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Research Documenting Improved Surgical Outcomes
Using Hypnotherapy and Mind-Body Techniques

Abstract An increasing focus on cost-containment in medical care has drawn attention to both provider and patient factors which can reduce health care utilization. Surgical procedures are costly interventions physiologically, emotionally and financially and may create significant risks of pain, discomfort and medical complications. The purpose of this randomized controlled study of patients undergoing total knee-joint replacement was to examine by group the cost-effectiveness of Huddleston’s protocol of mind-body techniques on length of stay and selected measures of anxiety prior to surgery. Huddleston’s protocol consists of 1) relaxation 2) visualization 3) forming a support group and 4) use of therapeutic statements during surgery. Each of these techniques has been documented to improve surgical outcomes when implemented individually. This study investigated the benefits that accrue when the four techniques are used synergistically. Forty-four subjects comprised the study sample. They were recruited from the New England Baptist Hospital, a Tufts University Medical School teaching hospital. Twenty control group subjects received traditional medical care and twenty-four intervention group subjects received a one-hour Prepare for Surgery, Heal Faster Workshop, book and relaxation audio-tape as their instruction. Descriptive statistics revealed a significant difference in the length of stay between the two groups. The mean number of hours for the control group was 114.29 (4.75 days) and 82.75 (3.44 days) for the experimental group, Mann-Whitney U 105.5, p=0.000. In addition, using the Spielberger State Trait Inventory Scale (STAI) subjects receiving the intervention had less anxiety during the study period when compared to the control group. The mean anxiety (state) scores decreased over time for the experimental group and there was a significant interaction of group by time. The General Linear Model repeated measure, revealed F=5.075, p=.032. A visual analog scale to measure anxiety over the 3 time periods revealed similar significant results. Between groups, no significant differences were found by body surface (BSA), smoking and on 11 medical conditions (stroke, MI, amputation, circulatory problem, asthma, stomach condition, depression, seizures, alcohol and drug use). No significant differences were found in the demographics using the Mann-Whitney test statistic on: marital status (married vs. other); job (working vs. not working); gender (males vs. female); age; education (HS graduate vs. not HS graduate); and income ($20,000). These results are both statistically significant and clinically relevant indicating that the intervention group was discharged from the hospital one-and-a-third days (31.54-hours) sooner than the control group. Implications include the value of Huddleston’s workshop, book and audio-tape as a multidimensional four-step, mind-body intervention to reduce patient anxiety prior to surgery and length of stay in the hospital. Since clinical use of the investigated intervention reports a reduction in post-surgical nausea, lessening in use of pain medication and increase in patient satisfaction, these outcome measures will be included in future trials of the intervention. Benjamin E. Bierbaum, MD, former Chief of Orthopedic Surgery, New England Baptist Hospital

Cost-Effectiveness of Using Mind-Body Techniques
for Total Knee-Joint Replacement

Margaret M. Huddleston and Benjamin E. Bierbaum

The Power of Relaxation: A Holistic Approach to Preoperative Patient Education

Abstract Principal Investigator: Merrie Watters, M.S., R.N., CNOR Co-investigators: Judith Feldman, M.D., David Schoetz, M.D., F.A.C.S., Mary Abrams, R.N., Cynthia Goy, R.N., Marie Catman, M.S., R.N., Peggy Huddleston, M.T.S. The Lahey Clinic, Burlington, MA Purpose of the Study The psychological, spiritual and physiological effects of stress on surgical patients are well documented in nursing and medical literature. Most preoperative education programs focus on cognitive and psychomotor content, overlooking the affective domain of learning. The purpose of this study was to evaluate outcomes for patients using a preoperative stress reduction program, “Prepare for Surgery, Heal Faster” in conjunction with standard preoperative education, compared to patients using only standard preoperative education. Outcomes measured included: Pre-operative calmness Post-operative calmness Postoperative irritability Postoperative headache Postoperative insomnia Postoperative nightmares Postoperative appetite Postoperative pain Use of pain medication Satisfaction Length of stay Description and Methodology Using an experimental design, a systematic random sample of 56 adult patients scheduled for major colon-rectal surgery was studied. Patients were enrolled at least one week before surgery. Experimental patients used, “Prepare for Surgery, Heal Faster,” TM a program developed by Peggy Huddleston, which included a book, Relaxation audiotape and a 1-hour telephone workshop. Data collection included three scripted telephone interviews, and retrospective chart reviews. Postoperative stress related symptoms were measured using a Likert type self-reporting scale. Descriptive statistics were used for demographic data. The Mann-Whitney U test and a 1-tailed T-test were used for length of stay and use of pain medication. ANCOVA was used to determine if differences between the two groups was due to age, which was not statistically significant. Results Clinically significant differences were found in all outcomes measured. Several statistically significant differences between the two groups were also found. Experimental patients were significantly calmer preoperatively and discharged 1.6 days sooner than the control group. This resulted in a savings of approximately $3,200 per patient. Two days after discharge they had significantly less postoperative irritability, insomnia, nightmares and loss of appetite, and were using 60% less pain medication. Perioperative Nursing Implications “Prepare for Surgery, Heal Faster” TM is a cost-effective and therapeutic approach to preoperative patient education that facilitates recovery and empowers the patient as a full partner in the healing process. It has direct applications as a quality improvement initiative for both patient safety and pain management. Watters, R.N.

A Pilot Study for a Randomized, Controlled Trial on the Effect of Guided Imagery in Hospitalized Medical Patients

At the Beth Israel Deaconess Medical Center, a Harvard Medical School teaching Hospital, a study with 23 hospitalized patients not having surgery documented that patients using self-hypnosis twice a day for 20-minutes for two days had a reduction in anxiety, used less medication for anxiety and a significant improvement in heart rate variability. Russell S. Phillips, MD, Chief of Medicine was a co-investigator. The findings were published in Journal of Alternative and Complementary Medicine, March 2007.

A Meta-Analysis of 191 Studies with 8,600 Surgical Patients

A meta-analysis of 191 studies with 8,600 patients documents that patients who prepared for surgery had improved postoperative outcomes such as a reduction in use of pain medication, less blood loss, fewer surgical complications and shorter length of stay. These outcomes were the same for men and women, old and young from different geographical locations. This analysis was undertaken by Elizabeth C. Devine, professor of nursing at the University of Wisconsin School of Nursing. (Devine & Cook 1983,1986,1992a,b). A meta-analysis of 68 studies with 4,018 patients, (2,413 received preoperative instruction and 1,605 control group subjects), documentated a significant improvement in speed of recovery, length of hospital stay and use of pain medication. “Their outcomes were 20% better than those not receiving preoperative instruction (Hathaway 1986).” Donna Hathaway, an assistant professor in the School of Nursing at the University of Tennessee conducted the meta-analysis. Another meta-analysis of 34 controlled studies with 3,254 patients facing surgery or recovery from heart attack showed that “patients who are provided information or emotional support to help them master the medical crisis do better than patients who receive only ordinary care.” Psychological and behavioral interventions reduced length of stay by an average of 2.4 days.” Emily Mumford, Ph.D. and her associates at the University of Colorado undertook this quantitative review (Mumford, 1982). These findings suggest that patientinitiated psychological techniques may benefit the surgical patient’s physical and emotional well-being. In addition, the reduced length of stay may result in signicant savings in hospitalization costs.

Use of Prepare for Surgery, Heal Faster in Oncology Surgical Patients

Roger Maris Cancer Center, Fargo, ND

Cheryl Hysjulien, RN, PsyD and Andrea Paradis, 500 ERYT, AYS, CRMT, LR

Background Surgery is stressful. (Ramsay, 1972) With the addition of a cancer diagnosis, stress grows exponentially. Prepare for Surgery, Heal Faster (PSHF) is a five-step program developed by Peggy Huddleston to prepare patients for the stress of surgery using mind-body techniques of relaxation, healing imagery and hypnotic statements. Additionally, it incorporates the use of community support. PSHF is an evidence based program that decreases pain, need for pain medications, surgical complications and promotes quicker recovery. Enhanced Recovery After Surgery (ERAS) is a multi-modal, evidence based treatment program to improve outcomes for surgical patients. “Central to this mission is a culture of inclusivity and the recognition of the importance of multi-professional and multi-disciplinarian collaboration.” (ERAS USA, 2019) PSHF is qualified to be part of the Pre-Operative portion (patient counseling) of ERAS. Purpose: the purpose of this poster is to provide information on implementing an evidence-based, stress reduction program to be used to assist surgical patients in healing and decrease narcotic use and complications. It will demonstrate the importance of interdisciplinary cooperation to improve perioperative care and enhance post-operative recovery. Methods Recruitment: Purposeful sampling through regional Sanford facility. Participants were self-selected after being approached. Participants: Cancer patients, prior to receiving cancer related surgery. Protocol: Two staff members trained under Peggy Huddleston and provided individual patient instruction. Interested breast cancer surgeon collaborated in pilot program. Initiated group class for breast surgery patients. Formalized the process for referral and monitoring outcomes. Created intentional relationship with Nurse Navigators to grow referrals to group class as well as private instruction. Positive patient report to anesthesia generated initial discussions between ERAS and PSHF groups. Education and demonstration for staff. Patients’ level of stress was measured at: pre/post class instruction and immediately prior to surgery. Outcomes • Even though this study had limitations (ie. no post-op data, lack of understanding of importance of stress reduction before surgery, etc) results show increase of patient referrals and decrease of patient stress/anxiety. Furthermore we were able to identify barriers and solutions to implementing this integrative program within a hospital. Much of the growth hinged on collaboration between teams, staff education and awareness of expansion opportunities. • The program grew exponentially with the PSHF and ERAS teams working together. Referrals grew by an estimated 150% due to assistance from Nurse Navigators and surgeon’s nurses. Through the positive outcomes from breast surgical patients, the Head and Neck team at RMCC approached the PSHF team to begin implementing the program with their surgical patients. • Our data demonstrates significant improvement in patient stress/anxiety measures pre and post the PSHF class. This shows the importance of continuing to nurture collaboration and implement this program with all oncology patients requiring surgery. Implications Implications for patients: Reduces stress and anxiety associated with surgery. Increased comfort to adhere to steps of program due to interdisciplinary support. Anecdotal evidence shows increase of patient satisfaction through surgical process. Implications for professionals: Skillful negotiation with multidisciplinary team members is essential to the success of the implementation of this program. More group collaboration and efficient communication is necessary to improve outcomes. Anecdotally systematic and cultural factors affected fulfillment of outcome measures. Moving forward, addressing these systematic and cultural factors will be critical for success and program growth. Interdisciplinary collaboration demonstrated an increase in referrals. Barriers and Resolutions Physician Unfamiliarity with research behind mind body techniques and positive impact on pain management, stress, surgical recovery, etc. A number of surgeons were reluctant to “make” patients attend classes. Initially educate and work with one breast surgeon. Expand the program to all breast surgeons via education. Talk about the benefits for patients at case conference presentations. Receive patient to physician endorsements. Nursing May be hesitant to support patients’ participation in PSHF and data collection for PSHF. Lack of knowledge and understanding of the importance of the impact of the mental state going into surgery. Provide multiple opportunities for staff to learn about PSHF, including demonstrations of PSHF sessions. Regularly assess compliance of referrals from surgeons’ nurses. Design an online survey for postoperative data collection for future use. Anesthesia department Some anesthesiologists and nurse anesthetists were reluctant to participate in the portion of PSHF that involved them reading the patients statements due stated time constraint. Engage physician champion (i.e. professional ally) in anesthesia. Empower patients during PSHF class to request statements to be read while under anesthesia. Statements can be read by CNAs, Nurses or any member of the surgical team. Enhanced Recover After Surgery (ERAS) Protocol Pre-operative Phase •Patient counseling •Avoid bowl preparation • Minimize fasting • Pre-medications Intra-operative phase Avoid NG tubes Short acting anesthetics Intra-operative analgesia Goal directed fluids Avoid drains Intra-operative warming Post-operative care pathways Non-opiod analgesic PONV protocol Post-operative phase • Early mobilization • Early catheter removal • Early oral feeding • Audit • Follow up Prepare for Surgery, Heal Faster (PSHF) Protocol Step 1 Relax to Feel Peaceful Patients are taught the importance of stress reduction on the outcomes of surgery. Step 2 Visualize Healing With the help of class leader, patient creates three distinct imageries related to the healing process; 1. Immediately after surgery. 2. Intermediate healing. 3. Complete recovery. Patient is provided a CD to listen to a relaxation track twice a day which includes progressive muscle relaxation, safe place imagery and their personalized recovery imagery. Step 3 Organize a Support Group Patient organizes a support group within their own community and asks them to send them a personalized version of positive thoughts (blanket of love, prayers, positive thoughts, etc) 30 minutes before their surgery. Step 4 Healing Statements The patient personalizes healing statements that will be read by a surgical team member as they go under anesthesia and at the end of surgery. Step 5 Meet the Surgical Team Prompt patient to create relationships with their surgical team prior to surgery.

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