The Perioperative Surgical Home KSPAN Spring Seminar 3/12/2015 Jeff Oldham, MD Assistant Professor UK Dept of Anesthesiology

Perioperative Surgical Home I have no financial disclosures. All tables and figures obtained from “The Perioperative Surgical Home: A Comprehensive Literature Review for the American Society of Anesthesiologists” published June 12, 2014.

Learning Objectives Discuss the role of the anesthesia team in the perioperative surgical home. Define preoperative, intraoperative and postoperative responsibilities. Explain the role of perioperative nursing in this evolving healthcare model.

Perioperative Surgical Home “An innovative model of delivering healthcare during the entire patient surgical/procedural experience; from the time of the decision for surgery until patient recovery” t4Perioperative Surgical Home t4Perioperative Surgical Home

Goals – Improving health – Improving delivery of healthcare – Reducing cost of healthcare Metrics – Improved operational efficiencies – Decreased resource utilization – Reduced length of stay and readmission – Decrease in complications and mortality

Perioperative Surgical Home Why do we need this model? – “Coordination is often lacking in the surgical care process; the medical home concept provides a relevant model to address this lack of coordination that has recently been evaluated for both impact on clinical outcomes and cost of surgery” (Warner, 2011).

Perioperative Surgical Home The Perioperative Surgical Home: A Comprehensive Literature Review for the ASA 1)Surgical home concept 2)Early patient engagement 3)Reduced preoperative testing 4)Intraoperative efforts leading to better efficiency 5)Postoperative care initiatives 6)Reduced postoperative complications 7)Care coordination and transition planning

1) Surgical Home Concept “This includes references, general literature reviews, and the history of coordinated surgical care that might refer to programs as a perioperative surgical home, a patient-centered coordinated surgery program, or any combination of two or more of the preoperative, intraoperative and postoperative phases in order to reduce cost and improve clinical outcomes.”

2) Early Patient Engagement “efforts and initiatives to engage patients early is beneficial to both the patient and the healthcare enterprise by creating open communications, supporting and educating patients to make decisions and participate in the process of undergoing surgery, and reducing unrealistic expectations.”

2) Early Patient Engagement COPD preoperative risk stratification and “prehabilitation” (Ergina et al., 1993) Improved OR throughput. Preoperative education and counseling have been shown to improve surgical outcomes.

3) Reduced Preop Testing Cost reduction – Minimizing unnecessary preoperative tests could reduce nationwide healthcare costs by $10 billion and actually improve patient experience and care (Brown & Brown, 2011). No detrimental effect on outcomes.

4) Intraop Efforts Leading to Better Efficiency Faster into OR. Efficient use of intraoperative time. Faster out of OR.

5) Postoperative Care Initiatives “Fast track” surgery – Quicken patient recovery – Reduce morbidity Enhanced Recovery After Surgery (ERAS) – decrease complications and to hasten patient recovery, encouraging early discharge Requires considerable time investment

6) Reduced Postop Complications Postoperative complications are expensive. Average cost of surgical complication $35,465 (Krupka et al., 2012) Complications for those in the ERAS group of an elective colonic surgery were found to be significantly fewer (Sammour et al., 2010). Better communication of details of procedures and postoperative patient responsibilities may improve complication factors contributing to postoperative complications, including perioperative feeding, mobilization, pain control, and respiratory physiotherapy (Gustafsson et al., 2012).

7) Care Coordination/Transition Planning Postoperative care coordination may be lacking in many surgical settings (Toscan, Manderson, Santi, & Stolee, 2013).

Perioperative Surgial Home

Intraoperative Key Elements Integrated pain management Fast track surgery and discharge home Precise fluid management OR delay reduction techniques Increased OR efficiency through improved OR flow Scheduling initiatives to reduce cancellations and increase efficiency

Perioperative Surgial Home Postoperative Key Elements Integrated pain management Early postoperative mobilization by physical therapy and integrated acute- care/rehabilitation care Improved coordination of care from postoperative period to discharge home Improved discharge protocol Increased patient and caretaker education concerning post-discharge care

Challenges “stepping on toes” Changing the culture of postoperative patient care. Expanded training during anesthesia residency Billing

Perioperative Surgical Home Will this work in real life? – UAB Pre-anesthesia care unit General OR’s and Cardiothoracic OR’s PACU – UCI PSH focused on joint replacement surgery UC Irvine Center for Perioperative Care