From left, Anne Fitzgerald, Emilie Schlitt and Juliet Starr present a poster on the pre-op course at the ERAS Conference in New Orleans.

From left, Anne Fitzgerald, Emilie Schlitt and Juliet Starr present a poster on the pre-op course at the ERAS Conference in New Orleans.

Preparing for any kind of surgery can cause a certain degree of fear or anxiety for patients. But those with bladder cancer who are facing a radical cystectomy—the removal of the bladder and some of the reproductive organs—often have so much anxiety about the procedure and the impending changes to their lifestyle that it affects their outcomes and increases their chances of readmission.

“The amount of anxiety these patients have can negatively affect how much knowledge they retain about how to care for themselves in recovery,” said Emilie Schlitt, BSN, RN, of Tower 12A. “Some have never even seen the equipment that they’ll be using every day after surgery.”

During a radical cystectomy, surgeons create an opening in the abdomen through which urine can exit the body to an external pouch that patients must regularly empty and change. About 120 patients—many of whom have additional medical issues—undergo the procedure at the Brigham each year.

Wanting to help patients better prepare for surgery and recovery, Schlitt and her colleagues Juliet Starr, RN, and Anne Fitzgerald, BSN, RN, created a presentation highlighting additional education that would benefit patients and sent it to interprofessional colleagues at the Brigham.

It turned out that one of the physicians who received it was working on a similar “prehabilitation” program. “It was good timing,” said Matthew Mossanen, MD, of the Department of Surgery. “It also made sense that nurses should lead the course because they are the ones who are with patients 24/7 after surgery.”

Comprehensive Education and Supportresults infographic

With input from physical therapists, dietitians and wound/ostomy nurses, Mossanen, Schlitt, Starr and Fitzgerald developed a comprehensive 1.5-hour pre-operative course and began offering it in February 2018.
The course covers lifestyle changes that patients can make to help them improve their health prior to surgery and recovery.

“This includes strengthening exercises that they can do, as well as education about the importance of hydration and a healthy diet,” said Schlitt.

Nurses also educate patients about what to expect during every phase of surgery, recovery and post-discharge. This is important because radical cystectomy patients follow the ERAS (Enhanced Recovery After Surgery) protocol. One of the requirements of the protocol is that patients must get out of bed and move around shortly after the procedure to reduce the risk of blood clots and regain gastrointestinal motility.

“We don’t want patients to be surprised when we ask them to try getting out of bed six hours after surgery,” Schlitt said. “It’s especially helpful to have education before the surgery so they know what to expect going home and don’t feel overwhelmed on the day of discharge with all the information they need to retain.”

During the course, Mary Willis, MS, RN, CWOCN, gives patients an opportunity for hands-on learning with the equipment they will be using following surgery, such as pouches and neobladder supplies, to help them prepare for their new routine.

An unexpected result of the class was that patients began to open up and talk among each other, similar to a support group, Schlitt said. “It’s a big, life-changing surgery, and people often feel self-conscious about what they’ll need to do afterward. It helps to know other people going through it.”

Patients who participated in the class affirmed how helpful it was to them via a survey.
“This class turned out to be a godsend,” one patient wrote. Another shared that it made the entire procedure “less scary” and that they felt more at ease about how to care for themselves at home.

Next Steps

Schlitt and her colleagues attended the ERAS Conference in New Orleans in November to present a poster on the course and the positive outcomes it has yielded so far.

“Although the data is preliminary, and we need to study this further, we know that patients who come to the class love it, and so do their caregivers,” Mossanen said.

He says the next step is to consider whether the pre-op course can become the standard of care for these patients and to determine how to help patients who cannot come to the class get the information they need. Mossanen also sees value in sharing this work with colleagues in other areas to determine whether it could be adapted for patients undergoing different procedures.