Name: Surgeon: Surgical Procedure:

[Pages:18]January 2020

Name: _____________________________________________________ Surgeon: ___________________________________________________ Surgical Procedure: ___________________________________________ ___________________________________________________________ Surgery is scheduled for: Date: ___________ Time: _______ GBMC Location: ______________

? Patients UNDER 12 years of age, arrive 1 hour prior to scheduled surgery. ? Patients OVER 12 years of age, arrive 2 hours prior to scheduled surgery in the

Virginia Sherwood General Operating Room and 1 1/2 hours prior to surgery in the Women's and Outpatient Surgical Center.

**Bring the Packet with you to ALL appointments regarding surgery**

For Questions about the Enhanced Recovery Program Please Contact: Rachel Hellmann MSN, RN, CNOR

Office: (443)468-1642 Office Hours: Monday-Friday 8am-430pm 1

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TABLE OF CONTENTS GBMC ENHANCED RECOVERY PATHWAY PRE-OPTIMIZATION GRID (OFFICE USE).................................3-4 PRE-ADMISSION TESTING....................................................5 PERSONALIZED ENHANCED RECOVERY PATHWAY....................6 SURGERY TIMELINE.............................................................7-11 SHOPPING LIST AND PURCHASING OPTIONS...........................12 FUELING UP FOR SURGERY..................................................13 DEEP BREATHING EXERCISE AND HIBICLENS/CHG WASH..........14 DIRECTIONS.......................................................................15 MAP AND GENERAL REMINDERS...........................................16 RESOURCES.......................................................................17-18

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Patient Name Patient Date of Birth Date Filled Out:

IF Yes, take the following action in reference to the Preoperative Optimization Grid

Yes

No Weight >300 lbs

Diabetes: If yes, do you take Metformin, Glucophage, Glucovance, Insulin, or

Yes

No have an insulin pump?

Yes

No High Blood Pressure

Yes

No Pacemaker or AICD (Internal Defibrillator)

Yes

No Positive PPD- screening test for tuberculosis (positive tuberculosis/TB)

Yes

No Chronic Obstructive Pulmonary Disease, Sever Asthma, Shortness of Breath

Yes

No Liver Disease, Hepatitis

Yes

No Kidney Disease, Kidney Transplant, Dialysis, Chronic Renal Insufficiency

Yes

No Stroke in the last 6 weeks

Date:

Yes

No Do you have Sleep Apnea?

Yes

No Smoker or Former Smoker? How Much?

How Long?

Yes

No Alcohol or Drug Abuse

Yes

No On Aspirin or blood thinners

Yes

No Diuretic Use (Lasix, HCTZ, Fluid Pills)

Yes

No Are you currently on steroids, either oral or inhaled?

Cardiology

Are you under the care of a Cardiologist? Y N

Name of Physician

Have you had any of the following Cardiac Events in the last year? Angina, Heart Failure, Heart Attack (MI), Arrhythmia, Atrial Fibrillation, Angioplasty, Cardiac Stent

2. g. 2. h. Pump agreement form is required for insulin pumps 1. a. 1. d. *Notify Posting* 2. a. 2. f. 2. c. & 2. d. *Include in H&P 2. b.

2. f. 3. a 3. b. *Notify Posting*

Y N

1. b or 1.c. or 1.d. or 1.e

Pulmonary

Are you under the care of a Pulmonologist? Name of Physician

1.e. or 2.a.

Power of Attorney

Please provide and scan all Power of Attorney Documentation into EPIC

Perioperative Testing Center (PTC) at GBMC 6535 N. Charles Street, Physician Pavilion North

Suite 425 Towson MD 21204

(443) 849-3461

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Pre-Surgical Testing Center

GBMC Campus North Pavilion- Suite 425

443-849-3461- Phone

Pre-Admission Testing

GBMC highly recommends you use the GBMC Pre-Surgical Testing Center for your pre-

surgical evaluation

Patient:

Surgery Date:

Hospital:

Type of Surgery:

Please perform the following PRE-ADMISSION TESTING to fulfill ANESTHESIA REQUIREMENTS

Complete History and Physical: Within 30 days of surgery. EACH page must state date of service, patient's name, DOB and physicians signature.

EKG: Within 60 days of surgery if risk factors OR 12 months if no risk factors. Must state patients name, DOB, and physicians signature and date of service on EKG interpretation o 60 Days: History of high blood pressure, Weight >300lbs/ BMI >39, Diabetes, Cardiovascular disease, sleep apnea with use of CPAP machine.

Cardiac Clearance: Within 12 months for stable risk factors. Within 30 days of surgery for any cardiac event within the last year (i.e.: chest pain, new atrial fibrillation or other arrhythmia, Heart Failure, cardiac surgery, or angioplasty)

Chest X-Ray: Acute moderate or severe COPD or Acute CHF ECHO within 24 months for a patient with asymptomatic aortic stenosis, pulmonary hypertension, heart

failure.

Bloodwork within 60 days of surgery

Amylase & Lipase: Basic Metabolic Panel: CBC with Platelet: Hemoglobin A1C (all Diabetics): PT, PTT: Serum HCG (within 7 days): Urinalysis: Sodium and Potassium within 24 hours:

ALL Pre-admission testing paperwork MUST BE Faxed to your surgeon's office AND GBMC Pre-Surgical Testing 72 hours prior to surgery to avoid cancellation.

Surgeon FAX: _____________________

GBMC FAX: 443-849-3013

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Pre-Surgical Personalized Enhanced Recovery Pathway Educator or Surgeon will check the boxes that apply to you:

Practice Deep Breathing Exercises Use Incentive Spirometer Increase Exercise See Exercise Trainer See Dietician Shower with Hibiclens/CHG Solution (Theraworx if CHG allergic) Drink Ensure Immunonutrition before and after surgery Drink Ensure Pre-Surgery night before surgery Drink Ensure Pre-Surgery morning of surgery Complete Bowel Preparation (circle choice)

Miralax _______________________ Dulcolax ______________________ Other _________________________ Take Oral Antibiotics (circle choice) Neomycin Cipro Flagyl Erythromycin

*Ensure Pre-Surgery is fat-free, gluten-free, suitable for lactose intolerance, Kosher, Halal. It is NOT recommended for people with Galactoremia.

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Surgery Timeline

Follow this timeline based on the medications you currently take, and the Enhanced Recovery Pathway created for you:

Consult your Primary Care Physician or Cardiologist if you are taking

Blood thinners (Coumadin, Xarelto, Plavix, Warfarin, Celebrex, Pradaxa, or Eliquis).

Aspirin or salicylates including Alka-Seltzer and Pepto-Bismol. Non-Steroidal Anti-inflammatory Drugs (NSAIDS):

Ibuprofen Advil Motrin Aleve Naposyn Naproxen Excedrin

Meloxicam Mobic Etodolac Duexis (ibupfoen/famotidine) Vimovo (naproxen/esomeprazole) Treximet (sumatriptan/ naproxen)

Consult your Primary Care Physician if you are taking Erectile Dysfunction Drugs (Viagra, Cialis, or Levitra). Consult your Primary Care Physician if you are currently on Hormone Replacement Therapy. Consult your Primary Care Physician and/or Endocrinologist if taking insulin or using an insulin pump. TAKE Heartburn/Ulcer medications/acid blockers (Axid, Pepcid, Prilosec, Propulsid, Reglan and Zantac) TAKE Anti-depressants

TAKE Anti-anxiety medications

TAKE Psychiatric medications

TAKE Anti-Seizure medications

TAKE Asthma Inhalers/medications

TAKE Birth Control Pills

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TAKE Eye Drops TAKE Thyroid medications TAKE Cholesterol medications TAKE Blood Pressure medications except for Angiotensin Converting

Enzyme (ACE) inhibitors and Angiotensin Receptor Blockers (ARB)s (See Pg. 7 included in this packet) Try to increase walking/exercise to 30 minutes a day. If you have not already, stop smoking cigarettes/cannabis, vaping Perform Daily oral care-Brush your teeth 3-4 times a day to reduce risk of developing pneumonia and other associated infections Eat a healthy diet ? this helps you to recover faster Appoint a friend or a family member to be your support person. This person can help you prepare for surgery and can also help you recover by picking up your prescriptions, shopping, completing household tasks.

STOP All diet/ weight loss medications (Phentermine, Glucomannan, CLA (conjugated linoleic acid), Orlistat (Alli), Garcinia cambogia, Hydroxycut, Raspberry ketones, Meratrim, green tea extract, Forskolin, Synephrine)

STOP All herbal medications and non-vitamin supplements (Fish oil/Omega Vitamin E, Glucosamine, Gingko Biloba, Garlic, Ginseng, Tumeric, CoQ10)

Start Protein shakes if recommended by your surgeon. Do NOT Shave.

Nardil [Phenelzine], Emsam

[Selegline], Marplan [Isocarboxazid], Parnate [Tranylcypromine].

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