Authors (including presenting author) :
Wong MK(1), Kwong KW(1), Ding Q(2), Ma HM(2), Tsung P(1), Chan SY(1), Lam S(4), Ting T(5), Chan KM (1), Lau NM(1), Au SW(1), Yip HC(3), Ho MF(3), Yee S(3), KC Ng(3)
Affiliation :
(1) Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, (2) Department of Medicine and Therapeutics, Shatin Hospital, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, (4) Department of Physiotherapy, Shatin Hospital, (5) Department of Dietitian, Shatin Hospital
Introduction :
Frailty is a multidimensional syndrome in which multiple small physiological deficits accumulate gradually, resulting in a loss of physiological reserve and adaptability, putting a patient that is exposed to stressor at a higher risk of adverse outcomes. Both pre-frailty and frailty are associated with worse outcomes and higher healthcare costs. With the potential “teachable” moment from the long surgical waiting time in Hong Kong, the effect of a one-stop multidisciplinary prehabilitation program incorporated into clinical care pathway in high-risk frail patients undergoing elective major surgery were evaluated.
Objectives :
(1) To evaluate the feasibility of incorporating a multidisciplinary prehabilitation program into the routine clinical care pathway
(2) To investigate the impact of prehabilitation on high-risk frail patients undergoing elective major operations
Methodology :
This is a single-centre, unblinded, retrospective observation study. Patients were screened by anaesthetists for inclusion into prehabilitation clinic at least 4 weeks prior to operation. Eligible patients would further receive nutritional screen with Malnutrition Screening Tool (MST), functional capacity screen with 6-minute walk test (6MWT) and Duke Activity Status Index (DASI) questionnaire. Patients with MST >1 would be referred to dietitian for preoperative nutritional optimization; while patients with ASA 3 or above and Clinical Frailty Scale (CFS) 4-6, together with 6MWT < 400m or DASI < 34 would be referred to physiotherapist for exercise prehabilitation. In addition to the patient-specific criteria, patients undergoing major surgery such as major hepatectomy, esophagectomy, pancreaticoduodenectomy and radical cystectomy would be referred for prehabilitation. A one-stop prehabilitation program was arranged in a geriatric day hospital for the first time in Hong Kong that provides seamless support from geriatricians and allied health. The exercise prescription is a structured exercise (aerobic and resistance) training, supervised by physiotherapist, 2-3 sessions per week for 4-6 weeks before surgery with early health promotion advice. Nutritional prehabilitation involved baseline assessment, dietary support and immunonutrition.
Result & Outcome :
Outcomes
Primary (feasibility) outcomes are recruitment, attrition and adherence of patients to prehabilitation program. Secondary outcomes include differences in 6MWT distance and calculated peak oxygen uptake (VO2peak); changes in hand-grip strength, time-up-and-go test (TUGT) and 30-second chair sit-stand test; emotional resilience assessed by Depression Anxiety Stress Scale (DASS-21); and nutritional status measured with body weight, BMI, muscle mass and percentage body fat before and after prehabilitation.
Results
Over a 12 months period, 111 patients were screened into prehabilitation clinic. 64.9% (n=72) patients were eligible for prehabilitation, of which 76.4% (n=55) were successfully enrolled. Most patients enrolled also completed prehabilitation. The overall adherence rate is 96.4% (n=53). The mean number of prehabilitation sessions attended per patient was 6.5 +/- 3.1. Advancement of operation schedule is the main reason for fewer training sessions. The mean age of patients joining prehabilitation program was 71.9 +/- 6.9. (43% ASA >=3, 27.5% CFS >=4). There was no significant difference in mean 6MWT distance (405.5 +/- 99.0m vs 419.8 +/- 104.2m, p=0.13) and VO2peak (11.0 +/- 3.3ml/kg/min vs 11.1 +/- 3.1ml/kg/min, p=0.78) before and after prehabilitation. However, there was significant improvement in muscle strength in terms of mean hand grip strength (23.4 +/- 9.0kg vs 24.7 +/- 8.9kg, p=0.016) and 30s Chair Stand test (11.9 +/- 3.5 times vs 13.8 +/- 3.8 times, p < 0.001). There was also significant improvement in functional mobility as demonstrated by mean time required in TUGT (10.9 +/- 5.1s vs 8.4 +/- 2.8s, p < 0.001). There was no difference in cognitive function as assessed by Montreal Cognitive Assessment score and emotional resilience as measured by Depression Anxiety Assessment Scale. No significant difference in nutritional status was noted.
Conclusion
This is the first one-stop multidisciplinary prehabilitation program for high-risk patients before major elective operations in Hong Kong. The results of this trial support the feasibility of incorporating the program into routine clinical care pathway. Prehabilitation may lead to improved muscle strength and functional mobility.
