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Year : 2022  |  Volume : 15  |  Issue : 4  |  Page : 214-219

Knowledge and attitude of resident doctors towards prehabilitation: An audit in a tertiary care centre

Department of Anaesthesiology and Critical Care, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi, India

Date of Submission14-Aug-2022
Date of Acceptance19-Aug-2022
Date of Web Publication22-Dec-2022

Correspondence Address:
Ruchi Kumari
Department of Anaesthesiology and Critical Care, Maulana Azad Medical College and Associated Hospitals, New Delhi - 110 002
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hmj.hmj_67_22

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Background: Major surgery is associated with a significant decline in the functional capacity of patients. Prehabilitation is the practice of enhancing a patient's functional capacity prior to surgery and thus improving postoperative outcomes. It is a multimodal approach, encompassing medical optimization, preoperative physical exercise, nutritional support, and stress/anxiety reduction. In this audit, we tried to find out how many resident doctors know about prehabilitation and, how they implement it in their patients in routine practice. Aims and Objectives: To study the knowledge amongst resident doctors regarding the role of prehabilitation in surgical patients; and to create awareness and implement quality practices for better post-operative outcomes. Materials and Methods: A questionnaire was prepared on Google docs with multiple choice questions and circulated electronically through emails with the participants. The submitted data were updated on Google docs and analyzed subsequently. Results: One hundred and ninety resident doctors participated in the audit. One hundred seventy residents (89.7%) were aware of holistic multimodal interventions. Three- fourths of residents (150 residents; 78.95%) accurately understood the rationale behind prehabilitation. Most of the residents (183 residents; 96.84%) were aware of preoperative medical optimization. A majority (188 residents; 98.95%) were familiar with the techniques of psychological support to patients. However, the knowledge with regard to the rationale behind prehabilitation and the category of patients requiring it, baseline functional capacity assessment, techniques for exercise intensity optimization, and questions pertaining to nutrition was unsatisfactory. Conclusion: Our audit focuses on the need to enhance the knowledge of resident doctors regarding the prehabilitation program to improve post-operative outcomes in patients.

Keywords: Optimization, prehabilitation, pre-operative risk

How to cite this article:
Kumari R, Bhalotra AR, Singh R. Knowledge and attitude of resident doctors towards prehabilitation: An audit in a tertiary care centre. Hamdan Med J 2022;15:214-9

How to cite this URL:
Kumari R, Bhalotra AR, Singh R. Knowledge and attitude of resident doctors towards prehabilitation: An audit in a tertiary care centre. Hamdan Med J [serial online] 2022 [cited 2023 Feb 1];15:214-9. Available from: http://www.hamdanjournal.org/text.asp?2022/15/4/214/364694

  Introduction Top

Prehabilitation aims at enhancing a patient's functional capacity before surgical interventions and improving post-operative outcomes.[1] This involves physiological assessment of the patient and multidisciplinary workup before surgery. Moreover, it optimises physical and psychological health through the delivery of tailored interventions which includes exercise, nutrition and psychological support. Barriers to the implementation of robust prehabilitation programmes include clinician knowledge, acceptability and programme-related health-care access.[2] Very few studies exist in the literature describing the perceptions and attitudes towards prehabilitation in medical professionals. This audit aims to evaluate existing knowledge regarding prehabilitation among the resident doctors and its implementation into routine practice.

  Materials and Methods Top

The audit was conducted as an online survey. An email invitation with the link to the survey was sent to 190 resident doctors in a tertiary care and teaching hospital. A set of 12 multiple-choice questionnaires was prepared on Google Docs, which was circulated electronically sharing the link with the participants. The database was created and responses were analysed. The questionnaire is present in the supplementary material [Annexure].

Statistical analysis

The survey was imported into a Microsoft Excel spreadsheet for analysis. Simple descriptive statistics were used. Categorical data were presented as frequency distribution – numbers and percentages, and continuous data were presented as numbers.

  Results Top

One hundred and ninety resident doctors participated in the audit. One hundred and seventy residents (89.7%) were aware of holistic multimodal interventions; four residents (2.1%) considered nutrition and psychological support, whereas eight residents (4.1%) opined either medical optimisation or improving pre-operative functional reserve as prehabilitation. Three- fourths of residents (150 residents; 78.95%) accurately understood the rationale behind prehabilitation, whereas one-third of residents (32 residents; 16.84%) considered it a means to improve lung function. For the remaining (8 residents; 4.2%), this facilitated ASA grading or is useful in prognosticating patients. The responses to questionnaire pertaining to patient categories requiring prehabilitation were: only in frail patients (130 residents; 68.4%) and day-care procedures (58 residents; 30.5%). One resident (0.05%) replied negative for well-controlled diabetic patients, yet another resident (0.05%) was affirmative for good exercise tolerance. Almost all residents (183 residents; 96.84%) were aware that pre-operative smoking cessation, management of blood sugars, anaemia, optimisation of weight and pharmacological treatment, are required for pre-operative medical optimisation in a patient. For baseline functional capacity assessment, 122 residents (64.21%) considered the metabolic equivalent of tasks (METs), 40 residents (21.05%) opined for cardiopulmonary exercise testing (CPET) and 26 residents (13.68%) were affirmative for pulmonary function tests (PFT). However, 2 residents (1.05%) thought of using blood gas analysis. The responses to optimisation of exercise intensity were: 112 residents (36.84%) were not sure, 56 residents (29.47%) opted for a stress test, 30 residents (15.79%) for a Borg scale and 2 residents (1.05%) for blood pressure monitoring. However, no one was aware that the Bruce protocol may be used for the optimisation of exercise intensity. Poor nutritional status is directly linked to an increase in infection and mortality rates and was opined by 96 (50.3%) and 80 (41.82%) resident doctors, respectively. Nine residents (4.85%) also thought that it increases the hospital length of stay but only six residents (3.03%) thought that it delays the earlier recovery from anaesthesia. One-hundred and forty residents (73.68%) were aware of perioperative screening of nutritional status while 22 residents (11.58%) were completely unaware of it. However, 28 residents (14.74%) thought that it may be needed in all surgical patients. Seventy-seven (40.51%) resident doctors considered nutritional screening necessary for patients undergoing major surgeries, whereas 64 residents (33.54%) thought that it is mandatory only for the malnourished. However, 45 residents (23.42%) still agreed for its requirement in all surgical patients regardless of the nature of the surgery and nutritional status of patients, whereas 5 residents (2.53%) thought it is required in all patients undergoing outpatient procedures. Regarding responses to optimal timing of starting nutritional support before surgery: 74 residents (38.95%): 3-6 months before; 70 residents (36.84%): 11-15 days prior; 40 residents (21.05%): 7-10 days prior; and 6 residents (3.16%): 4-6 days before surgery. Omega-3 fatty acids and nucleotides were considered by 130 residents (68.42%), whereas amino acids (e.g. glutamine and arginine), glucose and polyunsaturated fatty acids were considered by 34 residents (17.89%). High protein and calories were included by 16 residents (8.42%), whereas 10 residents (5.26%) skipped this question and none were in favour of giving omega-3 fatty acids, nucleotides and fibers as immunonutrition. Almost all resident doctors (188 residents; 98.95%) were aware that a positive attitude, behavioural instructions, relaxation techniques as well as discussion of emotions are required to support the patients psychologically before surgery.

  Discussion Top

This study shows a lack of awareness and knowledge in resident doctors with regard to the rationale behind prehabilitation and the category of patients requiring it, baseline functional capacity assessment, techniques for exercise intensity optimisation and questions pertaining to nutrition (patients requiring screening for nutritional status, the effect of nutrition on post-operative outcomes, the ideal time for nutritional support and components of immunonutrition). Almost all residents were aware of multimodal intervention and psychological support methods.

Prehabilitation is a multimodal strategy which includes – physical exercise and nutritional and psychosocial interventions in the pre-operative period to improve fitness. Its comprehensive aim is to increase the pre-operative functional reserves, resulting in better post-operative functional recovery and a reduced incidence of complications.[3] In this audit, 78.95% of the resident doctors ensured that prehabilitation helps in improving postoperative Quality of Life (QoL), whereas 16.84% thought that it only improves pulmonary functions and thus decreases the incidence of post-operative pulmonary complications.

Evidence suggests multimodal interventions may be more effective than single or sequential interventions, but it is not fully established.[4] Modifications of risk factors such as physical inactivity, smoking, alcohol consumption and increased weight can reduce the risk of perioperative morbidity and improves patient outcomes.[5] In our audit, 89.47% of the resident doctors had an awareness that prehabilitation aims to improve the patient medically, nutritionally and psychologically along with improvements in pre-operative functional reserves.

Prehabilitation includes 'risk prediction to risk attenuation.' It aims to optimise the pre-operative comorbidities pharmacologically along with modifications in the risk factors to increase the physiological reserves with an appropriate time window between diagnosis and surgery.[6]

In practice, the decision to operate or not is made between the surgeon and the patient and/or caregivers. The high risk, frail and old patients are then sent to other physicians (cardiologists, geriatricians and pulmonologists) for further consultation before surgical interventions for patient-specific risk attenuation. Engagement of perioperative physicians to consider prehabilitation represents a transformation from a traditional silo-driven surgeon-centric approach.[6]

To predict the likelihood of a poor outcome, screening is the first and foremost step towards prehabilitation, preceded by a structured assessment of functional capacity and nutritional and psychological status along with laboratory testing.

All patients who are scheduled for major or high-risk surgeries should be evaluated for benefit from prehabilitation programmes. Patients with poor exercise tolerance, frailty and sarcopenia, should be targeted on a priority basis.[3] According to this audit, 68.42% of the doctors ensured that prehabilitation is required only in frail patients, whereas 30.53% ensured that it is required in all patients undergoing day-care procedures.

Pre-operative medical optimisation is simply beyond pre-operative risk assessment which aims to improve surgical outcomes. It targets patients with pre-existing physiological compromises in whom physiologic reserves can be improved to better withstand the planned surgical interventions. It focuses on optimising cardiopulmonary status, frailty management, medication management, glucose control and cessation of smoking.[7] This audit suggested that 96.84% of the resident doctors were aware that pre-operative smoking cessation, management of blood sugars, anaemia, optimisation of weight and pharmacological treatment, all are required for pre-operative medical optimisation.

Ageing, comorbidities, physical fitness and nutritional and psychological status are the main determinants of functional capacity. Pre-operative functional capacity in cancer patients is found to be weakened by several factors such as malnutrition, cachexia, sarcopenia, frailty, depression, anxiety, anaemia and treatment-related factors such as chemotherapy, radiotherapy and/or surgery. Multiple tools could be useful when patients have physical limitations that prevent daily activities such as – cardiopulmonary exercise testing (CPET), Metabolic Equivalents of Tasks (METs), 6-min walk test, Duke Activity Status Index and recently, N-terminal pro-B-type natriuretic peptide.[8]

CPET is considered the gold standard for cardiopulmonary status and provides objective information on cardiopulmonary function. It determines oxygen consumption at the anaerobic threshold and the peak oxygen consumption and thus provides information about the patient's ability to withstand the increased metabolic demand induced by surgical stress.[8]

According to our audit, 64.21% of residents opined that METs can be used for the assessment of functional capacity, whereas CPET and PFTs were suggested by 21.05% and 13.68%, respectively.

The majority of prehabilitation programmes focus on improving functional capacity through structured exercise programmes such as combinations of aerobic exercise, resistance training and inspiratory muscle training.[9] In this audit, 36.84% were not sure about any of the methods of optimisation of exercise intensity.

A combination of strength and aerobic exercises is foremost for muscle strength and cardiopulmonary reserves which decline in the post-operative period. Optimisation of exercise intensity can be done using the Borg scale or by monitoring the heart rate. In our audit, only 15.79% of the residents were aware of the use of the Borg scale, which is a subjective tool used during exercise to assess how strenuous the exercise feels like. It correlates well with heart rate, ventilatory frequency, serum lactate and percentage maximal oxygen consumption (VO2 max). Patients perceived barriers such as – pain during exercise, the financial burden of logistics and negativism for physical activities have to be reduced by creating an environment that facilitates their engagement.[1]

Inadequate intake and metabolic or inflammatory changes may lead to muscle wasting, cachexia, decreased fitness and reduced metabolic reserves. The primary purpose of nutritional prehabilitation is to restore nutrient and metabolic reserves pre-operatively and to provide a buffer to compensate for the catabolic response during surgery. Appropriate nutritional interventions during the pre-operative period have been shown to improve the perioperative gastrointestinal and oncological surgery outcomes, especially surgical site infections.[10],[11],[12],[13]

Various screening tools for nutritional assessment have been developed such as Subjective Global Assessment (SGA) and the Patient-Generated SGA screening tools are the most documented tools in the oncology literature.[14]

Others are – the Malnutrition Universal Screening Tool, the Malnutrition Screening Tool, Nutrition Risk Screening 2002 and the Short Nutrition Assessment Questionnaire©. Recently, a novel Perioperative Nutrition Screen score (PONS) has been proposed.[15]

When oral nutrition is not able to meet the protein and caloric requirements in malnourished patients, enteral supplementation should be preferred over parenteral, whenever possible. A period of 7-14 days for parenteral nutrition[16] and 7-10 days for enteral nutrition[11] is recommended. If parenteral nutrition is required, it should be combined with enteral or oral nutrition whenever possible.[16]

Nutritional interventions include – pre-operative carbohydrate loading, which reduces insulin resistance, promotes abolishment, minimises protein loss, and lean body mass and muscle function. A daily protein intake of 1.5 g/kg ideal body weight is required in patients undergoing surgery to limit nitrogen losses.[11] Immunonutritions such as amino acids (e.g., glutamine and arginine), omega-3 fatty acids and nucleotides counteract hyperinflammation and immune function impairment, caused by surgical stress, promote wound healing and reduce infection rates.[11] Such types of regimens should be commenced 5-7 days before surgery and should be continued for a similar period post-operatively in the malnourished.

Diagnosis, surgery, anaesthesia, pain, survival and recovery, all contribute towards the aetiology of fear in patients awaiting surgery. Pre-operative psychological interventions have an impact on immunologic, psychological and QoL outcomes. However, the mechanism is not known, although the effect of psychological stress on wound healing and immune function is well-documented.[17],[18],[19],[20]

The psychosocial stressor immune dysregulation through the immune-brain loop, functions the same way that produces surgical stress response.[21] Psychological interventions provide sensory information or 'guided imagery' (how the perioperative experience will feel like), cognitive interventions – development of a positive attitude, behavioural instructions on what can be done for a better outcome, relaxation techniques (breathing, meditation and hypnosis) and progressive muscle relaxation (sequential tensing and relaxing). Other psychological interventions such as providing procedural information (details of all the aspects of the patient journey) and emotion-focused interventions like the discussion of emotions show the most ubiquitous effects in improving measures of post-operative recovery.[22]

  Conclusion Top

Our audit focuses on the need to enhance the knowledge of resident doctors regarding the prehabilitation programme to improve post-operative outcomes regarding baseline functional capacity assessment, techniques for exercise intensity optimisation and questions pertaining to nutrition.

Ethical Clearance

The study was approved by the Institutional Ethics Committee of Maulana Azad Medical College, New Delhi; Approval No.: F. No./11/IEC/MAMC/2021/517.

Declaration of participant consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consents for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  Annexure Top

1. What does prehabilitation involve?

  1. Medical optimisation
  2. Nutritional interventions
  3. Psychosocial optimisation
  4. Improving pre-operative functional reserves
  5. All of the above.

2. What is the rationale behind prehabilitation?

  1. To improve post-operative Quality of Life
  2. To improve lung function and decrease post-operative pulmonary complications
  3. To facilitate ASA grading
  4. To prognosticate the patient.

3. Which patients need prehabilitation?

  1. All patients undergoing day-care surgical procedures
  2. Patients with good exercise tolerance
  3. Frail patients
  4. Well-controlled diabetic patients.

4. How is medical optimisation done? (More than one answer may be ticked)

  1. Pre-operative smoking cessation
  2. Weight optimisation
  3. Management of anaemia
  4. Control of blood sugars
  5. Optimisation of pharmacological treatment
  6. All of the above.

5. How is a baseline assessment of functional capacity done?

  1. Cardiopulmonary exercise testing (CPET)
  2. Pulmonary function tests (PFT)
  3. Blood gas analysis
  4. >4 Metabolic Equivalent of Tasks (METs).

6. How can optimisation of exercise intensity done?

  1. BP monitoring
  2. Use of the Borg scale
  3. Use of the Bruce protocol
  4. Stress testing
  5. Not sure.

7. How does poor nutritional status affect the perioperative outcome? (More than one answer may be ticked):

  1. Increase in hospital stay
  2. Increase in infection rates
  3. Increase in mortality rates
  4. Delay in recovery from anaesthesia.

8. Do you think that screening of nutritional status should be done perioperatively in all surgical patients?

  1. Yes
  2. No
  3. May be.

9. Screening should be done on which type of patients? (More than one answer may be ticked):

  1. Patients undergoing major surgery
  2. Malnourished patients
  3. Patients undergoing outpatient procedures
  4. All of the above.

10. What should be the ideal time required to support nutrition in pre-operative period?

  1. 4-6 days
  2. 7-10 days
  3. 11-15 days
  4. 3-6 months.

11. Components of immunonutrition include:

  1. Amino acids (e.g., glutamine and arginine), omega-3 fatty acids and nucleotides
  2. High proteins and calories
  3. Amino acids (e.g., glutamine and arginine), glucose and polyunsaturated fatty acids
  4. Omega-3 fatty acids, nucleotides and fibres.

12. How can psychological support be given to a patient?

  1. Development of a positive attitude
  2. Behavioural instructions
  3. Relaxation techniques
  4. Discussion on emotions
  5. All of the above.

  References Top

Banugo P, Amoako D. Prehabilitation. BJA Educ 2017;17:401-5.  Back to cited text no. 1
Shukla A, Granger CL, Wright GM, Edbrooke L, Denehy L. Attitudes and perceptions to prehabilitation in lung cancer. Integr Cancer Ther 2020;19:1534735420924466.  Back to cited text no. 2
Carli F, Gillis C, Scheede-Bergdahl C. Promoting a culture of prehabilitation for the surgical cancer patient. Acta Oncol 2017;56:128-33.  Back to cited text no. 3
Durrand J, Singh SJ, Danjoux G. Prehabilitation. Clin Med (Lond) 2019;19:458-64.  Back to cited text no. 4
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Britton-Jones CA. Prehabilitation. Br J Hosp Med (Lond) 2017;78:729.  Back to cited text no. 9
Drover JW, Cahill NE, Kutsogiannis J, Pagliarello G, Wischmeyer P, Wang M, et al. Nutrition therapy for the critically ill surgical patient: We need to do better! JPEN J Parenter Enteral Nutr 2010;34:644-52.  Back to cited text no. 10
Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, et al. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr 2017;36:623-50.  Back to cited text no. 11
Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr 2003;22:235-9.  Back to cited text no. 12
Kassin MT, Owen RM, Perez SD, Leeds I, Cox JC, Schnier K, et al. Risk factors for 30-day hospital readmission among general surgery patients. J Am Coll Surg 2012;215:322-30.  Back to cited text no. 13
da Silva Fink J, Daniel de Mello P, Daniel de Mello E. Subjective global assessment of nutritional status – A systematic review of the literature. Clin Nutr 2015;34:785-92.  Back to cited text no. 14
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Andersen BL, Farrar WB, Golden-Kreutz D, Kutz LA, MacCallum R, Courtney ME, et al. Stress and immune responses after surgical treatment for regional breast cancer. J Natl Cancer Inst 1998;90:30-6.  Back to cited text no. 17
Andersen BL, Farrar WB, Golden-Kreutz DM, Glaser R, Emery CF, Crespin TR, et al. Psychological, behavioral, and immune changes after a psychological intervention: A clinical trial. J Clin Oncol 2004;22:3570-80.  Back to cited text no. 18
Antoni MH, Lutgendorf SK, Cole SW, Dhabhar FS, Sephton SE, McDonald PG, et al. The influence of bio-behavioural factors on tumour biology: Pathways and mechanisms. Nat Rev Cancer 2006;6:240-8.  Back to cited text no. 19
Christian LM, Graham JE, Padgett DA, Glaser R, Kiecolt-Glaser JK. Stress and wound healing. Neuroimmunomodulation 2006;13:337-46.  Back to cited text no. 20
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