Anesthesia & Analgesia is not affiliated with the American Society of Anesthesiologists. However, most subscribers, (and possibly most readers), are members of the ASA and have heard the discussion about the concept of the Perioperative Surgical Home. The Perioperative Surgical Home is a patient-centered and physician-led multidisciplinary and team-based system of coordinated care. This may represent the future of our specialty, and merits serious discussion.
Change is difficult. Dr. Zeev Kain, Department of Anesthesiology & Perioperative Care, University of California Irvine, Irvine, California, and colleagues describe how they developed and implemented such a model for their patients undergoing total joint replacement. Their description, published in this month’s edition of Anesthesia & Analgesia, is summarized in the article “Implementation of a Total Joint Replacement-Focused Perioperative Surgical Home: A Management Case Report.”
The joint replacement center at the University of California Irvine implemented a Lean Six Sigma initiative, one where the processes surrounding patient care are standardized to eliminate defects/reduce variability. Members of different departments, including chairs of the Departments of Anesthesiology and Orthopedic Surgery along with the hospital’s Chief Operating Officer, got together to implement evidence-based practice within clinical pathways. The pathways included optimal preparation of patients for surgery. Patients were seen at least 2-4 weeks before surgery in a preoperative clinic where standardized testing and management protocols were applied. These included nasal Staphylococcus aureus screening, nosocomial infection prevention protocol, thromboembolic risk prevention protocol, blood conservation strategies, and urinalysis protocol. Pain, fluid management, and other processes were standardized intraoperatively. Postoperative protocols for pain management, anticoagulation and thromboembolic event prevention, and intensive physical therapy (PT) were implemented. A dedicated anesthesiologist managed postoperative medical issues.
Blood administration was also standardized: the hemoglobin transfusion trigger was 10 mg/dl in patients with known coronary artery disease, and 7 mg/dl for the other patients. Outcome data was collected prospectively. Outcomes included a median length of stay of 3 days for patients undergoing either total hip or knee arthroplasty. Nearly half of the patients were discharged to a location other than home. Emergency department visit rates within 30 days of discharge were 3.9% for patients undergoing total hip arthroplasty and 4.2% for patients undergoing total knee arthroplasty. The 30-day hospital readmission rate was 0% for patients undergoing total hip arthroplasty and 1.1% for patients undergoing total knee arthroplasty. No patient died and there were no major complications.
Although these outcomes seem impressive, it’s difficult to objectively interpret these outcomes without a control group. However, the authors have developed a model that can be tested in future studies.
This month’s issue of Anesthesia & Analgesia contains a collection of articles and editorials on the Perioperative Surgical Home. As Drs. Steven L. Shafer, Editor-in-Chief, Anesthesia & Analgesia, Professor of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, and John Donovan, East Bay Anesthesiology Medical Group, Alta Bates Summit Medical Center, Oakland, California, note in their accompanying editorial titled “Anesthesia & Analgesia’s Collection on The Perioperative Surgical Home,” “Like everything else in life, the PSH is an experiment. If this experiment succeeds, our patients will benefit, health care will become more affordable, and our profession will evolve in new directions. If it fails, at least we stepped up to the challenge of improving health care using the resource most completely under our control: ourselves.”