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34
Members of the transdisciplinary Geriatric Surgery Service conduct regular
meetings as a platform for the requirements of this model described by Reilly ( 2001 )
to be incorporated. Practice-based learning and improvement was feasible through
discussions on cases managed by the team. Interpersonal and communication skill
had allowed effective role enrichment, release and support among team members.
Through this platform, the transdisciplinary nurse was able to establish the horizon-
tal stroke of the ‘T’ that represents the disposition and collaboration across disci-
plines as illustrated in Fig. 3.1 .
Role enrichment through
regular ward rounds and
meetings with team
Transdisciplinary nurse as
pharmacist performing
medication recondiliation
Horizontal stroke representing disposition for
collaboration across disciplines
Horizontal stroke representing disposition for
collaboration across disciplines
Transdisciplinary nurse as therapists.
Specialized
medical/nursing
knowledge
Vertical stroke representing
depth of skill
Transdisciplinary Nures caring for ‘U’
Fig. 3.1 Holistic patient-centred care formulated by ‘T’-shaped transdisciplinary nurse and ‘U’
that is referred to as ‘You’, the geriatric surgical patient
P.X.-Z. Tan et al.
35
The team recognised that achieving exemplary surgical and functional outcome
for elderly patients involves not only rehabilitation during early post-operative days
but a period of prehabilitation is crucial to optimise their nutritional, functional and
physiological state before major surgery. The transdisciplinary nurse works collab-
oratively with allied health members to visit elderly surgical patients who satisfy
criteria for home-based optimisation regime during prehabilitation and rehabilita-
tion phases. She would take on the role as physiotherapist and assist the patients
with strengthening exercises to enhance their functional recovery to baseline fol-
lowing major surgery. This nurse also plays the role as dietitian and reviews the oral
intake and nutritional status with plans established together with the team’s dieti-
tian. The role as pharmacist is also undertaken by the same nurse during home visits
to ensure that the physiological health of the elderly surgical patients is effectively
optimised through medication compliance.
Tables 3.1 and 3.2 further illustrate the perioperative role of the nurse in transdis-
ciplinary nursing.
3.4.1 Case Study
Mdm. Tan S. N. is an 84-year-old lady with a background history of hypertension
and hyperlipidaemia. She is widowed with two children and stays with her son who
works as lecturer in the university. Family is extremely supportive. She is indepen-
dent in managing her own activities of daily living and is community ambulant
without aid. Mdm. Tan was diagnosed with cancer of the colon. Both patient and
family were extensively spoken to by the surgeon together with the nurse specialist
on her disease process as well as exploration of treatment goals and options. Benefi ts
and risks of various treatment options were discussed bearing in mind the risk
stratifi cation for the patient.
Table 3.1 Preoperative role of the nurse in transdisciplinary nursing
Preoperative transdisciplinary nursing
Risk
stratifi cation
Preoperative assessment to stratify the risks of patient and direct who in the
team can optimise for his/her operation
Goal setting Goals jointly set with patient and communicated to all team members
Planning Pre- and post-operative optimisation plan will be made with considerations
above. This is done through effective communication and collaboration with all
members of the Geriatric Surgery Service. Means of communication with the
patient and family will be established in the planning phase with considerations
for cognitive and intellectual status of individual patients as well as limitations
from physiological changes related to the ageing process
Education Educational package will be provided after the surgeon’s consultation for
psychological preparation. Personalised prehabilitation plans established with
patient and team members during the planning phase as well as measures to
prevent post-operative delirium will be reinforced during the education process
to allow better patient engagement during the perioperative period
3 Transdisciplinary Nursing
36
Although her risk profi les were unremarkable, Mdm. Tan was adamant towards
refusal for surgical resection of her diseased colon. Ample time was invested to
establish the rapport and trust between the nurse and patient before further coun-
selling and reiteration of surgeon’s advice could take place. Mdm. Tan eventually
understood that the likelihood of having her independence robbed by the disease
process would soon become a reality if surgery was not performed. The rapport
established had allowed Mdm. Tan to confi de her fears and worries to the trusted
nurse which were predominantly loss of independence and being a burden to her
family. Educational slides with video testimonies of patients with similar condi-
tions who have had surgeries done were shown to reassure her of the high possi-
bility of a good surgical outcome with collaboration of the transdisciplinary
Geriatric Surgery Team. She eventually agreed to undergo surgery after much
consideration and support received. Jointly set goals were communicated to all
members of the transdisciplinary team to establish a care plan that focused on
achieving the goals.
During her early post-operative days, quality nursing care was rendered to com-
pliment the established goals which include closer monitoring and reporting of any
deranged parameters, protocol-driven prevention of post-operative delirium, timely
administration of oral analgesics for pain free rehabilitation, elimination of distur-
bances to sleep and proper communication of treatment plans to Mdm. Tan and her
family. With support from the family and healthcare team, Mdm. Tan’s active
engagement during the perioperative period had allowed her to recover uneventfully
from her major surgery. She had returned to her premorbid functional status on the
day of discharge which was within a week post-operatively. A few days after her
discharge from the hospital, Mdm. Tan noticed there was purulent discharge oozing
from her surgical site. She could then receive treatment for the superfi cial wound
infection from a transdisciplinary team member without having to go through the
hassle of long waiting hours at the emergency department.
Table 3.2 Post-operative role of the nurse in transdisciplinary nursing
Post-operative transdisciplinary nursing
Nursing care Constant post-operative reviews with focus on the following:
Communication and supervision of junior nurses to manage nursing care
and goals that are in line with goals established with the transdisciplinary
geriatric surgery members
Clinical assessment of patient between team reviews to detect early signs of
perioperative complications
Constant updates on progress and management plans to patient, family and
team members. This is to allow mutual understanding for better
management of expectations during the course of recovery
Role release and role support among team members to allow for
rehabilitative activities to take place from fi rst post-operative day
Education Reinforcement of preoperative education to improve compliance
Discharge
care
Post-discharge follow-up to ensure the well-being of patient is maintained
P.X.-Z. Tan et al.
37
She was extremely appreciative of the effort from the transdisciplinary team
for spending much time and patience that changed her mind towards surgery
and the holistic care she received throughout her hospitalisation from all mem-
bers of the healthcare team. She continued to do well functionally and resumed
her usual daily activities without many difficulties. Mdm. Tan participates in
annual gathering organised by the Geriatric Surgery Service of Alexandra
Health (Singapore) for their elderly patients who underwent their surgical jour-
ney with them.
The Geriatric Surgery Service of Alexandra Health (Singapore) maintains a data-
base that tracks the outcome of elderly patients after major colorectal surgery.
Outcomes of nursing care for 130 patients above 75 years old who underwent major
colorectal resection between January 2007 and March 2012 were reviewed. Nursing
failures during the course of care were identifi ed. These included inaccurate docu-
mentation, delayed recognition of deterioration, non-compliance to orders and
improper discharge planning. Comparisons were made between the transdisci-
plinary model and traditional multidisciplinary model of care. Cumulative summa-
tion (CUSUM) methodology was used to plot sequential performance of both
groups. A continuous downward slope as illustrated in Fig. 3.2 denotes sequential
success, while a graph without consistent trend as shown in Fig. 3.3 denotes incon-
sistent nursing outcomes.
Differences in demographics, comorbidities and functional status of both groups
as shown in Table 3.3 were not signifi cant. In Table 3.4 , the overall nursing failures
were lower in the transdisciplinary group compared to the standard group. Results
analysed as shown in Table 3.5 revealed that patients who were not managed peri-
operatively using the transdisciplinary approach had 5.7 times higher risk of nursing
failures which were independently associated with Clavien 2 and above
complications.
4
2
0
–2
–4
–6
–8
1 3 5 7 9 111315171921 2325272931333537394143454749
Fig. 3.2 CUSUM curve of nursing care in transdisciplinary approach
3 Transdisciplinary Nursing
38
With the analysed results, the Geriatric Surgery Service at Alexandra Health
(Singapore) concluded that transdisciplinary approach reduces nursing failures
which is independently associated with morbidity.
In order for evolution to take place from multidisciplinary nursing model to
transdisciplinary nursing, it is quintessential that a paradigm shift occurs from the
traditional nursing practice of nurses only performing basic nursing care related to
activities of daily living, while the rest of the activities pertaining to the recovery
process are left to be performed by various specialists and allied health members.
Nurses form the frontline in terms of time spent with the patient when compared
to surgeons, medical specialists and allied health members. Breaking the boundary
to take on greater roles can create positive impact on the outcome of recovery for the
12
10
8
6
4
2
0
1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89
Fig. 3.3 CUSUM curve of nursing care in non-transdisciplinary group
Table 3.3 Demographics, comorbidities and functional status of both groups
Transdisciplinary
( n = 41)
Non-transdisciplinary
( n = 89)
p
value
Gender Female 21 (51.2 %) 43 (48.3 %) 0.758
Male 20 (48.8 %) 46 (51.7 %)
ASA 1–2 16 (39 %) 48 (53.9 %) 0.114
3–4 25 (61 %) 41 (46.1 %)
Comorbidity index Below 4 37 (90.2 %) 79 (88.8 %) 0.8
Above 4 4 (9.8 %) 10 (11.2 %)
Barthel’s Below 80 6 (14.6 %) 12 (13.4 %) 0.8
Above 80 35 (85.4 %) 61 (68.5 %)
No data – 16 (18.1 %)
Urgency Elective 31 (75.6 %) 66 (74.2 %) 0.86
Emergency 10 (24.4 %) 23 (25.8 %)
P.X.-Z. Tan et al.
39
elderly surgical patient. In order to achieve transdisciplinary care, nursing staff must
be empowered with the autonomy to perform skills or tasks at a greater level and
across disciplines. The barriers of engaging oneself beyond the described responsi-
bilities of a nurse need to be overcome before evolution can take place. The key
factors to build the horizontal stroke on ‘I’-shaped nurses who work in silos to trans-
form them into ‘T’-shaped transdisciplinary nurses are to equip them with the funda-
mentals of relevant skills, knowledge and effective communication. With this added
confi dence, nurses can then expand roles and undertake greater responsibilities.
One good example is collaboration with the physiotherapists to enhance the
rehabilitation potential of elderly surgical patients. With various precautionary
assessment tools such as fall precaution in place, nurses are often abiding by these
strict measures to prevent falls among the patients. The fear of penalty associated
with a fall occurrence in patients often prevents the nursing staff from engaging in
activities that may expedite the recovery process of patient following major surgery.
Nurses tend to leave it to the ‘trained’ personnel in this instance, physiotherapists,
to avoid the risk of a patient falling under their watch. This routine often results in
nurses neglecting an imperative aspect of patient recovery borne either due to fear
of accidents occurring or due to a lack of interest in hastening the recovery process
of a post-surgical patient.
If every nurse that comes on each shift participates in a common and shared
rehabilitation plan, the patient would receive rehabilitative physiotherapy four times
a day instead of once daily during the therapist’s attendance. This alone will prevent
muscle weakening or functional decline associated with prolonged confi nement to
bed which may inadvertently contribute to the fall risk of the patient. Other compli-
cations related to prolonged bed rest such as chest infection, deep vein thrombosis
and urinary tract infection may also be avoided.
Table 3.4 Multivariate analysis correlating to nursing failures
Risk outcome
Risk ratio 95 % Cl
p
ASA ≥3 1.097 0.375–3.211 0.804
Comorbidity index ≥4 1.388 0.305–6.318 0.613
Barthel’s index ≤80 1.573 0.443–5.577 0.224
Urgency (emergency) 1.524 0.438–5.302 0.150
Clavien ≥2 3.136 1.043–9.430 0.005
Not transdisciplinary 5.662 1.685–19.027 0.002
Table 3.5 Factors contributing to nursing failures in both groups
Types of nursing failures
Transdisciplinary ( N = 41)
Non transdisciplinary ( N = 89)
Overall nursing failure
9.8 % ( n = 4) 41.6 % ( n = 37)
Inaccurate documentation Nil
13.5 % ( n = 12)
Delay in recognition of
deterioration
2.4 % ( n = 1) 25.8 % ( n = 23)
Non compliance to orders
7.3 % ( n = 3) 18.0 % ( n = 16)
Improper discharge planning Nil
5.6 % ( n = 5)
3 Transdisciplinary Nursing
40
Conclusion
The management of a complex elderly surgical patient requires a holistic
approach. Multidisciplinary nursing model should evolve to a transdisciplinary
nursing model to compliment the same model of care adopted by the Geriatric
Surgical Team. This will essentially involve a high level of communication and
coordination among team members to deliver the highest level of care to this
group of complex and vulnerable elderly surgical patients.
References
Brown T (2009) Change by design: how design thinking transforms organizations and inspires
innovations. HarperCollins, New York
Nandiwada DR, Dang-Vu C (2010) Transdisciplinary health care education: training team players.
J Health Care Poor Underserved 21(1):26–34
Rainforth B (1997) Analysis of physical therapy practice acts: implications for role release in
educational environments. Pediatr Phys Ther 9:54–61
Reilly C (2001) Transdisciplinary approach: an atypical strategy for improving outcomes in reha-
bilitative and long-term acute care settings. Rehabil Nurs 26(6):216–220, 244
Shelden ML, Rush DD (2001) The ten myths about providing early intervention services in natural
environments. Infants Young Child 14(1):1–13
Tan PXZ, Chua GC (2013) Nursing care of the elderly surgical patients. In: Tan KY (ed) Colorectal
cancer in the elderly. Springer, Berlin/Heidelberg, pp 121–140
Tan KY, Tan PXZ (2013) Transdisciplinary care for elderly surgical patients. In: Tan KY (ed)
Colorectal cancer in the elderly. Springer, Berlin/Heidelberg, pp 83–92
P.X.-Z. Tan et al.
41
© Springer-Verlag Berlin Heidelberg 2015
K.-Y. Tan (ed.), Transdisciplinary Perioperative Care in Colorectal Surgery:
An Integrative Approach, DOI 10.1007/978-3-662-44020-9_4
Myth #1
Enteral feeding cannot be started in patients without bowel sounds or passage of
fl atus or stool.
Truth #1
There are no studies showing a correlation between bowel sounds or peristalsis and
feeding tolerance; therefore, ESPEN does not recommend withholding enteral feed-
ing based on bowel sounds or passage of fl atus or stool (McClave et al. 2009 ).
Myth #2
There is no limit to the individualized modifi cations that can be made to the
constituents of a PN bag, e.g., replacement electrolytes, extra protein, and drugs
(e.g., insulin).
Y. -L. Cheah (*)
Department of Surgery , Khoo Teck Puat Hospital , Singapore , Singapore
e-mail:
cheah.yee.lee@alexandrahealth.com.sg
G. C. -H. Toh
Department of Nutrition and Dietetics , Khoo Teck Puat Hospital , Singapore , Singapore
e-mail:
toh.george.ch@alexandrahealth.com.sg
J. -W. Heng
Department of Pharmacy , Khoo Teck Puat Hospital , Singapore , Singapore
e-mail:
heng.jian.wei@alexandrahealth.com.sg
E. W. -L. Wee
Department of General Medicine, Gastroenterology , Khoo Teck Puat Hospital ,
Singapore , Singapore
e-mail:
wee.eric.wl@alexandrahealth.com.sg
4
Transdisciplinary Management
of Perioperative Nutrition
Yee- Lee Cheah , George Chee- Hong Toh , Jian- Wei Heng ,
and Eric Wei- Long Wee
42
Truth #2
There are many compatibility and stability issues pertaining to PN. PN is an emul-
sion that may crack (if proportion of fat components and nonfat components are
wrong) or precipitate (if electrolytes safety ranges are exceeded, e.g., calcium,
phosphate, or various salt forms of drugs or additives interact with PN). Insulin
should not be added in PN unless the patient is metabolically stable with consistent
requirements of insulin doses (e.g., home PN). Always check with the compounding
pharmacist in your institution.
Myth #3
PN is not expensive with current improvements in the production process; therefore,
we should administer PN even if the benefi t is marginal.
Truth #3
Careful deliberation, fi nancial counselling, and engaging the patient and family are
necessary when starting PN. The risks overweigh the benefi ts most of the time
unless the patient is truly indicated (enteral access/feeding attempted and non-
feasible and severely malnourished). Average cost of 7 days of PN including cost of
PICC insertion, PN bag, and lab monitoring is estimated to be SGD$2,400, and this
fi gure excludes the cost of possible complications (e.g., infection) and increased
duration of admission that may be associated with PN use.
Take-Home Pearls
• Colorectal surgical patients are at risk of malnutrition (up to 39 %).
• Malnutrition negatively affects surgical outcomes, hospital lengths of stay,
and cost of hospitalization.
• All patients should be screened and appropriately diagnosed with malnutri-
tion based on guidelines internationally developed and accepted by medical
nutritional societies.
• Transdisciplinary management of nutrition therapy, via the Nutrition Support
Team, is crucial for success in the treatment of malnutrition.
• At the initiation of nutrition therapy, daily requirements for calories, protein,
fl uid, electrolytes, trace elements, and vitamins should be calculated and
monitored throughout the length of treatment.
• Routine prolonged fasting before surgery and routine nasogastric decompres-
sion after surgery should be avoided.
• Preoperative nutrition therapy, ideally enteral nutrition, is recommended in
severely malnourished patients.
• Immediate resumption of oral intake in elective surgery is safe and not associ-
ated with anastomotic leak.
• In malnourished patients unable to meet requirements via oral intake
alone, nutritional therapy is recommended, ideally enteral nutrition; par-
enteral nutrition should be reserved for patients unable to tolerate enteral
nutrition.
• During the period of nutrition therapy, careful monitoring must be performed
to identify and treat complications associated with each therapy.
Y.-L. Cheah et al.
43
4.1 Introduction
Colorectal surgery patients are at risk of malnutrition due to a multitude of factors
including poor intake secondary to intestinal obstruction or cancer-associated
anorexia, impaired absorption in infl ammatory bowel disease, excessive losses from
intestinal fi stulas, and a marked infl ammatory response in the setting of sepsis from
perforated diverticulitis or tumor. The infl uence of malnutrition on surgical out-
comes has been increasingly recognized since 1939, when Studley fi rst reported on
the association between preoperative weight loss and mortality in surgical patients
(Studley
1936 ). Improvements in research methodology and refi nement of thera-
peutic methods have led to the establishment of internationally accepted clinical
guidelines on nutrition therapy from the European Society for Clinical Nutrition
and Metabolism (ESPEN) and the American Society for Parenteral and Enteral
Nutrition (ASPEN). In the era of modern colorectal surgery, optimization of the
patient’s nutritional status plays an important role in improving the results of surgi-
cal intervention. This chapter will provide an overview on the nutritional manage-
ment of the colorectal surgery patient.
4.2 Influence of Malnutrition on Surgical Outcomes
The worldwide prevalence of malnutrition in hospitalized patients ranges from 15
to 50 % (Kondrup et al. 2003 ; Sorensen et al. 2008 ; Lim et al. 2012 ; Waitzberg et al.
2001 ), while up to 39 % of colorectal cancer patients are malnourished (Schwegler
et al. 2010 ; Chen et al. 2011 ). Populations around the world are rapidly aging with
a projected World Health Organization (WHO) estimate of two billion people aged
60 years and older by the year 2050 (World Health Organization 2013 ). This popu-
lation has a signifi cant risk of malnutrition, with reported rates of 14 % in nursing
home occupants, 39 % in hospitalized patients, and 51 % in patients undergoing
rehabilitation (Kaiser et al. 2010 ).
In addition to preexisting malnutrition, weight loss tends to occur during the
course of a hospital admission; a UK study of inpatients revealed that 39 % of nor-
mal patients and 75 % of malnourished patients lost an average of 5–10 % of body
weight during their hospital stay (McWhirter and Pennington 1994 ). Adverse hos-
pital routines contribute to this decline; patients are frequently ordered nil by mouth
prior to investigations, meals are served at predetermined times, and hospital food
is often less palatable. The data on prevalence of malnutrition, however, has often
been diffi cult to interpret and compare because of various different methods used
for diagnosis and screening.
In 2012, the Academy of Nutrition and Dietetics and ASPEN released a con-
sensus statement on a standardized set of diagnostic characteristics (previously
endorsed by ASPEN and ESPEN) to be used to identify and document adult
malnutrition with the aim of improving consistency in defi nition (White et al.
2012 ). Malnutrition was defi ned based on the etiology of the condition and
broadly categorized according to the level of infl ammation (Fig. 4.1 ). Six clinical
characteristics which support the presence of malnutrition were identifi ed; at a
4 Transdisciplinary Management of Perioperative Nutrition