American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

About Strong for Surgery

Strong for Surgery is helping to improve clinical outcomes.

A patient’s risk of negative outcomes from an operation can be improved by using best practices in the preparation for surgery. We've searched the globe to bring effective methods into checklists and ensure patients are optimally prepared for their upcoming operation.

Strong for Surgery brings a presurgery checklist to surgeons' offices to help with education, communication, and standardization of best practices to improve clinical outcomes.

Introduction to Strong for Surgery from Dr. Varghese


Strong for Surgery is an initiative aimed at identifying and evaluating evidence-based practices to optimize the health of patients prior to an operation.

Over the past several years, Strong for Surgery worked with stakeholders from across Washington State to raise awareness of key factors in preoperative care that can improve postoperative outcomes. The quality improvement tools generated by this initiative help hospitals, clinicians, and patients implement best practices toward optimizing patient health for surgery.

The first Strong for Surgery initiative addressed preoperative nutrition intervention—a priority topic identified by SCOAP clinicians and quality leaders. Nutritional status is a major determinant of outcome for the high-risk surgical patient and is one of the most important preoperative predictors of outcome in any type of operation.

The objectives of Strong for Surgery’s smoking cessation initiative are to educate surgical staff and patients about the added risk smoking contributes to negative surgical outcomes (for example, surgical site infections, hospital readmissions) and to provide information about smoking cessation options. The program includes recommendations around preoperative optimization of blood sugar and management of medications.

Overview of Strong for Surgery

Strong for Surgery is a public health campaign that engages patients and their surgeons to improve overall health and increase the likelihood of a positive surgical outcome. Preoperative checklists serve as a communication tool for patients and clinicians to consider four common risk areas. 


Nutritional status is an important independent predictor of surgical outcomes. Factors such as unintentional weight loss, changes in dietary intake, and gastrointestinal distress indicate that a patient may be at risk and should be referred for nutritional counseling. Use of a specialized nutrition formula to address immune suppression can reduce infectious complications by 40 to 60 percent.

Smoking Cessation

Smoking correlates with 40 percent higher prevalence of postoperative complications and is an independent risk factor for infections and cardiovascular events after an operation. Smokers who undergo spine surgery have a two to three times higher rate of non-union for spine fusion, are less likely to return to work after surgery, and have more pain and lower satisfaction with their recovery. To improve outcomes in patients currently smoking, providers will advise patients to stop smoking and choose a quit date, and refer them to available resources.

Glycemic Control

Proper blood glucose control in diabetic patients having surgery can help support healing and lower the length of stay. Establishing control of blood glucose prior to surgery reduces the chance of hyperglycemia and hypoglycemia during the perioperative period. Studies have shown hyperglycemia can double the risk of surgical site infections. Checking blood glucose prior to an operation is a way to identify patients with undiagnosed diabetes, a reported one-third of all patients having operations, and let clinicians start treatment before hospitalization.

Medication Use

A thorough review of all medications including over-the-counter drugs, supplements, and herbal remedies is important so that the patient can be advised accordingly. Evidence shows that aspirin and beta blockers can be safely continued throughout the perioperative period for cardiac protection with most operations. Some medications, however, increase bleeding risks and should be stopped before an operation. Specific herbal medications, including echinacea, garlic, gingko, ginseng, kava, saw palmetto, St. John’s wort, valerian, can also increase risks.