EVOLUTIONARY STEPS IN THE IMPLEMENTATION OF A PREHABILITATION SERVICE: FROM KNOWLEDGE GENERATION TO CLINICAL PRACTICE

Marta Ubre; Graciela Martínez-Pallí

doi:10.34635/rpc.935

Marta Ubre Anaesthesiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
Graciela Martínez-Pallí Anaesthesiology Department, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d’Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain http://orcid.org/0000-0002-7163-8090

Abstract

The surgical population is becoming increasingly older, with complex medical needs (including deconditioning from sedentary lifestyles)1. This phenomenon represents a challenge for the perioperative team, because it leads to a significant increase in surgery-related morbidity and mortality rates. Poor physical condition and functional status reduces the ability to cope, mentally and physically, with hospitalization and surgery and may compromise postoperative functional recovery, potentially leading to postoperative complications and death2.

Multimodal prehabilitation has emerged in recent years as an innovative intervention that focuses on optimizing physiological and psychological resilience to withstand the upcoming stress of surgery. It involves a comprehensive, preventive, short-term, patient-centred programme lasting around four weeks designed to improve the patient’s aerobic capacity, nutritional balance, and psychological status, and to optimize existing multimorbidities3,4. Its ultimate aim is to enhance the patient’s functional capacity in order to minimize postoperative morbidity and accelerate recovery.

Several studies assessing prehabilitation have shown it to be an effective and highly advantageous strategy to prevent postoperative complications and reduce hospital length of stay in different populations5-8. However, despite the expected benefit, emerging recommendations from experts, and its cost-saving potential, the implementation of prehabilitation programmes in clinical practice is a major unmet need and an ongoing challenge for most hospitals. A comprehensive assessment of the implementation process is critical to identify the factors that can ensure success, and to generate recommendations for service transferability.

In this paper, we report our experience in imple- menting a multimodal prehabilitation programme as a mainstream service at the Hospital Clínic de Barcelona (HCB). The project started with a randomised clinical trial (RCT) carried out between 2013 and 2016, which showed the efficacy and cost-saving potential of prehabilitation. This was followed by the present multimodal programme, which has been adapted over time in accordance with the available resources and the feedback received from clinicians and patients. Over the years, we have identified the factors needed to scale-up the prehabilitation service. For successful, large scale implementation of a prehabilitation service more evidence of the effectiveness of such a programme in real-world scenarios is needed, the service needs to be standardised and modularised, and digital platforms and portable devices are required to improve patient access and empower self-management.

Downloads

Download data is not yet available.

References

1. Palladino R, Tayu Lee J, Ashworth M, Triassi M, Millett C. Associations between multimorbidity, healthcare utilisation and health status: evidence from 16 European countries. Age Ageing. 2016;45(3):431-435.

2. Kim S, Marsh AP, Rustowicz L, Roach C, Leng XI, Kritchevsky SB, et al. Self-reported mobility in older patients predicts early postoperative outcomes after elective noncardiac surgery. Anesthesiology. 2016;124(4):815-825.

3. Carli F, Zavorsky GS. Optimizing functional exercise capacity in the elderly surgical population. Curr Opin Clin Nutr Metab Care 2005;8(1):23-32.

4. Carli F. Prehabilitation for the Anesthesiologist. Anesthesiology. 2020;133(3):645-652.

5. Barberan-Garcia A, Ubré M, Roca J, Lacy AM, Burgos F, Risco R, et al. Personalised prehabilitation in high-risk patients undergoing elective major abdominal surgery: A randomized blinded controlled trial. Ann Surg. 2018; 267(1):50-56.

6. Minnella EM, Liberman AS, Charlebois P, Stein B, Scheede-Bergdahl C, Awasthi R, et al. The impact of improved functional capacity before surgery on postoperative complications: A study in colorectal cancer. Acta Oncol. 2019; 58(5):573-978.

7. Hughes MJ, Hackney RJ, Lamb PJ, Wigmore SJ, Christopher Deans DA, Skipworth RJE. Prehabilitation before major abdominal surgery: A systematic review and meta-analysis. World J Surg. 2019; 43(7):1661-1668.

8. Barberan-Garcia A, Ubré M, Pascual-Argente N, Risco R, Faner J, Balust J, et al. Post-discharge impact and cost-consequence analysis of prehabilitation in highrisk patients undergoing major abdominal surgery: Secondary results from a randomised controlled trial. Br J Anaesth. 2019; 123(4):450-456.

9. Scheede-Bergdahl C, Minnella EM, Carli F. Multi-modal prehabilitation: addressing the why, when, what, how, who and where next?. Anaesthesia. 2019;74 Suppl 1:20-26.

10. Minnella EM, Awasthi R, Gillis C, Fiore JF Jr, Liberman AS, Charlebois P, et al. Patients with poor baseline walking capacity are most likely to improve their functional status with multimodal prehabilitation. Surgery. 2016;160(4):1070-1079.

11. Haskell WL. J.B. Wolffe Memorial Lecture. Health consequences of physical activity: understanding and challenges regarding dose- response. Med Sci Sports Exerc. 1994;26(6):649-660.

12. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14(5):377-381.

13. Tudor-Locke C, Craig CL, Aoyagi Y, Bell RC, Croteau KA, De Bourdeaudhuij I, et al. How many steps/day are enough? For older adults and special populations. Int J Behav Nutr Phys Act. 2011;8:79.

14. Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann A, Bozzetti F; ESPEN. ESPEN Guidelines on Parenteral Nutrition: Surgery. Clin Nutr. 2009;28(4):378-386.

15. Malnutrition Advisory Group, a Standing Committee of BAPEN. Malnutrition universal screening tool. May 2003 (review August 2011). Available from: http://www.bapen.org.uk/pdfs/must/must_full.pdf.

16. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361-370.

17. Hijazi Y, Gondal U, Aziz O. A systematic review of prehabilitation programs in abdominal cancer surgery. Int J Surg. 2017;39:156-162.

18. Wen D, Utesch T, Wu J, Robertson S, Liu J, Hu G, Chen H. Effects of different protocols of high intensity interval training for VO2max improvements in adults: A meta-analysis of randomised controlled trials. J Sci Med Sport. 2019;22(8):941-947.

19. Anael Barberan-Garcia, Ramon Martínez, Isaac Cano, Genevieve Shaw, Fernando Ozores, Ferran Pruneda, et al. Role of Design Thinking for adoption of integrated care: Scalability of a prehabilitation service. Available from: https://stimulo.com/portfolio/prehab/

20. Bazzano AN, Martin J, Hicks E, Faughnan M, Murphy L. Human-centred design in global health: A scoping review of applications and contexts PLoS One. 2017 Nov 1;12(11): e0186744.

21. Wadell K, Janaudis Ferreira T, Arne M, Lisspers K, Ställberg B, Emtner M. Hospital-based pulmonary rehabilitation in patients with COPD in Sweden--a national survey. Respir Med. 2013;107(8):1195-1200.

22. Ferreira V, Agnihotram RV, Bergdahl A, van Rooijen SJ, Awasthi R, Carli F, et al. Maximizing patient adherence to prehabilitation: what do the patients say?. Support Care Cancer. 2018;26(8):2717-2723.

23. Chen BP, Awasthi R, Sweet SN, Minnella EM, Bergdahl A, Santa Mina D, et al. Four-week prehabilitation program is sufficient to modify exercise behaviors and improve preoperative functional walking capacity in patients with colorectal cancer. Support Care Cancer. 2017;25(1):33-40.

24. Trepanier M, Paradis T, Kouyoumdjian A, Dumitra T, Charlebois P, Stein BS, et al. The Impact of Delays to Definitive Surgical Care on Survival in Colorectal Cancer Patients. J Gastrointest Surg. 2020; 24(1):115-122.