In A Class By Itself

Pre-surgery education program improves patient experience, outcomes.

The vast majority of the nearly 1 million Colombians living in the United States emigrated during the 1980s and ’90s. Beatriz Irvin was part of that wave.

Beatriz Irvin poses with the equipment at Manatee Memorial Hospital

Beatriz Irvin

“I was always interested in the United States, and when we started studying it in high school in my social studies class, I fell in love with it,” Beatriz discloses. “It became my dream to move here, and I finally did that in the ’80s after living in London for a while.

“The thing I love most about living in America is the freedom we have here. I love all the things we have here that we didn’t have in Colombia. It’s a great country, and I’m fortunate to be living out the dream I had as a little girl.”

Beatriz’s childhood dream also included marrying and raising a family. She realized that in the US as well, marrying after five years of residency and raising a daughter who recently graduated from college and is now rearing children of her own.

About five years ago, while her daughter was wrapping up her education, Beatriz began to feel discomfort in her left knee. At first, she was bothered only occasionally by the pain. Before long, though, she was forced to alter her routine at work.

“I was working as a supervisor at a hotel, and I was on my feet a lot in that job, constantly moving,” Beatriz relates. “Instead of taking the elevator, I often took the stairs when moving from one floor to another. But that became a problem for me. Whenever I went up and down the stairs, my knee would hurt something terrible.”

So, she stopped taking the stairs. That helped, but one day she sat down to do paperwork “and my knee hurt so bad I could hardly bend it to sit down.”

Another problem developed while driving.

“My drive to work was about 20 minutes long, and by the time I got to work and had to get out of the car, my knee was so stiff that I could hardly move it,” she explains.

“The best thing about the class is that they go over so many things that you would never really think of.” – Beatriz

Beatriz fought through the pain for a couple of years. When she finally sought medical help, she was diagnosed with arthritis and given injections to alleviate the pain. The injections provided only temporary relief.

“Then the coronavirus pandemic came, and I don’t know what happened, but my knee just got worse,” Beatriz laments. “The pain was like nothing I’d ever felt before. It was like it was burning, and it didn’t matter whether I was walking or not, it was always like that.

“The only thing that made it feel any better was if I put ice on it or if I fell asleep. I went back to my doctor, and he said I needed to have surgery to replace my knee. That’s how I wound up seeing Dr. Retino.”

Out With The Old

Beatriz works out on machines as Monica watches.

At the Rehabilitation and Sports Medicine Center, a service of Manatee Memorial Hospital, Beatriz rehabs under the watchful eye of Monica Reid, PT (right).

Michael A. Retino, DO, is an orthopedic surgeon on staff at Manatee Memorial Hospital. He first saw Beatriz in February, when he ordered an MRI that revealed the true extent of her arthritic disease.

“Beatriz had a badly arthritic knee, and she was at the point where it was interfering greatly with normal activities of daily living and causing functional limitations,” the doctor reports. “She was no longer responding to conservative measures and when we talked about knee replacement surgery, she committed to it.

“Our plan was to do a total knee arthroplasty, which means you’re resurfacing all three compartments: the medial, or inside, part of the knee; the lateral, or outside, compartment; and the patellofemoral, which is the front or anterior aspect of the knee.”

To provide the patient with optimum stability and mobility following surgery, Dr. Retino prefers to use the ATTUNE® Total Knee System. Made by DePuy, the ATTUNE knee allows for improved stability and kinematics, creating a more naturally feeling joint replacement.

Dr. Retino typically performs such surgeries at Manatee Memorial Hospital, where joint replacement surgery patients are encouraged to participate in a pre-surgical education program designed to ensure better experiences and outcomes.

“In the past, when the patient came in ready for surgery, we simply placed them on the schedule,” Dr. Retino relates. “Now, we go well beyond that and try to get the patient into the best possible shape, both physically and mentally, before putting them through surgery.”

In With The New

The coordinator of Manatee Memorial Hospital’s joint replacement pre-surgical education program is Andrew Stritzl. His official title is orthopedic nurse navigator, and his primary goal is to ensure the patient remains safe leading up to surgery, during their stay and through their recovery.

“Undergoing surgery is like running a marathon,” Andrew offers. “My job is to make sure each patient is as prepared as they possibly can be to run that marathon, finish it and not suffer from any complications afterward.

“Our first touch point with the patient is during our pre-surgery educational classes for total knee, hip and shoulder replacements. The classes I offer are held on Mondays and Wednesdays, and our focus is on pre- and post-surgery preparedness.”

“The focus is on functional safety and safety awareness.” – Andrew

One of the primary objectives of the pre-surgical education program is to avoid complications following the procedure. Among the most serious possible complication is infection of the surgical site. It’s a concern Andrew covers in great detail in his class.

“A surgical site infection can be a life-changing event,” Andrew warns. “That’s why our pre-surgery education class puts such great emphasis on it. We go over what patients need to do before and after surgery to help reduce the risk of getting an infection.”

The regimen to reduce the risk of infection begins several days before the procedure, when patients are asked to make simple, but important changes to their home environment and to their bathing habits.

“Everybody has heard about the horrors of staph infections,” Dr. Retino explains. “The problem is that everybody is walking around with what we call MRSA (methicillin-resistant Staphylococcus) on their skin. There’s just no way around it. That’s why I ask the patients to bathe up to a week prior to surgery using a special soap that removes harmful flora on the skin. It’s a way to be proactive and decolonize the skin to further reduce the risk of infection.”

Andrew suggests that before surgery patients “bust out the disinfecting wipes” and clean all kitchen countertops and other surface areas in their homes to ensure they’re recovering in an aseptic environment.

Changing the bed sheets prior to surgery, ensuring pet care is planned for and emphasizing proper hand hygiene habits are maintained all go a long way toward reducing the possibility of infection.

So does eating properly before and after surgery. Andrew encourages patients to adopt a high-calorie, high-protein dietary regimen to reduce the possibility of surgical site infections and expedite the healing process.

Also, as part of the preop educational program, additional information is provided by a registered dietitian on healthy high-protein diets in preparation for surgery and after to enhance healing and recovery.

“It’s an example of old-fashioned caring.” – Dr. Retino.

“We also ask that patients enjoy a good pasta dinner the night before surgery because long-lasting carbs will help them get through the day of surgery and reduce the surgical stress of the process,” Andrew notes.

“Again, it’s like a marathon runner or any athlete who’s preparing for an event the next day. By eating that spaghetti dinner, you’re increasing the glycogen storages in the muscles that help provide the body with energy when needed during and after the surgery to reduce surgical stress on the body. It gives the body the energy it needs so the patient has a better outcome and feels more comfortable and more at ease after surgery. It also helps decrease postoperative nausea and vomiting and preserves
muscle mass.”

The benchmarks of recovery times and what to expect after surgery are also among the topics discussed by Andrew during the preoperative educational program.

“For knee and hip replacement patients, I talk about making sure they have a way to elevate their leg properly to limit swelling,” Andrew explains. “I also talk about creating an ambulation regimen within the home that incorporates frequently moving, in balance with icing, elevation and specific exercises.

“This regimen is to help limit pain and swelling, reduce inflammation, and to get reasonable range of motion during the first week or two after surgery. In preparing the home to receive you, patients are instructed to remove from high traffic areas anything that could cause the patient to stumble, trip or fall such as throw rugs, extension cords or cables.

“We also talk about pain management quite a bit. Each patient is different, so I go over the broad pain management regimen that has an emphasis on a layered multimodal pain management approach. Using scheduled acetaminophen as well as NSAIDs (non-steroidal anti-inflammatory drugs) when possible can help patients use fewer narcotics, which tend to have more side effects.

“We cover what to expect in the hospital before and after surgery with a focus on rehab and the goals of functional safety. The roles of physical therapy and occupational therapy are discussed as well as individualized discharging planning. Discussions of equipment needs and family involvement and their role are also explained in detail.”

The Team Dynamic

Monica evaluates the condition of Beatriz left knee.

With the help of Monica Reid, PT, Beatriz (right) is making a full recovery from her knee surgery.

Andrew’s job doesn’t end when class is dismissed. He follows patients through their hospitalization and remains the point man for the collaboration between the interdisciplinary team that consists of the surgeon, nursing, physical therapist and case managers. Andrew literally takes a hands-on approach to patient care and collaborates with the team on when the patient is meeting the functional safety goals to get home safely.

“With most joint-replacement patients, it’s a next-day, if not same-day discharge to home, and as we are working with patients by ambulating them, we’re deciding if they’re functionally safe to go home,” Andrew relates.

“Collaboration with the surgeon and case managers ensures we have a clear plan of care when the patient is ready for discharge, either with home health care services or straight to outpatient physical therapy. I complete the discharge process for each patient, ensuring prescriptions, instructions and any last-minute questions are answered.

“But even after the patient has returned home, I always tell them, I’m only a phone call away so don’t hesitate to call me. Just like your surgeon’s office is there if you have questions or concerns, so am I. It’s just an added safety net of communication.”

Andrew says the tremendous support the program gets from surgeons such as Dr. Retino is one reason Manatee Memorial Hospital is achieving its goal of creating better patient outcomes. Dr. Retino says he’s happy to be a part of the program.

“It’s an example of old-fashioned caring,” Dr. Retino concludes. “We’re very thoughtful about the surgical process, so we’re always looking for ways to fine-tune that process so we can get good solid outcomes. One way to do that is by doing more with preop education.”

“Doing Great”

Beatriz wasn’t surprised to learn that her knee required surgery, but she had no idea what she needed to do to prepare or what needed to be done to ensure a good recovery.
She learned all that and more in the pre-surgery education class.

“I thought the class was very helpful,” she shares. “They did a great job of explaining how the surgery would go and how the recovery would be, but the best thing about the class is that they go over so many things that you would never really think of.

“The parts about how to prepare for the day of surgery and how to prepare your home for the day you come home from surgery are very important, so the class was very informative. They give you lots of good tips to help you get through it all.”

After attending the class, Beatriz had surgery in February. Following an overnight stay at the hospital, she began her recovery the next day. She’s well on her way to a full recovery now.

“One thing I learned in the class is that you have to be patient. The recovery is going to take some time, and you have to go through the therapy and rehabilitation and do everything they ask,” Beatriz reports. “But I’m feeling better and moving better. I’m still recovering, but I always feel better after physical therapy.

“I think Dr. Retino did a very good job. He’s a good surgeon and he helped me a lot. Attending the class helped me a lot, too. It’s a good class, and having it is a good idea.”

© FHCN article by Roy Cummings. Photos courtesy of Manatee Memorial Hospital. mkb
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