Perioperative Surgical Home Models

Pro-Con Debate: Anesthesiologists Should Be Responsible for Treating Preoperative Anemia

In this Pro-Con commentary article, we discuss whether anesthesiologists should be responsible for treating preoperative anemia. This debate was proposed based on the article published in this issue of Anesthesia & Analgesia by Warner et al, which is an advisory on managing preoperative anemia endorsed by both the Society of Cardiovascular Anesthesiologists and the Society for Advancement of Patient Blood Management. All evidence suggests that anemia is not just an innocent "bystander" which can be solved by transfusion. In fact, both anemia and transfusion are independently associated with adverse outcomes, so why not avoid both? It just makes sense that patients show up for surgery with enough red blood cells to avoid needing transfusion with someone else's. Even if we agree that preoperative anemia is worth treating before surgery, the question remains who should be responsible for doing so, and therein lies the reason for this Pro-Con debate. Should it be the responsibility of the anesthesiologist, or not? Let the readers decide.

Improving safety and outcomes in perioperative care: does implementation matter?

The IMPROVE study describes a large perioperative quality improvement project with reporting of both compliance with improvement activities and patient outcomes. It highlights the importance of such projects, as well as the challenges in implementing change and proving benefit. Challenges identified include the importance of effective training in practice change, selection of trial design and relevant quality measures, and how the context of quality improvement initiatives may influence outcomes. Quality improvement programmes of this nature, despite the difficulties with implementation and trial design, remain a high priority because of their positive influence on improving clinical practice.

The Perioperative Surgical Home, Enhanced Recovery After Surgery and how integration of these models may improve care for medically complex patients

Perioperative medicine is changing rapidly, and with this change comes the opportunity to improve upon current models of care delivery and integration within the health care system. Perioperative models of care are structured or conceptual arrangements for surgical patients before, during and after their surgery. Models of care such as the Perioperative Surgical Home and Enhanced Recovery After Surgery pathways are increasingly used to guide the structure of perioperative care delivery with an aim to improve patient outcomes and experience in Canadian settings. In this narrative review, we summarize the origins of these perioperative models of care. They are fundamentally different in scope and level of evidence. Both models have potential benefits and limitations to their broad implementation in our health care system. As currently developed, both models are limited in their application to patients with chronic disease. We discuss how these models of care can be used to develop integrated horizontal and vertical perioperative pathways in a Canadian setting. Such integration is a potential solution that will improve their applicability to patients with medically complex conditions and in times when health care systems are under pressure. We describe this approach using the example of patients with kidney failure receiving dialysis.

Anesthesiology Residents' Experiences and Perspectives of Residency Training

BACKGROUND

Anesthesiology residents' experiences and perspectives about their programs may be helpful in improving training. The goals of this repeated cross-sectional survey study are to determine: (1) the most important factors residents consider in choosing an anesthesiology residency, (2) the aspects of the clinical base year that best prepare residents for anesthesia clinical training, and what could be improved, (3) whether residents are satisfied with their anesthesiology residency and what their primary struggles are, and (4) whether residents believe their residency prepares them for proficiency in the 6 Accreditation Council for Graduate Medical Education (ACGME) Core Competencies and for independent practice.

METHODS

Anesthesiologists beginning their US residency training from 2013 to 2016 were invited to participate in anonymous, confidential, and voluntary self-administered online surveys. Resident cohort was defined by clinical anesthesia year 1, such that 9 survey administrations were included in this study-3 surveys for the 2013 and 2014 cohorts (clinical anesthesia years 1-3), 2 surveys for the 2015 cohort (clinical anesthesia years 1-2), and 1 survey for the 2016 cohort (clinical anesthesia year 1).

RESULTS

The overall response rate was 36% (4707 responses to 12,929 invitations). On a 5-point Likert scale with 1 as "very unimportant" and 5 as "very important," quality of clinical experience (4.7-4.8 among the cohorts) and departmental commitment to education (4.3-4.5) were rated as the most important factors in anesthesiologists' choice of residency. Approximately 70% of first- and second-year residents agreed that their clinical base year prepared them well for anesthesiology residency, particularly clinical training experiences in critical care rotations, anesthesiology rotations, and surgery rotations/perioperative procedure management. Overall, residents were satisfied with their choice of anesthesiology specialty (4.4-4.5 on a 5-point scale among cohort-training levels) and their residency programs (4.0-4.1). The residency training experiences mostly met their expectations (3.8-4.0). Senior residents who reported any struggles highlighted academic more than interpersonal or technical difficulties. Senior residents generally agreed that the residency adequately prepared them for independent practice (4.1-4.4). Of the 6 ACGME Core Competencies, residents had the highest confidence in professionalism (4.7-4.9) and interpersonal and communication skills (4.6-4.8). Areas in residency that could be improved include the provision of an appropriate balance between education and service and allowance for sufficient time off to search and interview for a postresidency position.

CONCLUSIONS

Anesthesiology residents in the United States indicated they most value quality of clinical training experiences and are generally satisfied with their choice of specialty and residency program.

Surgery and the Smartphone: Can Technology Improve Equitable Access to Surgical Care?

Unfortunately, many patients in the United States experience disparities in access to surgical care, including geographic constraints, limited transportation and time, and financial hardships. Living in a "surgical care desert" results in a delay in care, driving up health care costs and reducing quality of care. In the age of COVID-19, patient access to health care has been further diminished by physical distancing guidelines, naturally increasing the need for innovative telehealth solutions. In this review, we focus on using smartphones for mobile health technology (mHealth) in the delivery of surgical care. This study is aimed at a general surgical audience that may be interested in exploring how mHealth can improve both access and health care quality for surgical patients and their families. We review the current uses of mHealth by surgeons for surgical site infection, new models of the perioperative surgical home, acute care surgical triage, remote patient monitoring devices, and evaluation and management of surgical consultations in the patient's home. We also review institutional and governmental barriers to the adoption of mHealth and offer some preliminary solutions that may aid the surgeon who wishes to implement this technology in their day-to-day practice.

Energy and Protein Intake After Return Home in Colorectal Surgery Patients With an Enhanced Recovery Program: A Prospective Observational Study

BACKGROUND

In patients scheduled for colorectal surgery with an enhanced recovery program (ERP), feeding after returning home has been insufficiently investigated. The aim of this study was to measure energy and protein intake during the first month at home.

METHODS

Seventy adult patients scheduled for colorectal surgery with ERP were included. Calorie and protein intakes were calculated, and body weight was measured preoperatively and 3, 7, 15, and 30 days after discharge home. Data are mean ± SD or median (interquartile range).

RESULTS

Patient characteristics were age 60.0 ± 15.0 years, BMI = 25.9 ± 5.5 kg/m² , and colon/rectum of 56/14. The duration of hospitalization was 3 (2-5) days. Calorie and protein intakes (21.9 [17.7-28.6] kilocalorie per kilogram of ideal body weight [kcal/kg IBW] and 0.81 [0.61-1.14] g/kg IBW) were significantly reduced (P < .01) by 15% on day 3, compared with preoperative values, and then increased gradually to reach preoperative values after 1 month. Almost 50% of the patients failed to reach the calorie intake target of 25 kcal/kg IBW, and almost no patient reached the protein intake target of 1.5 g/kg IBW 30 days after discharge home. Weight loss after 30 days at home remained at -1.8 ± 2.7 kg.

CONCLUSIONS

Colorectal surgery, even in an ERP, is associated with energy and protein intake below the targets recommended for the rehabilitation phase and results in weight loss. Whether nutrition counseling and prolonged administration of protein-enriched oral supplements could accelerate weight gain needs to be explored.