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Winter 2017

The Perioperative Surgical Home: Preoperative Risk Stratification, Optimization and Value

Rick Bushnell, MD, MBA
Director, Department of Anesthesia, Shriners Hospital for Children, Los Angeles, CA
and Clinical Anesthesiologist, Huntington Memorial Hospital, Pasadena, CA

Payers, patients and partners are demanding better outcomes, and evolving healthcare paradigms are begging for greater anesthesia engagement. If you have been following this series, then you already know that the perioperative surgical home (PSH) is the answer to the call and the future of our specialty. What you may not know is how easy it can be as an anesthesiologist to make a contribution.

Stationing an anesthesiologist in the preoperative clinic is magic. The presence of anesthesia medical knowledge is magic to the preoperative nurses, magic to the patients and magic to the surgeons. Preoperative clinic nurses need support and direction when complicated patients present. Surgeons need the ability to obtain an anesthesia consult and patients truly need reassurance sooner than three minutes before surgery that the entire surgical continuum is engaged for their benefit.

Anesthesia offers major value to all of these people. The fact that we selflimit our presence to three minutes before surgery sends the message that we are unengaged. As anesthesiologists, we know nothing could be farther from the truth. We each have spent years developing the skills needed to spot trouble. Too often, though, we’re spotting it too late in the process and off-loading the medical issues, responsibility and leadership.

It is now time to translate our intuitive anesthesia preoperative skills into more objective assessments, management and leadership. The PSH provides the practice platform by which to lead the entire surgical process and continuum. The anesthesia preoperative appointment uses the same skills you have honed for years. It consists of a directed anesthesia history and physical, risk stratification and management. You already know how to assess a patient and past medical record, so I’ll save the lecture. What’s new and improved is the use of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP)1 to objectify and augment your professional intuition and communicate the information effectively to others.

Consider the 83-year-old patient I recently saw in our PSH. She presented for right total knee arthroplasty with a diagnosis of diabetes, chronic poorly controlled hypertension, 3+ pitting edema at the ankles and no cardiac consult. Her NSQIP calculation is shown in Figure 1. Easy enough; I sent her for a cardiac consult, and the echocardiogram results came back with a hyper-dynamic heart, 81 percent ejection fractions and an ascending aortic root dilation of 4.8 cm (severe). The preoperative clinic appointment, the consult and the surgical risk calculator all facilitated a more timely and objective conversation between the surgeon, the patient and the anesthesiologist. This would not have been possible on the day of surgery, if the edema had been caught at all. This process saved time, money and maybe a life, all well worth the investment in the PSH.

For cases that are allowed to proceed to surgery, the PSH appointment then becomes about optimization. Consider the Generalized Protocol (Figure 2) for Enhanced Recovery After Surgery (ERAS). As an anesthesiologist, you control the largest portion of this protocol and you stand to make a huge contribution right there. This is because the largest portion of ERAS involves the avoidance of opioids. That avoidance starts during the PSH preoperative appointment. In our preoperative appointments, we start patients on a seven-day regimen of acetaminophen, Celebrex and gabapentin (two days preoperatively and five days postoperatively). By coupling this with intraoperative ultrasound regional nerve blocks, we have reduced our opioid requirements by 75 percent. (The depiction of the first-order pharmacokinetic dosing logic and the timing of surgical incision are shown in Figure 3.)

Pain management in the PSH—a service that only an anesthesiologist can provide—is essential for the effective delivery of the core ERAS protocols. Other portions of our protocol include two days of twice-daily skin decolonization (Hibiclens protocol for the surgical site), two days of pulmonary preconditioning with an incentive spirometer, and two days of amino acid, carbohydrate and essential fatty acid loading (immunonutritional optimization). Additionally, we should not underestimate the importance of the message being delivered by an anesthesiologist. Coaching by an anesthesiologist on these optimization protocols sends a powerful message to patients of the importance of their own medical outcome: “This is your surgery and your outcome and this is how to get the best result.” Mid-level providers do not have the credibility to deliver this message as effectively.

The PSH, NSQIP, ERAS and postoperative results can most effectively be managed by a physician anesthesiologist. It means using the skills you already have and understanding the importance of objective risk stratification and optimization. This is real value that only you as an anesthesiologist can deliver. These are positive outcomes that will become evident in your hospital’s quality metrics and increase your anesthesia group’s value to your institution. That value and those metrics will be useful in negotiations with your accountable care organization.

As the 5th century B.C. Japanese warlord Sun Tzu said: “Victorious warriors win first, then go to war.” Win first with your risk stratification, with your optimization and by demonstrating value in your metrics, and then have that ACO conversation.

1American College of Surgeons National Surgical Quality Improvement Program®,

Rick Bushnell, MD, MBA is the Director of the Department of Anesthesia, Shriners Hospital for Children, Los Angeles, CA and a Clinical Anesthesiologist at Huntington Memorial Hospital in Pasadena, CA. Dr. Bushnell graduated from the University of Illinois College of Medicine and attended the University of Pittsburgh Medical Center, and Loma Linda University for internship and residency. He has been with Pacific Valley Medical Group since 2003 and consults with Shriners Hospital for Children, Los Angeles. He and his partner have six adopted children in Tanzania where he serves as Visiting Clinical Anethesiologist at St. Elizabeth’s Hospital for the Poor in Arusha. He can be reached at