The Potential of Prehabilitation in Radical Cystectomy Pathways: Where Are We Now?

ObjectiveThe growing recognition of prehabilitation has caused an emerging paradigm shift in surgical cancer care and an integrated component of the cancer care continuum. This narrative review aims to update and inform the urological community of the potential of prehabilitation before radical cystectomy.Data SourcesA nonsystematic narrative review was performed through a database search in PubMed, and CINAHL using the following search terms: enhanced recovery after surgery (ERAS); Frailty; Prehabilitation and/or Rehabilitation; Physical Activity and/or exercises; Nutrition; Nutritional Care; Smoking cessation; Alcohol cessation; Prevention; Supportive Care; and combined with Radical Cystectomy.ConclusionA multimodal and multi-professional approach during the preoperative period may offer an opportunity to preserve or enhance physiological integrity and optimize surgical recovery. Studies indicate a positive effect of prehabilitation on postoperative functional capacity and earlier return to daily activities and health related quality of life. Meaningful outcomes that reflect recovery from a patient's perspective and clinical outcome measures, as well as validating metrics, are necessary to establish whether prehabilitation diminish the risk of developing long-term disability in high-risk patients.Implications for Nursing PracticeUro-oncology nurses are at the forefront in every ERAS program and vital in screening patients ahead of surgery for common risk factors, current impairments, and limitations that can compromise baseline functional capacity. The growing movement to standardize clinical implementation of prehabilitation, indicate there is a clear need for further investigation, optimization of a multimodal approach and an open discussion between health care providers from different areas of expertise who might best support and promote these initiatives.     

Organization Factors in the ERAS Bladder Cancer Pathway: The Multifarious Role of the ERAS Nurse,Why and What Is Important?

ObjectiveThis paper provides an overview of the multifarious role of nursing in enhanced recovery after surgery (ERAS) in advanced bladder cancer surgery with procedure-specific recommendations in radical cystectomy pathways.Data SourcesElectronic databases including PubMed and CINAHL.ConclusionThe growing evidence of preoperative, perioperative, and postoperative interventions and the concept of reacting proactively in ERAS, has led to the paradigm shift in the surgical pathway with establishment of nurse-led multi-professional prehabilitation academies. Moreover, although most patients will recover in real-life at home, there is a need for a change in postoperative and discharge management. Thus, a highly skilled discharge nurse is required to secure a comprehensive, safe discharge plan adjusted to the patient's needs in close cooperation with the primary care setting, family, and survivorship clinic if needed. Limited efforts have been made to evaluate rational principles and goals for rehabilitation after radical cystectomy; an important issue with major patient and perhaps socioeconomic consequences, wherein the ERAS nurse may take the future lead.Implication for Nursing PracticeIt has become a governmental demand in many countries to involve the patient and family in treatment decisions and care by using shared decision tools, and to educate and inform each family in concordance with the patient's needs and preferences, and the health care systems must react accordingly. However, to provide person-centeredness care within advanced surgical pathways, there remains a need for thought-leaders, strategic planners, managers, and decision-makers to anchor the process of change and stop “we do it anyway” arguments to defend organizational cultures that are not conducing the evidence-recommend practice.     

Setting Up a Prehabilitation Unit: Successes and Challenges

ObjectiveThe goal of this article is to provide a pragmatic approach to implementing a prehabilitation pathway and service guide.Data SourcesThe article presents data from peer-reviewed scientific articles (ie, reviews and original studies) and narrative reviews, as well as professional insights and experiences of the author in setting up a prehabilitation clinic.ConclusionSuccessful setup of a prehabilitation unit is highly feasible and rewarding, if led by enthusiastic idealists who work in cooperation with a passionate multidisciplinary team (MDT) with clear vision to collectively improve patient outcomes and experiences. It requires a well-integrated MDT to deliver a successful prehabilitation service.Implications for Nursing PracticeNurses are the supporting pillar in many areas of the health care system. The field of prehabilitation is no exception to this with the mainstay contribution nursing provides. A combination of patient care, medical knowledge, and administrative capabilities are required to modify the perioperative pathway and introduce the concept of prehabilitation. Nursing staff are ideally positioned to be strong advocates to developing and delivering an effective MDT prehabilitation clinical pathway.     

循证观念改善临床结局:妇科/肿瘤加速康复指南2019年更新及解读

加速康复外科(enhanced recovery after surgery, ERAS)目前已在全球范围内明确成为一项能够改善医疗服务、降低医疗成本的手术质量改善倡议。妇科/肿瘤ERAS指南发表于2016年2月, ERAS协会以及国际ERAS妇科分会于2019年2月依据现有最高质量的文献证据进行了首次更新。其中新增预康复、预防手术部位感染策略、患者报告结局、盆腔廓清及腹腔热灌注化疗、出院路径、ERAS评估及报告等6条, 更新文献证据级别及推荐级别10条, 其他5条未发生变化。本次指南更新从围手术期管理方面为妇科/肿瘤临床实践明确了发展方向。     

加速康复外科理念在围手术期患儿中的应用进展

加速康复外科指在多学科合作基础上,采取基于循证的围手术期系列优化措施,旨在减少手术患者生理及心理的创伤应激,从而实现手术患者的加速康复。该文综述了加速康复外科理念在国内外围手术期患儿中的应用现状,包括术前护理、术中精准管理和术后护理3个方面,并指出存在的不足和未来发展方向,旨在为国内加速康复在围手术期患儿中的进一步研究奠定基础。     

The Role of the Nurse in the Prehabilitation Unit

ObjectiveTo address some of the main nurse's role in facilitating patients’ participation and engagement to prepare for the stress of surgery.Data SourcesThese include published peer reviewed literature, web-based resources, and professional organizations’ resources.ConclusionPsychological and physical optimization of surgical patients during the preoperative phase is a novel approach known as the prehabilitation program. A multidisciplinary team of health professionals work in synergy to prepare patients for the upcoming surgery. Different roles and responsibilities may be allotted to the nurse, whereas one of which may focus on patient education. Being cognizant of low health literacy rates while using various teaching strategies known to promote patient understanding may increase patient participation to prepare for surgery.Implications for Nursing PracticeThis article may guide nurses who are new to the concept of health literacy and patient activation. We wish to sensitize nurses to a few strategies to support patient understanding and involvement. This overview can help others who are establishing a prehabilitation unit in their institution to highlight the important role a nurse can play toward patient education.     

Prehabilitation as Novel Paradigm Shift in Cancer Care

ObjectivesPrehabilitation aims to optimize patients’ preoperative risk factors while waiting for surgery. The preoperative period is a salient time to modify health behaviors with the aim to mitigate the stress of surgery and facilitate the recovery process.Data SourcesThis is a narrative review of scientific evidence and published reports on aspects of prehabilitation for patients with cancer.ConclusionWhile the prehabilitation team identifies the health issues ahead of the surgical date, patients become engaged in improving their health. This demands a shift in how the perioperative care is organized, taking into consideration the active role of the patient and the multidisciplinary team approach.Implications for Nursing PracticeWhile the patient with cancer is at the center of the perioperative care, the prehabilitation multidisciplinary team, which includes the perioperative physician, the physiotherapist/kinesiologist/exercise physiologist, the dietician, the psychologist, and the specialist nurse, works together with the surgeon and the oncologist to screen, assess, and plan a personalized intervention. In this context, the specialist nurse can collaborate with the team in identifying those patients at risk who might benefit from the prehabilitation program (eg, frail, older, malnourished, smoker, with many comorbidities) . The specialist nurse will be able to coordinate the time of visits, liaise with the caregivers, identify barriers, and participate in decision-making activities.     

Prehabilitation. An Interdisciplinary Patient-Centric Conceptual Framework

ObjectivesTo review the recent literature around patient-centric prehabilitation in oncology patients and propose a conceptual framework to inform development of interdisciplinary prehabilitation services leading to focused, individualized prehabilitation interventions.Data SourcesA review of recent peer-reviewed literature, national guidance, and government strategy on prehabilitation in oncology patients.ConclusionPatient- centric prehabilitation is key to improving patient's experiences of cancer throughout the cancer journey while improving population health and reducing financial costs. Successful personalized prehabilitation interventions are comprised of an interplay between individual interdisciplinary roles, as illustrated in the conceptual framework. The role of the nurse underpins this whole process in patient screening, assessment, implementation of the intervention, and patient reassessment, ensuring care is dynamic and tailored to patient need.Implications for Nursing PracticeThe review has discussed the key role that nurses play in the process but warrants more research in the area. The conceptual framework provides a basis to develop interdisciplinary prehabilitation services underpinned by the nurse's role. The review advocates the use of educational interventions to equip all health professionals with prehabilitation knowledge to enable interdisciplinary prehabilitation services to be developed.     

Nursing Implication of People Treated by Radical Cystectomy Postsurgery and Rehabilitation

ObjectiveThe purpose of this paper is to summarize existing evidence about nursing interventions to selected symptoms experienced by patients undergoing radical cystectomy (RC) to maintain or return to their daily life activities.Data SourcesA non-systematic narrative review was conducted. A search in PubMed and CINAHL was conducted eliciting evidence about frequent symptoms experienced after RC. The following search terms were used: radical cystectomy and/or nursing interventions, pain, distress, fatigue, urinary dysfunction, sexual dysfunction, loss of appetite, sleep disturbance, and enhanced recovery after surgery (ERAS).ConclusionEvidence in the ERAS pathway is still lacking regarding the effect of preoperative education and counseling of the patient and the most difficult part to implement is related to preoperative optimization of the patient such as lifestyle changes. Most nursing interventions to alleviate symptoms in the rehabilitation period after RC are still practice based.Implications for Nursing PracticePriority should be given to implementation of the ERAS protocol. To improve the management of symptoms experienced by patients in the RC rehabilitation period it is essential that validated screening tools to identify the symptoms be used. Accepted and effective strategies for treating the individual symptoms should be initiated and clear treatment outcomes should be defined. Urology nurse researchers should investigate the concept of symptom clusters to clarify whether there are more efficient methods to identify symptoms or symptom clusters and if so would the use of symptom clusters knowledge improve patient care.     

基于加速术后康复的胸外科手术预康复管理专家共识(2022)

预康复管理是加速术后康复的重要内容和启动环节。胸外科手术前多模式预康复可提高患者的围术期功能状态、改善手术预后的临床意义已得到广泛认可。但胸外科预康复的具体实施流程与内容尚缺乏指导规范,临床应用中也存在一定困惑。《基于加速术后康复的胸外科手术预康复管理专家共识(2022)》基于循证医学证据及多次专家讨论结果,在胸外科预康复适用范围、推荐应用时间、预康复前综合评估、具体实施内容及管理流程5个方面达成了初步共识,将为临床工作提供有益指导。     

加速康复外科理念在经胸前入路腔镜甲状腺外科领域中的临床应用

目的初步探讨加速康复外科(ERAS)理念在经胸前入路腔镜甲状腺外科手术应用中的可行性及有效性。方法回顾性分析2018年6月-2020年6月该院139例符合入组标准的经胸前入路腔镜甲状腺手术患者的临床资料,按时间段分为传统经胸前入路腔镜手术组(TES组)及加速康复手术组(ERAS组),比较两组患者术后并发症(出血、恶心呕吐)发生情况及应激指标。结果 ERAS组术后恶心呕吐等并发症明显少于传统组,疼痛评分、白细胞计数和C反应蛋白等明显低于TES组,两组患者比较,差异均有统计学意义(P 0.05)。结论多模式镇痛及超前镇吐等ERAS理念应用于经胸前入路腔镜甲状腺外科领域中安全可行,能有效降低术后并发症发生率,缩短住院时间,提高患者术后舒适度,值得临床应用及推广,但具体实施方案还有待进一步优化。     

加速康复措施对腹腔镜子宫内膜癌根治术患者术后康复的影响

目的:探讨加速康复外科(enhanced recovery after surgery, ERAS)措施对腹腔镜子宫内膜癌根治术患者术后康复的影响。方法:收集行腹腔镜分期手术的子宫内膜癌患者92例,分为2组:ERAS组(n=46)和对照组(n=46)。对照组患者实施常规妇科手术围手术期处理,ERAS组患者采用加速康复外科措施进行围术期干预,比较两组患者术后康复相关指标。结果:ERAS组患者术后下床活动时间、肛门排气、排便时间、平均住院日、平均住院费用均少于对照组,差异有统计学意义(P0.05)。ERAS组围术期并发症发生率低于对照组,差异有统计学意义(P0.05)。结论:加速康复可促进腹腔镜子宫内膜癌根治术患者术后恢复,缩短平均住院日及降低住院费用,降低患者术后并发症的发生。     

Successful Implementation of Enhanced Recovery After Surgery Program in a Safety-Net Hospital: Barriers and Facilitators

PurposeEnhanced recovery after surgery (ERAS) programs comprise bundles of evidence-based recommendations designed to reduce physiological stress and support early return of function after surgery. In this study, we sought to investigate the barriers and facilitators of successful implementation of ERAS in a major safety-net hospital.DesignOur ERAS program has been designed as a quality improvement pilot project in prospective fashion with a real-time feedback loop. The program is designed to address established culture of safety-net hospitals.MethodsAn extensive multidisciplinary team investigated the barriers to success for three different levels of program stakeholders: providers, patients, and the facility. After a systematic review of these barriers, solutions were offered and implemented in a multidisciplinary care model with special attention to outcomes and continuous feedback. The findings are summarized in a grid format for better understanding and implementation ease.FindingsPatients (N = 198) were enrolled in an ERAS program in a nonrandomized fashion during the pilot period of October 2017 to August 2018. ERAS cohort of patients’ outcomes were then compared with those of 20,328 non-ERAS patients. The ERAS group had less complication with shorter length of stay compared with their non-ERAS counterparts. Furthermore, it has cost less to take care of these patients. Interestingly, this decrease was not achieved by a reciprocal increase in subsequent readmission or reoperation rates.ConclusionsUnique barriers exist when implementing an ERAS protocol in a safety-net hospital. These barriers can be overcome to improve the quality of care at a decreased cost. We have provided a grid to facilitate the implementation process.     

The Role and Scope of Prehabilitation in Cancer Care

ObjectivesTo recognize cancer prehabilitation as a pretreatment regimen to increase functional status for patients requiring cancer treatment. This article presents current evidence addressing the efficacy and benefits of prehabilitation regimens in different cancer survivor populations.Data SourcesStudies and case reports in the PubMed database.ConclusionCancer prehabilitation may improve outcomes. Prehabilitation may include targeted or whole-body exercise, nutrition, education, psychologic counseling, and smoking cessation. Opportunities exist to further improve access to and delivery of multimodal prehabilitation, and nurses play a critical role in connecting patients to these services.Implications for Nursing PracticeOncology nurses who are knowledgeable of cancer treatment-related effects are poised to assess survivors for existing impairments, advocate for prehabilitation for existing and potential morbidities, and monitor functional status over time. As patient educators, they are key to informing cancer survivors about the role of prehabilitation.     

Cancer; Pathophysiology and Stress Modulation (Cancer,Therapeutic Interventions)

ObjectiveThe purpose of this review is to describe the myriad complications of cancer and its therapies to emphasize the pathophysiological need for prehabilitation.Data SourcesThe information presented in this review is from applicable, peer-reviewed scientific articles.ConclusionCancer itself renders negative effects on the body, most notably unintentional weight loss and fatigue. Cancer treatments, especially surgical interventions, can cause detrimental short- and long-term impacts on patients, which translate to suboptimal treatment outcomes. Prehabilitation can be used to improve patient health prior to anticancer therapies to improve treatment tolerance and efficacy.Implications for Nursing PracticeNurses play an important role in the treatment of patients with cancer throughout the cancer care continuum. Many nurses are already aiding their patients in cancer prehabilitation through education. By describing common impairments amenable to multimodal prehabilitation, nurses may better advocate for their patients and can become even more involved in this aspect of care.     

Prehabilitation before total knee arthroplasty: A systematic review on the use and efficacy of stratified care

BackgroundPreoperative rehabilitation (hereafter called “prehabilitation”) has been proposed as a potentially effective treatment to target preoperative risk factors to prevent insufficient outcome after total knee arthroplasty (TKA).PurposeWe aimed to assess whether previous clinical trials of non-surgical, non-pharmacological prehabilitation in individuals with knee osteoarthritis (KOA) awaiting TKA focused on specific clinical phenotypes or specific individual characteristics and whether the content of the prehabilitation was stratified accordingly. Second, we aimed to summarize and compare the long-term effects of stratified and non-stratified care on pain, satisfaction, function and quality of life.MethodsA systematic literature search of PubMed, Web of Science, Scopus and Embase was performed. All relevant articles published up to April 19, 2021 reporting “(randomized controlled) clinical trials or prospective cohort studies” (S) related to the key words “total knee arthroplasty” (P), “preoperative conservative interventions” (I), “pain, function, quality of life and/or satisfaction” (O) were included.ResultsAfter screening 3498 potentially eligible records, 18 studies were assessed for risk of bias. Twelve studies had low, 2 moderate, 3 serious, and one high risk of bias. The latter study was excluded, resulting in 17 included studies. Five studies investigated a“stratified prehabilitation care” and 12 “non-stratified prehabilitation care”. Stratified prehabilitation in 4 studies meant that the study sample was chosen considering a predefined intervention, and in the fifth study, the prehabilitation was stratified to individuals’ needs. No direct comparison between the 2 approaches was possible. We found weak evidence for a positive effect of biopsychosocial prehabilitation compared to no prehabilitation on function (stratified studies) and pain neuroscience education prehabilitation compared to biomedical education on satisfaction (non-stratified studies) at 6 months post-TKA. We found strong evidence for positive effects of exercise prehabilitation compared to no prehabilitation on pain at 6 months and on function at 12 months post-TKA (non-stratified studies).ConclusionMore research is needed of stratified prehabilitation care focusing on individual characteristics in people with KOA awaiting TKA.Registration numberThis systematic review was prospectively registered at PROSPERO on March 22, 2021 (no. CRD42021221098).     

Prostate Cancer Prehabilitation and the Importance of Multimodal Interventions for Person-centred Care and Recovery

BackgroundProstate cancer is the second most commonly diagnosed cancer globally. Cancer prehabilitation is defined as a process on the continuum of care that occurs between the time of a cancer diagnosis and the beginning of acute treatment. This article will discuss the importance of prostate cancer prehabilitation interventions in optimising physical and psychological recovery to enhance person-centred care.Data SourcesElectronic databases including CINAHL, MEDLINE, PsychINFO, Scopus, professional websites, and grey literature were searched using Google Scholar.ConclusionPrehabilitation in cancer care aims to enhance perioperative care and recovery. An emerging field of research suggests that the preoperative period may be physically and psychologically salient to introduce modifiable self-management behaviours to optimise overall recovery.Implications for Nursing PracticeProstate cancer specialist nurses provide the hub of person-centred care across the entire cancer care continuum embedded within the multidisciplinary team. Individually tailored interventions such as exercise and pelvic floor muscle training programmes, nutritional advice, anxiety and depression reduction, and sexual well-being interventions should be considered in the prehabilitation phase of the cancer care continuum.