The Strong for Surgery program includes checklists that target eight areas, including four lists that were released in November 2018. In addition to nutrition, glycemic control, and medication management, the new targets are safe and effective pain management after surgery, delirium, prehabilitation, and patient directives. (Editor’s Note: More details about each area are available at:

The program’s goal is to help every patient in need of surgery and to ensure the patient is strong enough to experience the best possible surgical outcome, says Thomas K. Varghese, Jr., MD, MS, FACS, a co-creator of the program. “If a patient is not strong for surgery, what can we do to help the patient prepare?”

Pain management is one of the new areas of focus because of the nation’s opioid epidemic. Prehabilitation addresses patient frailty, says David R. Flum, MD, MPH, FACS, professor of surgery at the University of Washington.

“With patient directives, we’re thinking about shared decision-making and making sure patients’ preferences are being incorporated,” Flum says.

Varghese and Flum offer further details about the new target areas and how ASCs can use the Strong for Surgery toolkit to address these issues:

Blood sugar control. “We know in the Medicare patient population that two out of four patients are diabetic,” Varghese notes. “Another one out of four is prediabetic, which is when the patient has normal blood levels, but whenever faced with stress, such as surgery, the patient will respond with elevated blood sugar levels.”

If surgeons wait until the prediabetic patient presents with high blood sugar levels, then the patient’s risk of infection has already increased, he warns. “We say, ‘Here are things for known diabetics to make sure their blood sugar is controlled, and we don’t want to miss out on screening prediabetics,’” Varghese says.

Patients’ glycemic levels can be controlled in the ambulatory surgery setting, but physicians need to be aware of these potential problems. Strong for Surgery encourages physicians to make glycemic control part of the pre-op preparation, including directing patients to meet with a primary care provider or specialist.

Prehabilitation. Physical fitness and nutritional status are underaddressed and modifiable risk factors for surgery patients. According to a new study, surgical patients are at risk for frailty, sarcopenia, and reduced physical fitness. The authors concluded these patients could benefit from exercise-based prehabilitation activities designed to improve aerobic fitness.1

Prehabilitation programs help patients improve their health before surgery so their postoperative recovery will be optimal. The Strong for Surgery program explains in layman terms that prehabilitation is “to get you to a better place physically before an operation.”

Program guidelines also advise patients that better fitness and a higher level of activity before surgery generally leads to better outcomes after an operation. (Editor’s Note: A detailed list of presurgery tips clinicians can share with patients is available at: The authors of a study about prehabilitation efforts (including muscle training, aerobic exercise, and/or resistance training) prior to intra-abdominal operations concluded that such efforts were beneficial in decreasing the incidence of postoperative complications.2

Nutritional optimization. “We’re coming to realize surgery is a stressful period for people, and some people’s bodies are depleted by surgery,” Flum says.

For instance, patients might be low on amino acids that help the immune system fight infections. Flum worked on a study of elective colorectal surgery patients and use of arginine supplementation. Flum and colleagues found that an arginine-based immunonutrition approach resulted in significantly fewer readmissions and hospital days for the intervention group and lowered risk for infections and venous thromboembolism. Total costs also were lower.3 Nutritional optimization also addresses undernourishment and obesity.

“Some people forget that some obese patients might be malnourished,” Varghese notes. “They might not get the appropriate protein energy they need.”

Other patients may only need to consider losing weight prior to a procedure.

Medication reconciliation. “If you ask patients what medications they are taking, most will say, ‘Here are my prescription medications,’” Varghese says, noting that patients sometimes forget about vitamins, over-the-counter drugs, and dietary supplements.

“There are 51,000 dietary supplements out on the market right now, and most are not FDA-regulated. We know of eight herbal medications that will increase bleeding after surgery.”

Unless physicians specifically ask about vitamins and herbal supplements, most people will not say they are taking any of these. The Strong for Surgery program provides tools for checking patients’ medications and supplements, ensuring patients stop taking the drugs and supplements that might increase their risk during and after surgery.


  1. Whittle J, Wischmeyer PE, Grocott MPW, et al. Surgical prehabilitation: nutrition and exercise. Anesthesiol Clin 2018;36:567-580.
  2. Moran J, Guinan E, McCormick P, et al. The ability of prehabilitation to influence postoperative outcome after intra-abdominal operation: A systematic review and meta-analysis. Surgery 2016;160:1189-1201.
  3. Banerjee S, Garrison LP, Danel A, et al. Effects of arginine-based immunonutrition on inpatient total costs and hospitalization outcomes for patients undergoing colorectal surgery. Nutrition 2017;42:106-113.