery through the pre-surgical screening appointment, the pre-operative education class, and preoperative phone call.

One or two days before your scheduled procedure, a nurse from HSS will call you with additional instructions and reminders. You will be told when and where to come the morning of surgery, and you will be reminded not to eat anything after midnight and to drink only clear liquids up to 2 hours before surgery. This does not apply to the medications that you have been instructed to take the morning of surgery with a small sip of water.

The Morning of Surgery

On the morning of your surgery,

• The “Holding Area”: You will come to the preoperative “Holding Area”, where you will be prepared for surgery. A locker will be provided for your belongings, but please leave any valuables at home. This includes all jewelry, as you will be asked to remove everything before entering the operating room. You will be asked to change into a hospital gown and assigned a bed in the Holding Area. Your family can be with you during this time. A nurse will start an intravenous line (commonly referred to as an ‘IV’) to give you fluids, and if you are a woman of child-bearing age, you will be asked to provide a urine specimen for a pregnancy test.
• The Pre-operative Exam: A physician assistant will update your history and perform a physical exam. The main purpose of this examination is to see if anything has changed since you last saw your medical or surgical physicians. You will be asked to confirm what type of surgery you are having and will be asked to sign consent for that surgery if you have not already done so. Your surgeon or one of his or her assisting physicians will come to speak to you and to sign your surgical site. This is simply a safeguard to confirm where on your body the surgery will be performed. At this time, you will also meet your anesthesiologist who will discuss what type of anesthesia you will receive.

Anesthesia

Depending on the nature of the scheduled surgery, most patients at HSS receive either general or regional anesthesia.

• General anesthesia involves being put to sleep with medications that are administered through an intravenous line. Once you are completely asleep, a breathing tube is placed in your windpipe and your breathing will be assisted with a ventilator. You will remain asleep and comfortable until the surgery is complete, at which time you will start breathing on your own, the tube in your windpipe will be removed, and you will awaken comfortably in the operating room.
• Regional anesthesia for surgery involves an injection that will numb the nerves going to the area involved in your procedure. You will be comfortably sedated before the injection, and depending on your preference, can be either lightly or heavily sedated for the surgery. More than 90% of the surgeries at HSS are performed under regional anesthesia. When you receive this type of anesthesia, you will feel no pain during the surgery. Regional anesthesia requires less sedative and pain medication and is generally associated with a faster recovery and fewer side effects such as sleepiness and nausea. In addition, the anesthesia will last for several hours after the procedure, significantly reducing pain and smoothing the transition to oral pain medications. (See Pain Control below for more information.)

The Operating and Recovery Rooms

In the operating room, the anesthesiologist will attach a blood pressure cuff and EKG leads (to help monitor your heart), and will administer sedative medication. One of the forms of anesthesia discussed above will be administered, and the surgery will begin. An anesthesiologist will be with you the entire time. When the surgery is complete, your surgeon will speak with your family and you will be taken to the recovery room.

Patients remain in the recovery room until they are fully awake. If you will be going home that same day, you will receive detailed instructions for taking care of yourself at home and a prescription for pain medication. If you will be staying in the hospital for a few days, you will be assigned a room and will go there later that day or early the next morning. While still in the recovery room, your pain will be controlled with the infusion catheter, the PCA, or oral pain medications.

Recovering in the Hospital

During recovery from surgery, all patients are monitored by their internist and PA. Patients also receive care from nurses, nurse practitioners, physical therapists, social workers, nutritionists, and other medical specialists as needed. Most patients begin working with a physical therapist the day after your surgery. This is an important part of recovery that allows patients to return to normal activities as quickly as possible.

Discharge from the hospital usually occurs after one to four days of recovery. For more information on discharge, see Preparing to Leave the Hospital below.

Pain Control

If your recovery is expected to require several days in the hospital, your anesthesiologist will choose one of two options to control your pain after surgery. He or she may place a small plastic catheter in the lower back. This will allow you to receive a continuous infusion of pain medication after the surgery and will make your recovery much more comfortable. Another option is called intravenous patient-controlled analgesia, or PCA in which a button may be pushed to administer a small dose of intravenous pain medication at specified intervals, on an as-needed basis. At times, patients receive pain medication orally.

• Pain Management: If you have a PCA, an anesthesiologist and nurse from the Acute Pain Service will visit you each day to evaluate your pain, optimize your pain medicine, and treat any side effects. On the first day or two after the surgery, you will be transitioned from the PCA to oral pain medications in preparation for discharge. The Recuperative Pain Medicine Service (RPM) will assist you in this transition and will ensure that a comprehensive and patient-specific discharge plan (including pain management) is in place for each patient, both during their stay at HSS and when they leave the hospital.

Specialty Nurse Practitioners and Consultants

At HSS, perioperative services have been enhanced by the introduction of specialty nurse practitioners - registered nurses with advanced clinical training in a specific area of care. These areas include endocrinology, cardiology and geriatric medicine. A perioperative psychologist is also available. Patients with a specific condition such as diabetes or a heart condition can expect to be followed by these professionals throughout their hospital stay; however, these members of the team are available to all patients should the need arise.

Preparing to Leave the Hospital

Together with the Case Management team, Perioperative services help each patient make the transition from hospital to home. Case management assists patients in determining which services their insurance will cover, how to arrange transportation to another facility if necessary, and help ensure that a family member or other caregiver is available at the time of the patient’s discharge from the hospital. In some cases, Visiting Nurses Services will be consulted in advance of admission to make sure that the patient returns to a safe home or other environment.

Often, patients are discharged while still taking Coumadin, an oral anticoagulant. This drug treats existing blood clots and helps prevent new ones from forming following orthopedic surgery. An HSS staff member meets with each patient prior to discharge to identify the healthcare provider who will be monitoring his or her Coumadin therapy. Regular blood tests are an important part of ongoing post-surgical care.  Learn more about continuing Coumadin therapy after hospitalization.

About the Division of Perioperative Medicine

As part of an institution-wide commitment to ensuring the best possible outcomes for surgical patients, the Division of Perioperative Medicine was created within the Department of Medicine of Hospital for Special Surgery. The goals of the Division are to focus on patient care, education, and research.

Posted: 9/26/2014

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Written by Nancy Novick