Ethical Opportunities with the Perioperative Surgical Home

Anesthesia Considerations for Placenta Accreta Spectrum

Anesthesiologists are critical members of the multidisciplinary team managing patients with suspected placenta accreta spectrum (PAS). Preoperatively, anesthesiologists provide predelivery consultation for patients with suspected PAS where anesthetic modality and invasive monitor placement is discussed. Additionally, anesthesiologists carefully assess patient and surgical risk factors to choose an anesthetic plan and to prepare for massive intraoperative hemorrhage. Postoperatively, the obstetric anesthesiologist hold unique skills to assist with postoperative pain management for cesarean hysterectomy. We review the unique aspects of peripartum care for patients with PAS who undergo cesarean hysterectomy and explain why these responsibilities are critical for achieving successful outcomes for patients with PAS. KEY POINTS: · Anesthesiologists are critical members of the multidisciplinary team planning for patients with suspected placenta accreta spectrum.. · Intraoperative preparation for massive hemorrhage is a key component of anesthetic care for patients with PAS.. · Obstetric anesthesiologists have a unique skill set to manage postpartum pain and postoperative disposition for patients with PAS who undergo cesarean hysterectomy..

Recognizing and Maximizing the Nexus of Perioperative Medicine and Narrative Medicine

Perioperative medicine remains an evolving, interdisciplinary subspecialty, which encompasses the unique perspectives and incorporates the respective vital expertise of numerous stakeholders. This integrated model of perioperative medicine and care has a wide-ranging set of clinical, strategic, and operational goals. Among these various programmatic goals, a subset of 4, specific, interdependent goals include (1) enhancing patient-centered care, (2) embracing shared decision-making, (3) optimizing health literacy, and (4) avoiding futile surgery. Achieving and sustaining this subset of 4 goals requires continued innovative approaches to perioperative care. The burgeoning field of narrative medicine represents 1 such innovative approach to perioperative care. Narrative medicine is considered the most prominent recent development in the medical humanities. Its central tenet is that attention to narrative-in the form of the patient's story, the clinician's story, or a story constructed together by the patient and clinician-is essential for optimal patient care. If we can view the health care experience through the patient's eyes, we will become more responsive to patients' needs and, thereby, better clinicians. There is a potential clinical nexus between the perioperative medicine practice and narrative medicine skills, which, if capitalized, can maximize perioperative patient care. There are a number of untapped educational and research opportunities in this fruitful nexus between perioperative medicine and narrative medicine.

Health Literacy in the Context of Implant Care-Perspectives of (Prospective) Implant Wearers on Individual and Organisational Factors

The continuous development of medical implants offers various benefits for persons with chronic conditions but also challenges an individual's, and the healthcare system's, ability to deal with technical innovation. Accessing and understanding new information, navigating healthcare, and appraising the role of the implant in body perceptions and everyday life requires health literacy (HL) of those affected as well as an HL-responsive healthcare system. The interconnectedness of these aspects to ethically relevant values such as health, dependence, responsibility and self-determination reinforces the need to address HL in implant care. Following a qualitative approach, we conducted group discussions and a diary study among wearers of a cochlear, glaucoma or cardiovascular implant (or their parents). Data were analysed using the documentary method and grounded theory. The data reveal the perceptions of implant wearers regarding the implant on (1) the ability to handle technical and ambiguous information; (2) dependence and responsibility within the healthcare system; and (3) the ethical aspects of HL. Knowing more about the experiences and values of implant wearers is highly beneficial to develop HL from an ethical perspective. Respective interventions need to initially address ethically relevant values in counselling processes and implant care.

Pro-Con Debate: Anesthesiologist- Versus Hospitalist- Run Preoperative Clinics and Perioperative Care

In this Pro-Con commentary article, we discuss the models, value propositions, and opportunities of preoperative clinics run by anesthesiologists versus hospitalists and their role in perioperative care. The medical and anesthesia evaluation before surgery has pivoted from the model of "clearance" to the model of risk assessment, preparation, and optimization of medical and psychosocial risk factors. Assessment of these risk factors, optimization, and care coordination in the preoperative period has expanded the roles of anesthesiologists and hospitalists as members of the perioperative care team. There is ongoing debate regarding which model of preoperative assessment provides the most optimal preparation for the patient undergoing surgery. This article hopes to shed light on this debate with the data and perspectives on these care models.

Narrative Medicine: Perioperative Opportunities and Applicable Health Services Research Methods

Narrative medicine is a humanities-based discipline that posits that attention to the patient narrative and the collaborative formation of a narrative between the patient and provider is essential for the provision of health care. In this Special Article, we review the basic theoretical constructs of the narrative medicine discipline and apply them to the perioperative setting. We frame our discussion around the 4 primary goals of the current iteration of the perioperative surgical home: enhancing patient-centered care, embracing shared decision making, optimizing health literacy, and avoiding futile surgery. We then examine the importance of incorporating narrative medicine into medical education and residency training and evaluate the literature on such narrative medicine didactics. Finally, we discuss applying health services research, specifically qualitative and mixed methods, in the rigorous evaluation of the efficacy and impact of narrative medicine clinical programs and medical education curricula.

Clinical Practice Guideline: Tympanostomy Tubes in Children (Update)

OBJECTIVE

Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy. All these conditions are encompassed by the term otitis media (middle ear inflammation). This guideline update provides evidence-based recommendations for patient selection and surgical indications for managing tympanostomy tubes in children. The guideline is intended for any clinician involved in managing children aged 6 months to 12 years with tympanostomy tubes or children being considered for tympanostomy tubes in any care setting as an intervention for otitis media of any type. The target audience includes specialists, primary care clinicians, and allied health professionals.

PURPOSE

The purpose of this clinical practice guideline update is to reassess and update recommendations in the prior guideline from 2013 and to provide clinicians with trustworthy, evidence-based recommendations on patient selection and surgical indications for managing tympanostomy tubes in children. In planning the content of the updated guideline, the guideline update group (GUG) affirmed and included all the original key action statements (KASs), based on external review and GUG assessment of the original recommendations. The guideline update was supplemented with new research evidence and expanded profiles that addressed quality improvement and implementation issues. The group also discussed and prioritized the need for new recommendations based on gaps in the initial guideline or new evidence that would warrant and support KASs. The GUG further sought to bring greater coherence to the guideline recommendations by displaying relationships in a new flowchart to facilitate clinical decision making. Last, knowledge gaps were identified to guide future research.

METHODS

In developing this update, the methods outlined in the American Academy of Otolaryngology-Head and Neck Surgery Foundation's "Clinical Practice Guideline Development Manual, Third Edition: A Quality-Driven Approach for Translating Evidence Into Action" were followed explicitly. The GUG was convened with representation from the disciplines of otolaryngology-head and neck surgery, otology, pediatrics, audiology, anesthesiology, family medicine, advanced practice nursing, speech-language pathology, and consumer advocacy.

ACTION STATEMENTS

The GUG made strong recommendations for the following KASs: (14) clinicians should prescribe topical antibiotic ear drops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea; (16) the surgeon or designee should examine the ears of a child within 3 months of tympanostomy tube insertion AND should educate families regarding the need for routine, periodic follow-up to examine the ears until the tubes extrude.The GUG made recommendations for the following KASs: (1) clinicians should not perform tympanostomy tube insertion in children with a single episode of otitis media with effusion (OME) of less than 3 months' duration, from the date of onset (if known) or from the date of diagnosis (if onset is unknown); (2) clinicians should obtain a hearing evaluation if OME persists for 3 months or longer OR prior to surgery when a child becomes a candidate for tympanostomy tube insertion; (3) clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer AND documented hearing difficulties; (5) clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who do not receive tympanostomy tubes, until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected; (6) clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media who do not have middle ear effusion in either ear at the time of assessment for tube candidacy; (7) clinicians should offer bilateral tympanostomy tube insertion in children with recurrent acute otitis media who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy; (8) clinicians should determine if a child with recurrent acute otitis media or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors; (10) the clinician should not place long-term tubes as initial surgery for children who meet criteria for tube insertion unless there is a specific reason based on an anticipated need for prolonged middle ear ventilation beyond that of a short-term tube; (12) in the perioperative period, clinicians should educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications; (13) clinicians should not routinely prescribe postoperative antibiotic ear drops after tympanostomy tube placement; (15) clinicians should not encourage routine, prophylactic water precautions (use of earplugs or headbands, avoidance of swimming or water sports) for children with tympanostomy tubes.The GUG offered the following KASs as options: (4) clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for 3 months or longer (chronic OME) AND symptoms that are likely attributable, all or in part, to OME that include, but are not limited to, balance (vestibular) problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life; (9) clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is likely to persist as reflected by a type B (flat) tympanogram or a documented effusion for 3 months or longer; (11) clinicians may perform adenoidectomy as an adjunct to tympanostomy tube insertion for children with symptoms directly related to the adenoids (adenoid infection or nasal obstruction) OR in children aged 4 years or older to potentially reduce future incidence of recurrent otitis media or the need for repeat tube insertion.

DISRUPTIVE INNOVATION IN HEALTHCARE: A REVIEW AND FUTURE RESEARCH AGENDAS

Disruptive innovation (DI) refers to a mode of low cost high ancillary performance innovation that starts at the lower end of the market and gradually moves up to eventually displace its incumbent counterparts. The concept of DI has become more and more popular in the healthcare sector. The paper studies how healthcare research has embraced the concept of DI in various areas within the healthcare sector. Areas of healthcare, where DI has been adopted as a management strategy, were identified in the last two decades, through initially shortlisting 157 papers and the final reviewed set of 117 papers. Through a multi-method approach comprising of co-word analysis, identification of themes, mapping of research work across these themes and geography, the study found that, although from a management perspective there are 13 major themes, the majority of the focus is on four major themes—healthcare delivery and services, healthcare administration, technology and equipment, and nursing and palliative care. Furthermore, the majority of the geography-specific research was conducted in developed countries, especially the USA. It was also observed that organisational strategies for successfully implementing DI in the healthcare sector are still in the nascent stage and the focus is mostly in the area of healthcare delivery and administration from the management perspective. Future research studies could aim at looking at the role that DI plays in the healthcare sector of the developing countries, as well as using DI in other areas of healthcare, rather than a few concentrated areas.

Exploring Factors Associated With Morbidity and Mortality in Patients With Do-Not-Resuscitate Orders: A National Surgical Quality Improvement Program Database Analysis Within Surgical Groups

BACKGROUND

Anesthesiologists caring for patients with do-not-resuscitate (DNR) orders may have ethical concerns because of their resuscitative wishes and may have clinical concerns because of their known increased risk of morbidity/mortality. Patient heterogeneity and/or emphasis on mortality outcomes make previous studies among patients with DNR orders difficult to interpret. We sought to explore factors associated with morbidity and mortality among patients with DNR orders, which were stratified by surgical subgroups.

METHODS

Exploratory retrospective cohort study in adult patients undergoing prespecified colorectal, vascular, and orthopedic surgeries was performed using the American College of Surgeons National Surgical Quality Improvement Program Participant Use File data from 2010 to 2013. Among patients with preoperative DNR orders (ie, active DNR order written in the patient's chart before surgery), factors associated with 30-day mortality, increased length of stay, and inpatient death were determined via penalized regression. Unadjusted and adjusted estimates for selected variables are presented.

RESULTS

After selection as above, 211,420 patients underwent prespecified procedures, and of those, 2755 (1.3%) had pre-existing DNR orders and met above selection to address morbidity/mortality aims. By specialty, of these patients with a preoperative DNR, 1149 underwent colorectal, 870 vascular, and 736 orthopedic surgery. Across groups, 36.2% were male and had a mean age 79.9 years (range 21-90). The 30-day mortality was 15.4%-27.2% and median length of stay was 6-12 days. Death at discharge was 7.0%, 13.1%, and 23.0% in orthopedics, vascular, and colorectal patients with a DNR, respectively. The strongest factors associated with increased odds of 30-day mortality were preoperative septic shock in colorectal patients, preoperative ascites in vascular patients, and any requirement of mechanical ventilation at admission in orthopedic patients.

CONCLUSIONS

In patients with DNR orders undergoing common surgical procedures, the association of characteristics with morbidity and mortality varies in both direction and magnitude. The DNR order itself should not be the defining measure of risk.

[Patient-centered perioperative vigilance: perioperative process quality, effectiveness of pain treatment and mobilization progress after implementation of a treatment bundle for total knee endoprosthesis]

Hintergrund

In den USA wurde das Konzept des „perioperative surgical home“ initialisiert, in dem ein teamorientiertes Vorgehen einen umfassenderen und zügigeren Heilverlauf erzielen soll.

Fragestellung

Evaluation des Effekts eines interdisziplinären Maßnahmenbündels (patient*innenzentrierte perioperative Versorgung, PPV) auf Aspekte der Prozessqualität unter deutschen Rahmenbedingungen.

Material und Methoden

Nach Einführung des PPV-Maßnahmenbündels (1. Patient*innenseminar, 2. spezifische Chirurgietechnik, 3. spezifische Anästhesietechnik, 4. Physiotherapiebeginn am Operationstag) wurden 34 Patient*innen mit elektiver Knietotalendoprothese prospektiv untersucht und mit „matched-pair“-Kontrollen verglichen. Endpunkte sind Dauer der Einleitungszeit (primär) und Krankenhausverweildauer, Ruhe- und Belastungsschmerz am 1. postoperativen Tag (numerische Analogskala), und Mobilisationsfortschritt (MBF) an den postoperativen Tagen 1, 3 und 6 (sekundär). Gruppenvergleiche wurden mit Wilcoxon-Mann-Whitney-Tests auf Nichtunterlegenheit durchgeführt. Im Fall von Nichtunterlegenheit wurde anschließend auf Überlegenheit getestet.

Ergebnisse

Die Einleitungszeit in der PPV-Gruppe betrug im Median 13,5 min (Kontrollgruppe: 60 min, p < 0,0001), die Krankenhausverweildauer betrug in der PPV-Gruppe 8 Tage (Kontrollgruppe: 12 Tage, p < 0,0001). Am ersten postoperativen Tag betrug die mediane Ruheschmerzstärke in der PPV-Gruppe 30 (Kontrollgruppe: 20); die Belastungsschmerzstärke war in beiden Gruppen gleich (Median 40). Die Mobilisation der Patienten*innen der PPV-Gruppe gelang an den postoperativen Tagen 1, 3 und 6 besser (jeweils p < 0,0001).

Schlussfolgerung

Das Konzept der patient*innenzentrierten perioperativen Versorgung (PPV) erscheint vielversprechend genug, um weitere klinische Studien zu rechtfertigen.

Perioperative Surgical Home Models

The rising prominence of value-based health care and population health management supports evolving perioperative surgical home (PSH) models that rely on continuously evolving evidence-based best practice and telemedicine and telehealth, including mobile technologies and connectivity. To successfully deliver greater perioperative valued-based care and to effectively contribute to sustained and meaningful perioperative population health management, the scope of existing perioperative management and its associated services and care provider skills must be expanded. This article focuses on the PSH model as continued opportunity and mechanism for delivering greater value-based, comprehensive perioperative assessment and global optimization of surgical patients.

Organization of Multidisciplinary Cancer Care for the Surgical Patient: Role of Anesthesiologists

Purpose of review

The purpose of this review is to describe significant recent trends or developments regarding the role of anesthesiologists in a multidisciplinary team approach to cancer care for the surgical patient. We also discuss our own institutional multidisciplinary approach as a comprehensive cancer center with high surgical volume.

Recent findings

Beyond the multidisciplinary team meeting concept, and local, institution-specific, or national programs, more formalized concepts and models of perioperative care have evolved. These provide a framework for robust involvement of anesthesiologists in cancer care for the surgical patient, with the goal of allowing for optimal individualized cancer outcomes.

Summary

Because of the wide-ranging nature of their perioperative expertise, anesthesiologists play an important role in multidisciplinary team cancer care for surgical patients. This role has been seen in the recent trends toward clinical models, such as the perioperative surgical home and enhanced recovery programs. Areas for future research include multidisciplinary assessment of the impact of such models on perioperative cancer outcomes through integration of data from national outcomes groups.

Undergraduate students' perspectives of healthcare professionals' use of shared decision-making skills

Essential for future healthcare professionals (HCPs) to delivering ethical and empathetic patient-centred care (PCC) as a team is the understanding of appropriate shared decision-making (SDM) responses when facilitating discussions with patients and family members. The purpose of this study was to evaluate undergraduate students' perspectives about HCPs' use of SDM as described in a case-study reflection assignment. An exploratory qualitative approach was used to analyse student-reflection assignments. The sample included 42 undergraduate students enrolled in an interprofessional education (IPE) course at a Midwest university based in the United States. Data consisted of student responses in a course reflection assignment that captured their perspectives about recommended SDM responses by HCPs. Student assignments were randomly selected using stratified sampling to provide representation of eight HCP roles. Analysis revealed two themes related to students' use of SDM responses. Results provide evidence supporting the tenet that through IPE, healthcare students can develop an understanding of SDM and ethical principles related to PCC.

An Ambulatory Surgery Perioperative Surgical Home in Kaiser Permanente Settings: Practice and Outcomes

BACKGROUND

The aim of this study is to describe the design, implementation, and associated outcome changes of a Perioperative Surgical Home (PSH) for patients undergoing ambulatory laparoscopic cholecystectomy in a Kaiser Permanente practice model.

METHODS

A multidisciplinary planning committee of 15 individuals developed and implemented a new PSH program. A total of 878 subjects were included in the preimplementation period (T-fast), and 1082 patients were included in the postimplementation period (PSH) based on the date of their surgery. The primary goal of this report was to assess the changes in patient outcomes associated with this new PSH implementation on variables such as total length of stay and unplanned hospital admission (UHA).

RESULTS

Patients assigned to the PSH model had a significantly shorter mean length of stay compared with patients in the T-fast group (162 ± 308 vs 369 ± 790 minutes, P = .00005). UHA was significantly higher in the T-fast group as compared with the PSH group (8.5% [95% CI 6.6-10.4] vs 1.7% [0.9-2.5], P < .00005). There was no difference in the 7 days readmission rates between patients managed in the T-fast track and the PSH track (5.4% [3.8-7.0] vs 5.0% [3.6-6.3], P = .066).

CONCLUSIONS

Introduction of the PSH into a Kaiser Permanente model of care was associated with a simultaneous decrease of length of stay and UHA for laparoscopic cholecystectomy patients.

An electronic surgical order, undertaking patient education, and obtaining informed consent for regional analgesia before the day of surgery reduce block-related delays

Background

Obtaining patient informed consent for a regional analgesia block on the day of surgery can result in surgical case delays. We hypothesized that implementing a preoperative electronic surgical order, undertaking patient education, and obtaining informed consent for a regional block in our preoperative assessment clinic prior to the day of surgery would reduce surgical case delays attributed to our regional anesthesia pain service and increase the percentage of patients for whom our regional anesthesia pain service was requested to provide a block.

Methods

A prospective two-group time-series design, with a nonrandomized, pre- and post-intervention data collection strategy, was applied. Based upon the surgeons’ newly implemented preoperative electronic outpatient orders, patients were identified by our preoperative assessment clinic staff to receive educational materials. The attending anesthesiologist in the preoperative assessment clinic then obtained written informed consent. Block-related delay and utilization data were analyzed with conventional inferential statistics.

Results

We observed a 14.8% (95% CI: 9.4%, 20.1%; P<0.001) decrease in surgical case delays, attributed to the regional nerve block, in the post- vs pre-intervention group. In addition, there was a 9.9% (95% CI: 4.7%, 15.1%); P<0.001) increase in the proportion of patients for whom a regional nerve block was ordered by our three high-volume orthopedic surgeons in the post- vs pre-intervention time periods.

Conclusion

When performed before the day of surgery, a surgeon’s electronic order, patient education, and informed consent for regional postoperative analgesia can improve patient throughput, thereby reducing block-related operating room delays. The preoperative assessment clinic can serve as a venue to achieve this goal, thereby adding value by decreasing downstream delays on the day of surgery.