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Standards and Staging

Strong for Surgery

Improve the outcome before the surgery

Strong for Surgery

Preoperative Checklists

Strong for Surgery empowers hospitals and clinics to integrate checklists into the preoperative phase of clinical practice for elective operations. The checklists are used to screen patients for potential risk factors that can lead to surgical complications, and to provide appropriate interventions to ensure better surgical outcomes. The checklists target 8 areas known to be highly influential determinants of surgical outcomes:

Nutrition

Nutritional status strongly impacts surgical outcomes. Signs like unintentional weight loss, poor intake, or GI issues may indicate risk and warrant nutrition counseling. Using specialized nutrition formulas can cut infection-related complications by 40–60%.

Smoking Cessation

Smoking increases postoperative complications by 40% and is a key risk factor for infections and heart issues. Spine surgery patients who smoke face 2–3 times higher non-union rates, more pain, lower satisfaction, and reduced return-to-work rates. To improve outcomes, providers recommend quitting, setting a quit date, and using support resources.

Glycemic Control

Proper blood glucose control in diabetic patients supports healing and can reduce hospital stay. Managing glucose before surgery lowers the risk of perioperative highs and lows. Hyperglycemia doubles the risk of surgical site infections. Pre-op glucose checks can also reveal undiagnosed diabetes in up to one-third of surgical patients.

Medication Use

A full review of all medications, including OTC drugs, supplements, and herbs, is key to guiding patients before surgery. Aspirin and beta blockers may be safely continued for cardiac protection. However, some drugs and herbs—like garlic, gingko, ginseng, and St. John’s wort—can raise bleeding or other risks and should be stopped pre-op.

Delirium

Recognizing and treating delirium is vital, as postoperative delirium is linked to worse outcomes—longer stays, decline in function, higher costs, and mortality. Risk factors include age, alcohol use, poor cognitive/physical function, and abnormal labs. High-risk patients can benefit from targeted interventions to prevent or lessen delirium.

Prehabilitation

Impairments in cognition, gait, balance, nutrition, and function raise the risk of complications around surgery. Prehabilitation helps patients recover faster and return to optimal function. It can lower surgery-related risks, shorten hospital and rehab stays, and reduce readmissions, improving overall outcomes.

Safe and Effective Pain Control

Unrelieved pain can lead to longer hospital stays, more readmissions and outpatient visits, and reduced function. To support effective pain management, patients should receive pre-op counseling. Discussing expectations, possible side effects, and non-prescription pain options helps set realistic recovery goals and improves outcomes.

Patient Directives

Patient education is key to safety and helps reduce pre-op anxiety. It’s important to discuss surgical risks, pain, financial concerns, and the need for the procedure. Patients should feel supported and be encouraged to share their thoughts and feelings about surgery to promote comfort and confidence before the operation.

Checklist References

Nutrition

Screening for Malnutrition

  • Mueller C, Compher C, Ellen DM, American Society for Parenteral and Enteral Nutrition (A.S.P.E.N) Board of Directors. ASPEN Clinical Guidelines: Nutrition screening, assessment, and intervention in adults. JPEN. 2011;35(1):16-24. http://www.ncbi.nlm.nih.gov/pubmed/21224430

Risk stratification with Albumin

  • Hennessey DB, Burke JP, Ni-Dhonochu T, Shields C, Winter DC, Mealy K. Preoperative hypoalbuminemia is an independent risk factor for the development of surgical site infection following gastrointestinal surgery: A multi-institutional study. Ann Surg. 2010; 252(2):325-329. http://www.ncbi.nlm.nih.gov/pubmed/20647925
  • Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF. Preoperative serum albumin level as a predictor of operative mortality and morbidity: Results from the National VA Surgical Risk Study. Arch Surg. 1999; 134:36-42. http://www.ncbi.nlm.nih.gov/pubmed/9927128

Benefits of Immunonutrition

  • Drover JW, Dhaliwal R, Weitzel L, Wischmeyer PE, Ochoa JB, Heyland DK. Perioperative use of arginine-supplemented diets: A systemic review of the evidence. J Am Coll Surg. 2011;212(3):385-399. http://www.ncbi.nlm.nih.gov/pubmed/21247782
  • Marimuthu K, Varadhan KK, Ljungqvist O, Lobo DN. A meta-analysis of the effect of combinations of immune modulating nutrients on outcome in patients undergoing major open gastrointestinal surgery. Ann Surg. 2012; 255(6):1060-1068. http://www.ncbi.nlm.nih.gov/pubmed/22549749
Glycemic (Blood Sugar) Control
Medication

Bleeding Risks

  • Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012; 141 (2): e326S-e350S. http://www.ncbi.nlm.nih.gov/pubmed/22315266
  • Hall R and Mazer CD. Antiplatelet drugs: a review of their pharmacology and management in the perioperative period. Anesth Analg. 2011;112:292-318. http://www.ncbi.nlm.nih.gov/pubmed/21212258

Beta-Blockers

  • Kwon S, Thompson R, Florence M, et al. β-blocker continuation after noncardiac surgery: A report from the surgical care and outcomes assessment program. Arch Surg. 2012;147(5):467-473. http://www.ncbi.nlm.nih.gov/pubmed/22249847

Aspirin Use

  • Gerstein NS, Schulan PM, Gerstein WH, et al. Should more patients continue aspiring therapy perioperatively?: Clinical impact of aspirin withdrawal syndrome. Ann Surg. 2012;255(5):811-819. http://www.ncbi.nlm.nih.gov/pubmed/22470078

Herbal Supplements

Smoking Cessation

Smoking and Increased Postoperative Risks

Smoking and Spine Surgery

  • Pearson A, Lurie J, Tosteson T, et al. Who should have surgery for an intervertebral disc herniation? Comparative effectiveness evidence from the spine patient outcomes research trial. Spine. 2012;37(2):140-149. http://www.ncbi.nlm.nih.gov/pubmed/21681140
  • Pearson A, Lurie J, Tosteson T, Zhao W, Abdu W, Weinstein JN. Who should have surgery for spinal stenosis? Treatment effect predictors in SPORT. Spine. 2012;37(21):1791-1802. https://www.ncbi.nlm.nih.gov/pubmed/23018805
  • Sandén B, Försth P, Michaëlsson K. Smokers show less improvement than nonsmokers two years after surgery for lumbar spinal stenosis: a study of 4555 patients from the Swedish spine register. Spine. 2011;36(13):1059-1064. http://www.ncbi.nlm.nih.gov/pubmed/21224770
  • Andersen T, Christensen FB, Laursen M, Høy K, Hansen ES, Bünger C. Smoking as a predictor of negative outcome in lumbar spinal fusion. Spine. 2001;26(23):2623-2628. http://www.ncbi.nlm.nih.gov/pubmed/11725245

Safety of Smoking in the Preoperative Setting

Preoperative Smoking Cessation Programs Reduce Post-Operative Complications

  • Lindström D, Azodi OS, Wladis A, et al. Effects of a perioperative smoking cessation intervention on postoperative complications: A randomized trial. Ann Surgery. 2008;248(5):739-745. http://www.ncbi.nlm.nih.gov/pubmed/18948800
  • Møller AM, Villebro N, Pedersen T, Tønnesen H. Effect of preoperative smoking intervention on postoperative complications: A randomised clinical trial. Lancet. 2002;359(9301):114-117. http://www.ncbi.nlm.nih.gov/pubmed/11809253
Delirium
  • Marcantonio ER, Juarez G, Goldman L, et al. The relationship of postoperative delirium with psychoactive medications. JAMA. 1994;272:1518-1522.
  • American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. Postoperative delirium in older adults: Best practice statement from the American Geriatrics Society. J Am Coll Surg. 2015;220(2):136-148.
  • Dasgupta M, Dumbrell AC. Preoperative risk assessment for delirium after noncardiac surgery: A systematic review. J Am Geriatr Soc. 2006;54:1578-1589.
  • Young J, Murthy L, Westby M, Akunne A, O'Mahony R; Guideline Development Group. Diagnosis, prevention, and management of delirium: Summary of NICE guidance. BMJ. 2010;341:c3704.
  • Fick DM, Semla TP. 2012 American Geriatrics Society Beers Criteria: New year, new criteria, new perspective. J Am Geriatr Soc. 2012;60:614-615.
  • Alagiakrishnan K, Wiens CA. An approach to drug induced delirium in the elderly. Postgrad Med J. 2004;80:388-393.
  • Robinson TN, Eiseman B. Postoperative delirium in the elderly: Diagnosis and management. Clin Interv Aging. 2008;3(2):351-355.
Prehabilitation
  • Carli F, Charlebois P, Stein B, et al. Randomized clinical trial of prehabilitation in colorectal surgery. Br J Surg. 2010;97(8):1187-1197.
  • Nielsen PR1, Jørgensen LD, Dahl B, Pedersen T, Tønnesen H. Prehabilitation and early rehabilitation after spinal surgery: Randomized clinical trial. Clin Rehabil. 2010;24:137-148.
  • Makary MA, Segev DL, Pronovost PJ, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210:901-908.
  • Polanczyk CA, Marcantonio E, Goldman L, et al. Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery. Ann Intern Med. 2001;134:637-643.
  • Wynter-Blyth V, Moorthy K. Prehabilitation: Preparing patients for surgery. BMJ. 2017;358:j3702.
SCOAP
  • SCOAP Collaborative, Writing Group for the SCOAP Collaborative, Kwon S, Florence M, et al. Creating a learning healthcare system in surgery: Washington State’s Surgical Care and Outcomes Assessment Program (SCOAP) at 5 years. Surgery. 2012;151(2):146-52. http://www.ncbi.nlm.nih.gov/pubmed/22129638

Questions?

If you have questions about the Strong for Surgery program, contact us today at qualityresources@facs.org.