Background
Prehabilitation prior to major surgery aims to optimise preoperative conditioning and has been recognised to have improved physical and functional post-operative outcomes. However, implementation of a multimodal prehabilitation programme is complex and challenging. This study aims to evaluate the implementation of a coordinated prehabilitation programme, SUrgical PREhabilitation for coMprehensive Enhanced recovery (SUPREME), in our local colorectal unit.
Methods
The SUPREME programme adopts a multimodal, coordinated system unifying services including blood management, sarcopenia screening, physiotherapy, nutrition, risk factor modification, geriatric evaluation and anaesthetic assessment via patient coordinators. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, an implementation science model for evaluation, was used to assess the fidelity and effectiveness of the programme since its inception in August 2022. 3-monthly audit and in-person panel discussions with key stakeholders identified implementation barriers and enablers using the constructs of the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) model.
Results
Four key themes emerged from 3-monthly iterations of the RE-AIM model contributing to limited programme fidelity and effectiveness: 1) Lack of stakeholder engagement; 2) Difficulty coordinating and monitoring multidisciplinary interventions; 3) Attrition of coordinators and 4) Cost. Application of the i-PARIHS framework further evaluated current barriers and informed key enablers: 1) Marketing programme value through patient champions, enhanced surgeon/coordinator communication and visual aids; 2) Optimising information technology for monitoring of interventions and improving staff training; 3) Coordinator recognition by programme leads and visible patient ownership through wearable technology and repeated measures; 4) Philanthropic funding, management investment and economic benefit of enhanced patient outcomes. These informed implementation strategies including: 1) Improving patient compliance through better understanding of repeated measures and its influence on outcomes; 2) Developing stakeholder inter-relationships through academic partnerships and collaborative research to pool resources; 3) Providing coordinators with training to optimise facilitation and improve patient buy-in; 4) Regular audit and reporting patient outcomes to improve clinician onboarding.
Conclusion
Multimodal prehabilitation is important to optimise patients before major colorectal surgery for improved patient outcomes. Implementation of a complex multidisciplinary programme can be difficult, however, a systematic and methodical approach, guided by implementation science, can help identify key barriers and facilitators which can inform targeted strategies for successful implementation.
