Nepean Implements Wider Prehabilitation of Surgery Patients through Telehealth

Short for pre-operative rehabilitation, prehabilitation helps to make people fitter for surgery by promoting physical exercise, better diet and a positive mindset.

Evidence shows that prehabilitation before major surgery can lead to a faster recovery, better health outcomes, improve the patient’s experience and save the healthcare system money.

But only three NSW hospitals currently offer prehabilitation, and there are numerous logistical and geographical barriers to its wider implementation.

In an attempt to solve the problem, NBMLHD Clinical Specialist physiotherapist Dr Anwar Hassan and University of Sydney Research Fellow Dr Sviatlana Kamarova are investigating whether the same prehabilitation program can be effectively delivered via telehealth.

Dr Kamarova, who is a Fellow of Sydney Health Partners’ Implementation Science Academy and works at the Allied Health Research Support Center at NBMLHD, says the randomised control trial, supported by a Sydney Health Partners Implementation Science Pilot Grant, will compare the effectiveness of the telehealth-delivered prehabilitation program with the usual face-to-face version.

“We know prehabilitation works, but up until now there’s been no real evidence about what the most effective way is to deliver it to the patients, so there is nothing to guide clinicians trying to decide whether to do the prehabilitation face-to-face or via teleconferencing,” said Dr Kamarova.

“In addition to patient outcomes, we are also analysing the trial outcomes at an organisational or system level, looking at the average length of patient stays in hospital and the health economic outcomes of that.”

Dr Anwar has been at the forefront of developing and evaluating prehabilitation since 2018, when he established a service at Nepean Hospital for people scheduled for major abdominal or thoracic surgery called the Preoperative Education and Prehabilitation Program (PrEPP).

After three years in operation, analysis of PrEPP patient data showed that the length of hospital stay was reduced from an average of ten days to 8.7 days. Unplanned ICU admissions were also significantly lowered.

“That has significant financial implications because just one day in an ICU costs the health system $5,000,” said Dr Anwar. “And that’s not to mention the reduced burden on patients and the health system that results from prehabilitation minimising postoperative complications like pneumonia, deep vein thrombosis and wound infections.”

The proposal to expand the reach of PrEPP through the use of telehealth arose as a result of the COVID-19 pandemic in 2020-21.

Nepean Hospital receives surgery patients from the central west of NSW and well as western Sydney and the Blue Mountains. With all elective surgery cancelled and clinicians unable to see patients face-to-face, Dr Anwar and his PrEPP team pivoted to consulting those on surgical waiting lists via video conferencing.

“We wanted to continue the prehabilitation of patients while we waited for elective surgeries to resume, and we had the idea that it would be possible via computer and phone. What we didn’t quite expect was that some of those patients - the ones who lived in places far from the hospital like Lithgow, Bathurst and Orange - actually preferred receiving the prehabilitation program online.”

In the telehealth trial, some of the patients who would normally attend physiotherapy at the hospital two days each week, do the exercises at home instead, supervised via teleconference. On three other days each week, they do home exercises without the supervision.

“One of the things we are looking at is patient compliance rates – are they doing the exercises? Said Dr Kamarova. “That will tell us a little bit more about the barriers to the uptake of this telehealth from a patient perspective.”

Dr Hassan says Australia lags behind comparable western health systems in prehabilitation, where it has been in use for long time. He believes that part of the solution lays in convincing surgeons of its value.

“We are dealing with lots of surgeons, all of whom are quite busy people. So, getting them to think about referring their patient to prehabilitation when they schedule them for surgery can be a challenge.”

“But the Agency for Clinical Innovation has made prehabilitation one of its four initiatives for elective surgery improvement in NSW, so people have started coming on board now and are taking a lot of interest.”

Whether online or in person, Dr Anwar believes that a large part of PrEPP’s success to date has been due to its “multi-modal” approach to preparing patients for surgery.

“We do several different things simultaneously to improve a patient’s readiness for surgery – physios work on their physical strength and fitness, dietitians review their eating habits, physicians assess their cardiovascular and lung health, and we might refer them to the acute pain team to make sure they understand pain management after surgery.”

At its heart, prehabilitation is about empowering the patients.  

“Most patients don't know what's going to happen in surgery or understand what happens when they go under general anesthesia,” said Dr Hassan. “And when they wake up in the intensive care unit, they don’t know what’s going to happen next, who they will see, what their responsibilities are, how the pain is being controlled, and what the benefits are of getting up and starting to mobilise early.

“Done well, prehabilitation can prepare them mentally, as well as physically, for all of those things.”