The current state of the preoperative “system” – if we can be so generous as to use that word – is riddled with unnecessary costs, unexpected complications, prolonged length of stay, and excessive readmissions. Rates of complications after surgery, for instance, hover in the 25% range, and mortality rates vary wildly – from 3.5% in very-low-mortality hospitals to nearly 7% in high-mortality hospitals.
Recently, the American Society of Anesthesiologists has proposed an alternative: the Perioperative Surgical Home, or PSH, the surgical answer to the Patient-Centered Medical Home (PCMH). Recognizing that variability in any process is a primary driver of error, the creators of the PSH set to minimize variability in perioperative care. In the PSH model, this is accomplished by treating the entire perioperative process as one continuum, as opposed to discrete and fragmented perioperative, intraoperative, and postoperative phases. In a PSH, anesthesiologists take on a broader scope of responsibility that extends well beyond the work in the operating room. Similar to a primary care physician in the PCMH, the anesthesiologist team becomes a patient’s primary source of care and guidance through the continuum.
Here’s a snapshot of what a patient’s journey through a Perioperative Surgical Home might look like.
The process begins with a visit to a preoperative assessment and consultation clinic, where a patient slated for surgery is evaluated by a nurse practitioner under the supervision of an attending anesthesiologist. Depending on a patient’s medical comorbidities, internists may be called on to provide further medical evaluation. A plan for preoperative medical optimization is developed, ensuring that evidence-based practices are carried out. Detailed information about surgery, anesthesia, and their attendant risks are provided to the patient to diminish anxiety and enhance postoperative recovery. Expectations regarding postoperative mobilization and respiratory therapy are aligned. Postoperative pain is discussed extensively, with the goal to educate and empower the patient regarding effective pain management options.
The extensive pre-operative phase lays critical groundwork for the day of surgery. In the setting of meticulous medical optimization and strong communication among the interdisciplinary team, the hope is that the procedure has a higher likelihood of continuing without delay or cancellation. Post-operatively, a single anesthesia-intensivist attending works in tandem with the surgical team to provide focused postoperative care throughout the post-anesthesia care unit to the intensive care unit to the hospital floor. The inpatient pain service works closely with the anesthesia and surgery teams to provide pain assessment and treatment recommendations, including de-escalation of intravenous analgesics as soon as appropriate. As discharge approaches, nurse practitioners coordinate post-discharge plans, and remain “on-call” for post-operative needs for 30 days following discharge. At every step along the way, patients are informed, educated, and engaged in shared decision-making with providers.
To date, this model remains entirely untested. Proponents point out, however, that there is good reason to believe the model could deliver on its promise of improved outcomes, decreased cost, and higher patient satisfaction, pointing to data collected from Europe’s Enhanced Recovery After Surgery protocol (ERAS). ERAS involves the protocolized implementation of 20 items, such as standardized management of perioperative pain, vomiting, and goal-directed fluid administration. The protocol, which underlies the chassis of the Perioperative Surgical Home, has indeed been shown to decrease hospital length of stay, improve outcomes, and increase satisfaction among surgical patients.
Clearly, much more research is needed to determine whether the PSH model can truly lead to better care for patients. Recognizing this, the American Society of Anesthesiologist has approved a $1 million budget to fund the formation of Perioperative Surgical Homes across hospitals nationwide, and conduct Comparative Effectiveness Research to answer the question of whether they actually work. Stay tuned.