How Can Residents Best Master Postoperative Protocols?

Q: Can you describe the ways in which your program provides education regarding various postoperative courses, both inpatient and outpatient?

A:

The panelists share that, in their experience, learning about postoperative care usually results from a combination of case-by-case collaboration and standardized protocols. During individual cases, the residents share that they often discuss postop instructions, medications and follow-up with the attending. Ruben Nuñez, DPM, MS relates that standardized postop protocols are difficult at his institution, as the residents work with a large number of attendings.

“We are free to ask questions as to (attendings’) choices,” he says. “We also incorporate some perioperative learning into other academics, such as journal clubs.”

Matthew Sieloff, DPM agrees, sharing that in addition to individual ones, academics and grand rounds discussions take place regarding postoperative courses, indications, contraindications and surgical technique.

“Generally, we have broad algorithms regarding appropriate weight-bearing, level of physical therapy, occupational therapy, patient transferring, bathing, toileting, dressing care, drain care, nursing team instructions, edema control, antibiotic dosing and DVT prophylaxis for the postoperative course, tailored to the procedure completed,” he adds. “Residents in clinic conduct patient postop visits to assess patient recovery and direct care.” 

Rebecca Van Dyke, DPM says her team often adjusts standard postop protocols based on a patient’s needs, but her program’s algorithm includes a formal physical therapy consultation for postop ambulation training and evaluation. This takes place at the bedside for inpatients or in the PT department for outpatients.

“One step in our preoperative course at UH includes formal crutch training prior to surgery if the patient is to undergo a period of strict non-weight-bearing,” she says. “If they do not pass the evaluation, the therapy team will usually recommend facility placement, whether to a skilled nursing facility or subacute/acute rehab. We generally follow those recommendations to make sure that the patient is not only adhering to their weight-bearing status, but also receives the therapy sessions that they need to return to their baseline activities of daily living.” 

Q: What do you feel are the pros and cons of the current methods of postop education that you and perhaps your peers at other programs experience?

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Daniel Fritz, DPM says that one pro is exposure to numerous attendings, which provides diversity in the way they observe and participate in postop care. However, he relates a lack of formal education in postop care as a negative, as the learning takes place on a case-by-case basis.

Dr. Nuñez feels the different perspectives on postoperative treatment they receive is a high point. However, he cites a universal issue amongst many residents as the relatively small amount of follow-up they receive on elective cases they participate in. As a result, he says residents rely on the word of attendings to learn how patients do. He says his program is working on addressing this, and that his experience in his institution’s limb salvage program is a good example of being able to see the perioperative process in its entirety.

“With our specialty being as focused as it is, I do believe that there is a general consensus on some standards of postop care,” says Dr. Van Dyke. “This includes the AO tenet of early and safe mobilization, as to prevent cast disease.” 

She goes on to say that one con to current teachings on postop courses is the variety of opinions in the literature. Dr. Van Dyke cites the question of the acceptable timeframe within which to commence weight-bearing in forefoot and midfoot fusions.

Dr. Sieloff says that actively participating in the entire continuum of care is a significant benefit of postoperative care training. This then leads to general algorithms and an objective checklist that may help residents develop skills and a sense of when something is not right, and requires intervention.

“Cons, however, include time away from the operating room, increased time in clinic, and adapting to differing surgeons’ postoperative approaches,” he says.    

Q: What aspects of postoperative care do you wish you received more guidance or education on?

A:

All of the panelists said that more exposure to working with complex postoperative scenarios would be ideal. Among such scenarios, they cited patients with complications, issues with adherence, advising patients with limited resources during the postop period, postop injury, and high-risk surgery strategies as important topics of interest.

Q: What ideas or thoughts do you have about how postoperative education should be provided in the future?

A:

Dr. Nuñez suggests that block scheduling of some rotations with single attendings might allow for a more detailed experience, along with looking into patient simulations or training modules as technologies like virtual reality and 3D printing continue to advance.

Early incorporation of postop goal setting, focused academic sessions on postoperative courses and how to balance patient and provider expectations are all important facets that Dr. Van Dyke feels are worth addressing in residency training. She also feels that rich experience in pain management including physical therapy modalities are important aspects of the postoperative course that warrant inclusion.

My training has entailed a well-rounded experience of off-service rotations such as pain management, internal medicine, vascular surgery and trauma which allow for residents to become even more well-versed in post op work up in the inpatient setting. This includes proper pain management, something that is not to be overlooked. Along with pain management modalities, educating residents on physical therapy techniques and what the patient in pain can expect from these modalities cannot be stressed enough to prevent cast disease and the difficult sequela of complex regional pain syndrome. Knowledge on gentle passive and active ROM exercises that they can commence at home can be useful once enough healing occurs. This can be performed in the time interval after surgery while setting up outpatient physical therapy sessions. 

Dr. Fritz feels that it could prove useful if programs met to discuss a given type of postoperative course, along with any relevant new literature.

“This would help us be up-to-date on the latest aspects of postoperative complications, medications, etc.,” he says.

More involvement in immediate postop conversations is an important potential addition, says Dr. Sieloff.

“Interpersonal and communication skills are a core competency, and the postoperative conversation is an opportunity to develop these skills,” he explains.

Dr. Fritz is a third-year resident at Bryn Mawr Hospital in Bryn Mawr, PA.

Dr. Sieloff is a third-year resident at Gundersen Health System in La Crosse, WI.

Dr. Nuñez is a third-year resident at St. Luke’s University Health Network in Allentown, PA.

Dr. Van Dyke is a third-year resident at University Hospital in Newark, NJ.