E THE OPEN MIND

The Perioperative Surgical Home as a Future Perioperative Practice Model

Zeev N. Kain, MD, MBA,* Shermeen Vakharia, MD, MBA,* Leslie Garson, MD,* Scott Engwall, MD, MBA,* Ran Schwarzkopf, MD,† Ranjan Gupta, MD,† and Maxime Cannesson, MD, PhD*

HEALTH CARE IN THE UNITED STATES: WHAT’S one continuum rather than discrete preoperative, intraop- THE UNDERLYING PROBLEM? erative, postoperative, and postdischarge episodes. This can Health care has been a subject of national debate in the be achieved by having one team headed by anesthesiolo- United States for the past decade, as we are facing a crisis gists, to manage all aspects of this continuum from the time in both the quality and the cost of delivered care. Why are that the patient and the surgeon make the decision for sur- health care costs in the United States so high, yet key quality gery until 30 days after discharge. During this perioperative indicators are lagging? The answer is complex and multi- episode, the goal of the PSH is to ensure that best evidence/ factorial, but perioperative care is one major example of the best practices are applied in a consistent and standardized dilemma of high cost, low quality, and thus marginal value way to every patient undergoing surgery. When best evi- of health care in the United States. Indeed, it is generally dence/best practice does not exist or is not clear, the PSH accepted that our current perioperative system is plagued team should develop an agreement for standardization of a with high costs, complications, longer than necessary particular practice that will be applied to all patients. In this lengths of stay, excess readmissions, and financial incen- situation, local systems and policies are highly important tives to perform surgery.1–6 in decision making. At each step of this continuum from The Perioperative Surgical Home (PSH)3,7 is a prac- the decision to undergo surgery until 30 days after surgery, tice model that has been proposed as one of the poten- patients will be informed, educated, and involved in the tial solutions to our fragmented and costly perioperative decision making and treatment planning. By applying these system. The PSH is defined by the American Society of concepts, anesthesiologists have a unique opportunity to Anesthesiologists as “a patient-centered and physician-led improve outcomes, decrease length of stay and other met- multidisciplinary and team-based system of coordinated rics, and improve patient satisfaction. care that guides the patient throughout the entire surgical Figure 1 underlines the major differences between the cur- experience”.a,3,7,8 The overall goal of the PSH is to provide rent and the future perioperative care under a PSH model. improved clinical outcomes and better perioperative ser- Briefly, in the PSH model, patient-centered care and shared vice at lower cost. The purpose of this The Open Mind is decision making would replace our current physician-cen- to detail how the PSH model will achieve these goals and tered care. This model considers patient’s preferences and how the specialty of anesthesiology may benefit from this values in all health care decisions, which in other settings practice model. has been associated with better outcomes, decreased uti- lization of expensive tests and procedures, and decreased THE SALIENT ELEMENTS OF PERIOPERATIVE postencounter discomfort.9 Expectation management, early SURGICAL HOME discharge planning, standardized protocol-driven­ health and Conceptually, the PSH model aims to reduce variability in risk assessment, optimization of underlying medical condi- perioperative care given that variability increases the likeli- tions and perioperative standardized anesthetic/nursing/ hood for errors and complications. One way in which this surgical protocols, and fluid management strategies are all variability can be reduced is through assuring continuity of determined in advance through the PSH pathway. Similarly, care and treating the entire perioperative episode of care as multimodal analgesia, postoperative targeted recovery plan, early ambulation, nutrition management, rescue from com- plications, and smooth transition of care to an appropriate dis- From the Departments of *Anesthesiology & Perioperative Care, and †Orthopedic Surgery, University of California Irvine, Irvine, California. charge setting are all also part of a PSH pathway. Importantly, Accepted for publication January 24, 2014. the aim of the PSH is not to replace the surgeon’s role in the Funding: Departmental funding. postoperative period but rather to assure adherence to mutu- Conflict of Interest: See Disclosures at the end of the article. ally agreed on recovery protocols and manage any medical Reprints will not be available from the authors. issue that arises during the episode of care. aASA Committee on Future Models of Anesthesia Practice Annual Report to the HOD. Accessed August 18, 2013. RATIONALISTIC DATA TO SUPPORT Address correspondence to Zeev N. Kain, MD, MBA, Department of Anes- THE EFFECTIVENESS OF PERIOPERATIVE thesiology & Perioperative Care, University of California Irvine, 333 City Dr., Suite 21Orange, CA 92868. Address e-mail to [email protected]. SURGICAL HOME Copyright © 2014 International Anesthesia Research Society Currently, there is a paucity of data regarding the effective- DOI: 10.1213/ANE.0000000000000190 ness of this new model. We can, however, draw from the

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Figure 1. Existing versus suggested perioperative flow system.

Table 1. Main Items of the Enhanced Recovery after Surgery Care Pathway Preoperative Intraoperative Postoperative Patient counseling No gastric tube Exercise therapy Administration of fluids and carbohydrates Thoracic epidural anesthesia No oral opioids No fasting Short-acting anesthetic drugs Use of NSAIDS Minimum bowel preparation Goal-directed fluid therapy PONV prevention No premedication with benzodiazepines Small incision Stimulation of intestinal motility No drains Early mobilization Body temperature control Early oral intake PONV = postoperative and nausea and vomiting; NSAIDS = nonsteroidal antiinflammatory drugs. literature on enhanced recovery after surgery (ERAS) and important to note that perioperative process standardiza- from our own experience at University of California (UC) tion and clinical care pathways within the surgical context Irvine Health and other institutions.8 ERAS is a periopera- have been used in the past both in Great Britain and the tive clinical protocol model that includes implementation United States. These pathways have been shown to improve of 20 items such as standardized management of periop- clinical care and reduce complications. Unfortunately, these erative pain, nausea and vomiting, and goal-directed fluid pathways have not achieved high levels of acceptance in the administration10,11 (Table 1). This model has been shown to United States and have not been widely adopted.14–17 be effective and to result in improved patient satisfaction Since the concept of PSH was conceived, different ver- and postoperative outcomes, reduced length of stay, and sions of the model have been implemented in other institu- reduced risk of hospital-acquired infections.12,13 A fully tions in the United States such as University of Alabama at developed PSH will have many of the elements of ERAS, Birmingham Health System.8 At UC Irvine Health, a PSH but will involve coordination of all aspects of perioperative for primary joint replacement surgery (hip and knee) was care rather than just implementation of the specific items implemented with the support of the Chairs of Orthopedics that are part of ERAS (Table 1). The PSH model also calls and Anesthesiology and Perioperative Care and the for adaptation to the local environment rather than strict Chief Operating Officer of the hospital. Multidisciplinary implementation of the predefined ERAS items. It is also teams consisting of anesthesiologists, surgeons, nurses,

May 2014 • Volume 118 • Number 5 www.anesthesia-analgesia.org 1127 E The Open Mind pharmacists, physical therapists, case managers, social management techniques, LEAN, and Six Sigma methodol- workers, and information technology experts met weekly ogy.19 Although most anesthesiologists are not necessarily during the implementation phase. All team leaders under- experts in these areas, most hospitals have resources that went training in LEAN Six Sigma methodology, and value anesthesiologist PSH champions can access. We also sug- stream maps for all the perioperative processes were devel- gest that in the future our residency programs should focus oped with evidence-based protocols used to standardize on these change management and performance improve- clinical care pathways. We have adopted the use of LEAN ment skills and indeed currently all our CA-1 residents Six Sigma as a cornerstone for our PSH implementation undergo a 2-day training course in LEAN Sigma that is because the perioperative process is very amenable to these taught by instructors from the Center for Innovation of processes. LEAN originated with Toyota, which revolution- Johns Hopkins. ized the car industry using rigorous standardization in their Once a PSH program with multiple service lines is devel- production lines.18 Conceptually. the perioperative environ- oped, the actual staffing of the program will be challenging ment could be paralleled to a car production line and stan- as well. Most anesthesiologists think of themselves as peri- dardization of all perioperative procedures could result in operative clinicians. However, their skillsets in the postop- an error-free, high-quality process. erative management of complex surgical patients may be Patient education, shared decision making, ­goal-oriented limited. We suggest that if the PSH is to be widely used, personal recovery pathway with a diary, and perfor- our residency training programs must include more train- mance benchmarks were incorporated at every phase. The ing in perioperative medicine, with particular emphasis on regional/acute pain team followed the patients on a daily postoperative care. basis and a “surgical home call system” was established to Finally, one can accept the conceptual model of the ensure continuity of care. A nurse navigator/case manager PSH but still raise the question of the suitability of anes- working with the PSH team ensured smooth transitions of thesiologists to be the leaders. We believe anesthesiologists care between home, hospital, and postdischarge facility. are uniquely qualified because of their involvement in all In April 2013, with the support of a UC Center for Health aspects of the preoperative, intraoperative, and postopera- Quality and Innovation award, UC Irvine began the first tive periods. Furthermore, anesthesiologists are typically phase of the Urological PSH, focusing on nephrectomy and “system-thinkers” as demonstrated by the improvement cystectomy, bringing the PSH teams together, and building we have made in patient safety.20 Surgeons are typically not the clinical pathways. The success of the Joint Replacement interested in the medical management of their patients and PSH has led to enthusiasm in the institution, and the plan are currently not involved in their preoperative optimiza- for 2014 is to include all elective inpatients and outpatients tion. It is our opinion that while hospitalists are interested who undergoing surgery in newly developed PSH models. in getting involved in the management of the PSH, they lack the fundamental understanding of perioperative physiol- OPERATIONAL BARRIERS TO THE DEVELOPMENT ogy that results from the surgical experience and thus are AND WIDESPREAD IMPLEMENTATION OF A not ideally positioned to deliver optimal postoperative care. PERIOPERATIVE SURGICAL HOME The implementation of a PSH at UC Irvine Health was not FISCAL BARRIERS TO THE DEVELOPMENT without challenges. Our first attempt to convince a group AND WIDESPREAD IMPLEMENTATION OF A of general surgeons to take part in such a model 3 years PERIOPERATIVE SURGICAL HOME ago was met with skepticism and resistance. In 2012, with Current financial constraints present a major barrier to a the endorsement of the Chair of Orthopedic Surgery, we PSH model because the “extra services” provided by anes- recruited a new orthopedic surgeon who understood the thesiologists cannot be reimbursed within the existing pay- potential benefits that PSH could offer as he started his ment system. However, looking at the future state of medical practice. Eighteen months later, after the robust results of payments, we suggest that we might be moving away from the PSH focused on the joint replacement service line, the the fee-for-service system toward a “bundle payment” sys- hospital administrators and the surgeons are convinced of tem, where anesthesiologists will no longer be paid based the effectiveness of this model and are now supporting it on time units but rather based on their “overall value” to with appropriate resources. the surgical episode. Under this new payment system, anes- Looking to the future, one of our challenges is the man- thesiologists will need to demonstrate value beyond just the agement of patients in the postoperative period. Our cur- operating rooms to maintain their current reimbursement rent model of care for the postoperative period is based on level. One way for anesthesiologists to demonstrate their our acute pain team. However, this model will not be sus- value is to move up in the value chain and become the lead- tainable once patient volume increases substantially. We are ers of the PSH model in their institutions. now moving to a model in which a designated anesthesiolo- Even in the current fee-for-service model, anesthesi- gist will supervise designated nurse practitioners who will ologists could be compensated for their role in PSH just manage the coordination of care and adherence to protocols like family practitioners get reimbursed for their role of these patients. in “patient-centered­ medical home”.21 The Centers for When moving to a PSH model, one needs to differenti- Medicare and Medicaid Services has now recognized ate between the skills needed to build such a program and the concept of patient-centered medical home,22 which the skills needed to maintain it. For the development phase, it defines as “a primary care model that aims to improve anesthesiologists need to be skilled in team building, change patient outcomes by adopting a patient-centered rather than

1128 www.anesthesia-analgesia.org anesthesia & analgesia Perioperative Surgical Home disease-centered approach”.21,23 Such compensation would Name: Shermeen Vakharia, MD, MBA. offset the costs associated with the implementation and Contribution: This author helped write the manuscript. maintenance of a PSH. Finally, once hospital administra- Attestation: Shermeen Vakharia approved the final manuscript. tors realize the savings achieved from improved outcomes Conflicts of Interest: The author has no conflicts of interest to with the PSH model, they may be motivated to compensate declare. anesthesiologists for their role as leaders of the PSH. When Name: Leslie Garson, MD. one communicates with the hospital leadership, it may be Contribution: This author helped write the manuscript. worthwhile to indicate that the National Health Service in Attestation: Leslie Garson approved the final manuscript. Great Britain estimates that ERAS generates a net savings of Conflicts of Interest: The author has no conflicts of interest to over $630 million every year.24 If PSH in the United States is declare. Name: Scott Engwall, MD, MBA. as successful as the ERAS program in the United Kingdom, Contribution: This author helped write the manuscript. savings in the millions of dollars will be realized by hospi- Attestation: Scott Engwall approved the final manuscript. tals. We do appreciate that at an early stage of implemen- Conflicts of Interest: The author has no conflicts of interest to tation anesthesiology departments may need to absorb the declare. costs of setting and maintaining a PSH model until hospitals Name: Ran Schwarzkopf, MD. and third party payers recognize its value. In our opinion, Contribution: This author helped write the manuscript. if anesthesiologists do not adopt the PSH model because of Attestation: Ran Schwarzkopf approved the final manuscript. these initial set-up costs, bundle payments would become Conflicts of Interest: Ran Schwarzkopf received a research a reality with anesthesiologists locked into the operating grant from Pacira Pharmaceutical, is a paid consultant for rooms with intraoperative anesthesia provision becoming a Smith & Nephew, and has stock options with Gauss Surgical. commodity. We see the PSH as a way for anesthesiologists Name: Ranjan Gupta, MD. to move beyond the operating rooms and the traditional Affiliation: Department of Orthopedic Surgery, University of conflict with health care extenders to play a critical role in California Irvine, Irvine, California. the changing environment. Contribution: This author helped write the manuscript. Attestation: Ranjan Gupta approved the final manuscript. CONCLUSIONS AND THE FUTURE OF Conflicts of Interest: The author has no conflicts of interest to PERIOPERATIVE SURGICAL HOME declare. Despite the current lack of definitive evidence that Name: Maxime Cannesson, MD, PhD. implementation of a PSH program leads to better clini- Contribution: This author helped write the manuscript. cal outcomes, better service to our patients, and reduced Attestation: Maxime Cannesson approved the final manuscript. costs, the successes and validation of the ERAS program Conflicts of Interest: Maxime Cannesson consulted for Edwards Lifesciences, received research funding from Edwards in Europe and results at the University of Alabama at Lifesciences, consulted for Masimo Corp., and received research Birmingham and at UC Irvine Health, and elsewhere in funding from Masimo Corp. the United States, give cause for optimism. Clearly, sig- nificant research needs to be conducted to validate the REFERENCES assertions made in this review. The American Society of 1. 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In press 8. Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, DISCLOSURES Pittet JF. The Perioperative Surgical Home: how can it make the Name: Zeev N. Kain, MD, MBA. case so everyone wins? BMC Anesthesiol 2013;13:6 Contribution: This author helped analyze the data and write 9. Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP. Enhanced recovery pathways optimize health outcomes the manuscript. and resource utilization: a meta-analysis of randomized con- Attestation: Zeev N. Kain approved the final manuscript. trolled trials in colorectal surgery. Surgery 2011;149:830–40 Conflicts of Interest: Zeev N. Kain lectures for Merck on team 10. Knott A, Pathak S, McGrath JS, Kennedy R, Horgan A, Mythen training and is funded by the National Institutes of Health. M, Carter F, Francis NK. Consensus views on implementation

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