Anesthesiologists’ Role in the Perioperative Surgical Home, and an Invitation

No three-word phrase was heard more frequently than “Perioperative Surgical Home” (PSH) at the ASA Practice Management Conference held in Dallas on January 24-26, 2013. 

The PSH is ASA’s response to the triple-aim challenge laid down by the Institute for Healthcare Improvement:  (1) improving the experience of care, (2) improving the health of populations and (3) reducing per capita costs of health care.  “The PSH,” according to ASA, “is an innovative model that will improve patient care and health care delivery, and reduce costs by implementing a seamless continuity of care from the moment surgery is planned, through recovery and discharge from a medical facility and beyond.”

The PSH model is based on the Patient-Centered Medical Home, the purpose of which is to address the fragmentation of chronic disease management by having a single primary care physician coordinate the patient’s care and engage a team of professionals and the patient in an individualized treatment plan.  Surgical care, similarly, has been characterized by “physicians practicing with an individualistic, artisan-like approach in a fragmented medical practice environment . . . relying on their own practice outcomes data for quality improvement.”  (Mackey D.  Can We Finally Conquer the Problem of Medical Quality? Anesthesiology 2012;117:225-6.)  The purpose of the PSH model is to standardize care to the greatest extent possible, to implement evidence-based practices and to reduce ineffective services—under the leadership of anesthesiology. 

The PSH encompasses the coordination of multi-disciplinary care from the time that the decision for surgery is made through discharge and the 30 days following, according to ASA, which breaks out the features of the model into the following phases: 

Preoperative:

• Prompt engagement with the patient once the decision for surgery is made
• Early assessment and triage of patients via email communication or telephone contact
• Further evaluation of complex patients via pre-procedure clinic or telemedicine
• Evidence-informed clinical protocols for preoperative testing and medical optimization (e.g. diabetes and hypertension control, anemia, pain management)
• Patient education and counseling to reduce anxiety, increase participation, confirm understanding of instructions, and ensure timely arrival
• Initial post-discharge transitional care planning and caregiver education

Intraoperative:

• Reduced cancellations and delays through consensus on the clinical criteria for proceeding with elective surgery
• Reduced variation in intraoperative care with systematic implementation of best practices for nursing, anesthesia and surgical management
• Standardized selection of materials and implants

Postoperative:

• Integrated postoperative care from the PACU to the ICU and/or inpatient unit
• Integrated pain management including regional and multimodal analgesia
• Standardized postoperative clinical care protocols and pathways
• Prevention of complications such as hospital-acquired infections, venous thromboembolism
• Coordination and communication of post-discharge plans; education of patients and caregivers
• Follow up for the first 30 days after discharge.

The PSH is very much in the early stages of model development—and our clients and readers can be part of the process.  On January 22, 2014, ASA issued an open invitation to Join the Learning Collaborative that will structure a process for up to 50 organizations to participate in redesigning the healthcare delivery model and sharing best practices, through bundled payment models that “move away from traditional fee-for-service and aligns incentives in the payment system to improve quality and efficiency while creating cost savings.”

ASA invites health care organizations (HCOs) interested in participating in the ASA PSH learning collaborative to submit a 1-2 page letter of interest signed by the hospital chief executive officer to ASA by February 28, 2014 through Celeste Kirschner, Perioperative Surgical Home Project Executive ( c.kirschner@asahq.org).  The letter should address the goals the health care organization wishes to achieve by participating in the collaborative as well as a general description of the organization.  Specific attributes or qualifications that the HCO might want to identify in its letter include quality registries such as the Anesthesia Quality Institute (AQI) and National Surgical Quality Improvement Project (NSQIP); any current surgical outcomes tracking, and electronic health record systems in use.

Two of the critical qualifications for an HCO seeking to be part of the learning collaborative are the commitment of “potential physician champions (anesthesiologist, surgeon, and/or hospitalist) and staff members for a PSH project team” and the available information technology.  Although the PSH is multi-disciplinary in nature and the active involvement of the hospital or health system is indispensable, having anesthesiologists in the lead makes the most sense because of their experience with the spectrum of perioperative events and patients’ medical as well as surgical requirements.  Anesthesiologists, additionally, have considerable familiarity and facility with health IT.  Newer technologies such as ePREOP™, which allows for the timely collection of all relevant patient data and integrates various electronic health records, using that information to deliver evidence-based preoperative recommendations, and the very new TelePREOP service, which debuted at the recent ASA Practice Management Conference and which adds a telemedicine component to the ePREOP system, should enable anesthesiologists to make an even greater contribution to preoperative care and perioperative planning.

As new as the concept of the PSH might appear, versions are already in operation at the University of Alabama at Birmingham (UAB) and at the University of California, Irvine (UCI). 

At UAB, anesthesiologists are serving as the surgical patient’s primary “perioperativists” in a model that emphasizes shared decision-making, with a goal of improving clinical outcomes and decreasing unnecessary resource utilization.  (Vetter et al. The Perioperative Surgical Home: how can it make the case so everyone wins? BMC Anesthesiology 2013, 13:6. )  At the ASA Practice Management Conference, Arthur M. Boudreaux, M.D., Chief of Staff at the UAB Health System and Vice Chair for Quality and Patient Safety for the Department of Anesthesiology, described the PSH structure, process and outcomes—all of which are driven by standardization of care protocols throughout the pre-,  intra- and post-operative as well as the discharge planning and transitions phases.

UCI took a somewhat different approach, as described by Zeev Kain, MD, Chair of the Anesthesiology Department and Associate Dean.  UCI focused on a single service line initially, joint replacement surgery, with results so impressive that that a urology PSH is now in the works.  Indeed, UCI will be holding the First Annual Perioperative Surgical Home Summit in Newport Beach on June 7-8.  Like Dr. Boudreaux, Dr. Kain emphasized, in his presentation at the Practice Management Conference, the need to get all the stakeholders in one room at the launch of a PSH to secure buy-in.  He also stressed that “metrics are everything” (UCI has 150 different metrics) and that reducing length of stay provides the biggest savings, at least thus far.

For further information, see http://www.periopsurghome.info/index.php and the PSH Comprehensive Literature Review prepared for ASA by the Health Science Center at Texas A&M.  

We at ABC find the concept and initial successes of the PSH very exciting and congratulate ASA on this initiative.  We encourage all readers to consider responding to ASA’s invitation.  We will be delighted to help clients who seek to participate in the learning collaborative.