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Coffman CR, Leng JC, Ye Y, Hunter OO, Walters TL, Wang R, Wong JK, Mudumbai SC, Mariano ER. More Than a Perioperative Surgical Home: An Opportunity for Anesthesiologists to Advance Public Health. Semin Cardiothorac Vasc Anesth 2023; 27:273-282. [PMID: 37679298 DOI: 10.1177/10892532231200620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Public health and the medical specialty of anesthesiology have been closely intertwined throughout history, dating back to the 1800s when Dr. John Snow used contact tracing methods to identify the Broad Street Pump as the source of a cholera outbreak in London. During the COVID-19 pandemic, leaders in anesthesiology and anesthesia patient safety came forward to develop swift recommendations in the face of rapidly changing evidence to help protect patients and healthcare workers. While these high-profile examples may seem like uncommon events, there are many common modern-day public health issues that regularly intersect with anesthesiology and surgery. These include, but are not limited to, smoking; chronic opioid use and opioid use disorder; and obstructive sleep apnea. As an evolving medical specialty that encompasses pre- and postoperative care and acute and chronic pain management, anesthesiologists are uniquely positioned to improve patient care and outcomes and promote long-lasting behavioral changes to improve overall health. In this article, we make the case for advancing the role of the anesthesiologist beyond the original perioperative surgical home model into promoting public health initiatives within the perioperative period.
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Affiliation(s)
- Clarity R Coffman
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jody C Leng
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ying Ye
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Oluwatobi O Hunter
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Tessa L Walters
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Rachel Wang
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jimmy K Wong
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Seshadri C Mudumbai
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Edward R Mariano
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Sridhar S, Mouat-Hunter A, McCrory B. Rural implementation of the perioperative surgical home: A case-control study. World J Orthop 2023; 14:123-135. [PMID: 36998383 PMCID: PMC10044325 DOI: 10.5312/wjo.v14.i3.123] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 01/01/2023] [Accepted: 02/15/2023] [Indexed: 03/17/2023] Open
Abstract
BACKGROUND Perioperative surgical home (PSH) is a novel patient-centric surgical system developed by American Society of Anesthesiologist to improve outcomes and patient satisfaction. PSH has proven success in large urban health centers by reducing surgery cancellation, operating room time, length of stay (LOS), and readmission rates. Yet, only limited studies have assessed the impact of PSH on surgical outcomes in rural areas.
AIM To evaluate the newly implemented PSH system at a community hospital by comparing the surgical outcomes using a longitudinal case-control study.
METHODS The research study was conducted at an 83-bed, licensed level-III trauma rural community hospital. A total of 3096 TJR procedures were collected retrospectively between January 2016 and December 2021 and were categorized as PSH and non-PSH cohorts (n = 2305). To evaluate the importance of PSH in the rural surgical system, a case-control study was performed to compare TJR surgical outcomes (LOS, discharge disposition, and 90-d readmission) of the PSH cohort against two control cohorts [Control-1 PSH (C1-PSH) (n = 1413) and Control-2 PSH (C2-PSH) (n = 892)]. Statistical tests including Chi-square test or Fischer’s exact test were performed for categorical variables and Mann-Whitney test or Student’s t-test were performed for continuous variables. The general linear models (Poisson regression and binomial logistic regression) were performed to fit adjusted models.
RESULTS The LOS was significantly shorter in PSH cohort compared to two control cohorts (median PSH = 34 h, C1-PSH = 53 h, C2-PSH = 35 h) (P value < 0.05). Similarly, the PSH cohort had lower percentages of discharges to other facilities (PSH = 3.5%, C1-PSH = 15.5%, C2-PSH = 6.7%) (P value < 0.05). There was no statistical difference observed in 90-d readmission between control and PSH cohorts. However, the PSH implementation reduced the 90-d readmission percentage (PSH = 4.7%, C1-PSH = 6.1%, C2-PSH = 3.6%) lower than the national average 30-d readmission percentage which is 5.5%. The PSH system was effectively established at the rural community hospital with the help of team-based coordinated multi-disciplinary clinicians or physician co-management. The elements of PSH including preoperative assessment, patient education and optimization, and longitudinal digital engagement were vital for improving the TJR surgical outcomes at the community hospital.
CONCLUSION Implementation of the PSH system in a rural community hospital reduced LOS, increased direct-to-home discharge, and reduced 90-d readmission percentages.
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Affiliation(s)
- Srinivasan Sridhar
- Center for Health Outcomes and Policy Evaluation, College of Public Health, The Ohio State University, Columbus, OH 43210, United States
| | - Amy Mouat-Hunter
- Preanesthesia Clinic, Bozeman Health, Bozeman, MT 59715, United States
| | - Bernadette McCrory
- Mechanical and Industrial Engineering, Montana State University, Bozeman, MT 59715, United States
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Sridhar S, Whitaker B, Mouat-Hunter A, McCrory B. Predicting Length of Stay using machine learning for total joint replacements performed at a rural community hospital. PLoS One 2022; 17:e0277479. [PMID: 36355762 PMCID: PMC9648742 DOI: 10.1371/journal.pone.0277479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 10/28/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Predicting patient's Length of Stay (LOS) before total joint replacement (TJR) surgery is vital for hospitals to optimally manage costs and resources. Many hospitals including in rural areas use publicly available models such as National Surgical Quality Improvement Program (NSQIP) calculator which, unfortunately, performs suboptimally when predicting LOS for TJR procedures. OBJECTIVE The objective of this research was to develop a Machine Learning (ML) model to predict LOS for TJR procedures performed at a Perioperative Surgical Home implemented rural community hospital for better accuracy and interpretation than the NSQIP calculator. METHODS A total of 158 TJR patients were collected and analyzed from a rural community hospital located in Montana. A random forest (RF) model was used to predict patient's LOS. For interpretation, permuted feature importance and partial dependence plot methods were used to identify the important variables and their relationship with the LOS. RESULTS The root mean square error for the RF model (0.7) was lower than the NSQIP calculator (1.21). The five most important variables for predicting LOS were BMI, Duke Activity Status-Index, diabetes, patient's household income, and patient's age. CONCLUSION This pilot study is the first of its kind to develop an ML model to predict LOS for TJR procedures that were performed at a small-scale rural community hospital. This pilot study contributes an approach for rural hospitals, making them more independent by developing their own predictions instead of relying on public models.
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Affiliation(s)
- Srinivasan Sridhar
- Mechanical and Industrial Engineering, Montana State University, Bozeman, Montana, United States of America
| | - Bradley Whitaker
- Electrical and Computer Engineering, Montana State University, Bozeman, Montana, United States of America
| | | | - Bernadette McCrory
- Mechanical and Industrial Engineering, Montana State University, Bozeman, Montana, United States of America
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Crain N, Qiu CY, Moy S, Thomas S, Nguyen VT, Lee-Brown M, Laplace D, Naughton J, Morkos J, Desai V. Implementation science for the adductor canal block: A new and adaptable methodology process. World J Orthop 2021; 12:899-908. [PMID: 34888150 PMCID: PMC8613678 DOI: 10.5312/wjo.v12.i11.899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/18/2021] [Accepted: 09/27/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Following the successful Perioperative Surgical Home (PSH) practice for total knee arthroplasty (TKA) at our institution, the need for continuous improvement was realized, including the deimplementation of antiquated PSH elements and introduction of new practices.
AIM To investigate the transition from femoral nerve blocks (FNB) to adductor canal nerve blocks (ACB) during TKA.
METHODS Our 13-month study from June 2016 to 2017 was divided into four periods: a three-month baseline (103 patients), a one-month pilot (47 patients), a three-month implementation and hardwiring period (100 patients), and a six-month evaluation period (185 patients). In total, 435 subjects were reviewed. Data within 30 postoperative days were extracted from electronic medical records, such as physical therapy results and administration of oral morphine equivalents (OME).
RESULTS Our institution reduced FNB application (64% to 3%) and increased ACB utilization (36% to 97%) at 10 mo. Patients in the ACB group were found to have increased ambulation on the day of surgery (4.1 vs 2.0 m) and lower incidence of falls (0 vs 1%) and buckling (5% vs 27%) compared with FNB patients (P < 0.05). While ACB patients (13.9) reported lower OME than FNB patients (15.9), the difference (P = 0.087) did not fall below our designated statistical threshold of P value < 0.05.
CONCLUSION By demonstrating closure of the “knowledge to action gap” within 6 mo, our institution’s findings demonstrate evidence in the value of implementation science. Physician education, technical support, and performance monitoring were deemed key facilitators of our program’s success. Expanded patient populations and additional orthopedic procedures are recommended for future study.
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Affiliation(s)
- Nikhil Crain
- Bowman Gray Center for Medical Education, Wake Forest School of Medicine, Winston-Salem, NC 27103, United States
| | - Chun-Yuan Qiu
- Perioperative Service and Anesthesiology, Kaiser Permanente Medical Center, Baldwin Park, CA 91706, United States
| | - Stephen Moy
- Department of Anesthesiology, Baldwin Park Medical Center, Southern California Kaiser Permanente Medical Group, Baldwin Park, CA 91706, United States
| | - Shawn Thomas
- Department of Anesthesiology, Baldwin Park Medical Center, Southern California Kaiser Permanente Medical Group, Baldwin Park, CA 91706, United States
| | - Vu Thuy Nguyen
- Department of Anesthesiology, Baldwin Park Medical Center, Southern California Kaiser Permanente Medical Group, Baldwin Park, CA 91706, United States
| | - Mijin Lee-Brown
- Department of Anesthesiology, Baldwin Park Medical Center, Southern California Kaiser Permanente Medical Group, Baldwin Park, CA 91706, United States
| | - Diana Laplace
- Department of Anesthesiology, Baldwin Park Medical Center, Southern California Kaiser Permanente Medical Group, Baldwin Park, CA 91706, United States
| | - Jennifer Naughton
- Department of Anesthesiology, Baldwin Park Medical Center, Southern California Kaiser Permanente Medical Group, Baldwin Park, CA 91706, United States
| | - John Morkos
- Johns Hopkins University, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, United States
| | - Vimal Desai
- Department of Anesthesiology, Baldwin Park Medical Center, Southern California Kaiser Permanente Medical Group, Baldwin Park, CA 91706, United States
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Perioperative population management for primary hip arthroplasty reduces hospital and postacute care utilization while maintaining or improving care quality. J Clin Anesth 2020; 68:110072. [PMID: 33099240 DOI: 10.1016/j.jclinane.2020.110072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/14/2020] [Accepted: 09/20/2020] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE Physician-led multidisciplinary care coordination decreases hospital-associated care needs. We aimed to determine whether such care coordination can show benefits through the posthospital discharge period for elective hip surgery. DESIGN Time Series of prospectively recorded and historical data. SETTING Academic tertiary care medical center and health system. PATIENTS 449 patients undergoing elective primary hip surgery. INTERVENTIONS For the intervention group we redesigned care with a comprehensive 14-16 week multidisciplinary standardized clinical pathway, the Ochsner hip arthroplasty perioperative surgical home (PSH). Essential pathway components were preoperative medical risk assessment, frailty scoring, home assessment, education and expectation setting. Collaborative team-based care, rigorous application of perioperative milestones, and proactive postoperative care coordination were key elements. MEASUREMENTS The intervention group was compared to historical controls with regard to demographics, risk factors, quality metrics, resource utilization and discharge disposition, the primary outcomes were hospital length of stay and postacute facility utilization. MAIN RESULTS Compared to historical controls, the intervention group had similar risk factors and the same or better quality outcomes. It had less combined skilled nursing facility (SNF) and inpatient rehabilitation facility (IRF) utilization compared to controls (16.5% vs. 27.5%). More intervention patients were discharged with home self-care compared to historical controls (10.7% vs 5.3%). During the intervention period combined SNF/IRF utilization decreased substantially from 19.8% early on, to 13.2% during a later phase. Intervention patients had fewer hospital days compared to historical controls (1.86 vs 3.34 days, respectively; P < 0.0001). CONCLUSIONS A perioperative population management oriented care model redesign was effective in decreasing hospital days and postacute facility-based care utilization, while quality metrics were maintained or improved.
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Park HS, Kim SH, Bong MR, Choi DK, Kim WJ, Ku SW, Ro YJ, Choi IC. Optimization of the Operating Room Scheduling Process for Improving Efficiency in a Tertiary Hospital. J Med Syst 2020; 44:171. [PMID: 32803733 DOI: 10.1007/s10916-020-01644-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/11/2020] [Indexed: 11/25/2022]
Abstract
Efficient operating room (OR) scheduling can improve OR utilization and reduce costs. We hypothesize that the scheduling office (ORSO) leading the modification scheduling process could increase OR utilization rate. Using retrospective data from a single tertiary hospital in two consecutive calendar years, we compared OR utilization rate, the number of daily cases and cumulative operative time in the pre- and post-implementation of scheduling process alteration. We operated about 100,609 cases in the OR during the study period. Daytime utilization rate increased from 85.6% to 89.4% (P < 0.001); overall OR utilization rate from 115.1% to 117.6% (P = 0.019); daily case numbers from 229.9 ± 7.3 to 239.6 ± 7.6 (P = 0.0.14); and cumulative operation time of total and daytime cases from 611.7 case-hour/day to 624.5 case-hour/day (P = 0.013) and from 510.8 case-hour/day to 533.8 case-hour/day (P < 0.001), respectively. Evening/night time case-hour significantly decreased from 100.9 case-hour/day to 90.7 case-hour/day (P < 0.001). The optimization of the scheduling process and coordination by the office during regular workhours resulted in enhanced OR efficiency. The OR scheduling office can act as a control tower to make OR management more flexible, which can improve efficiency and carry financial benefits in tertiary hospitals.
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Affiliation(s)
- Hee-Sun Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Seoul, Songpa-gu, 05505, South Korea
| | - Sung-Hoon Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Seoul, Songpa-gu, 05505, South Korea.
| | - Myoung-Rye Bong
- Office for Operating Room Schedule Management, Department of Nursing, Asan Medical Center, Seoul, Republic of Korea
| | - Dae-Kee Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Seoul, Songpa-gu, 05505, South Korea
| | - Wook-Jong Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Seoul, Songpa-gu, 05505, South Korea
| | - Seung-Woo Ku
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Seoul, Songpa-gu, 05505, South Korea
| | - Young Jin Ro
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Seoul, Songpa-gu, 05505, South Korea
| | - In-Cheol Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Seoul, Songpa-gu, 05505, South Korea
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Improving the cost, quality, and safety of perioperative care: A systematic review of the literature on implementation of the perioperative surgical home. J Clin Anesth 2020; 63:109760. [DOI: 10.1016/j.jclinane.2020.109760] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/17/2020] [Accepted: 02/28/2020] [Indexed: 12/14/2022]
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Adoption of a Urologic Oncology Perioperative Surgical Home is Associated with Decreased Total Length of Stay: A Pilot Study. UROLOGY PRACTICE 2019. [DOI: 10.1097/upj.0000000000000022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Weingarten TN, Taenzer AH, Elkassabany NM, Le Wendling L, Nin O, Kent ML. Safety in Acute Pain Medicine-Pharmacologic Considerations and the Impact of Systems-Based Gaps. PAIN MEDICINE 2019; 19:2296-2315. [PMID: 29727003 DOI: 10.1093/pm/pny079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective In the setting of an expanding prevalence of acute pain medicine services and the aggressive use of multimodal analgesia, an overview of systems-based safety gaps and safety concerns in the setting of aggressive multimodal analgesia is provided below. Setting Expert commentary. Methods Recent evidence focused on systems-based gaps in acute pain medicine is discussed. A focused literature review was conducted to assess safety concerns related to commonly used multimodal pharmacologic agents (opioids, nonsteroidal anti-inflammatory drugs, gabapentanoids, ketamine, acetaminophen) in the setting of inpatient acute pain management. Conclusions Optimization of systems-based gaps will increase the probability of accurate pain assessment, improve the application of uniform evidence-based multimodal analgesia, and ensure a continuum of pain care. While acute pain medicine strategies should be aggressively applied, multimodal regimens must be strategically utilized to minimize risk to patients and in a comorbidity-specific fashion.
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Affiliation(s)
- Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andreas H Taenzer
- Departments of Anesthesiology.,Pediatrics, The Dartmouth Institute, Dartmouth Hitchcock Medical Center, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda Le Wendling
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Olga Nin
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Michael L Kent
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
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Shah SB, Hariharan U, Chawla R. Integrating perioperative medicine with anaesthesia in India: Can the best be achieved? A review. Indian J Anaesth 2019; 63:338-349. [PMID: 31142876 PMCID: PMC6530285 DOI: 10.4103/0019-5049.258058] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Integrating perioperative medicine with anaesthesia is the need of the hour. Evolution of a new superspeciality called perioperative anaesthesia can improve surgical outcomes by quality perioperative care and guarantee imminent escalation of influence and power for anaesthesiologists. All original peer-reviewed manuscripts pertaining to surgery-specific perioperative surgical home models involving preoperative, intraoperative and postoperative initiatives spanning the past 5 years have been reviewed using PubMed and Google Scholar. Whether the perioperative surgical home model is feasible or still a distant dream in the Indian perspective has been analysed.
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Affiliation(s)
- SB Shah
- Department of Anaesthesia and Critical Care, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - U Hariharan
- Department of Anaesthesia and Intensive Care, Dr. Ram Manohar Lohia Hospital and PGIMER, CHS, New Delhi, India
| | - R Chawla
- Department of Anaesthesia and Critical Care, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
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Abstract
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.
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Affiliation(s)
- Thomas R Vetter
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Health Discovery Building, Room 6.812, 1701 Trinity Street, Austin, TX 78712-1875, USA; Department of Population Health, Dell Medical School at the University of Texas at Austin, Health Discovery Building, Room 6.812, 1701 Trinity Street, Austin, TX 78712-1875, USA.
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Abstract
Frailty is a state of decreased physiologic reserve and resistance to stressors. Its prevalence increases with age and is estimated to be 26% in those aged above 85 years. As the population ages, frailty will be increasingly seen in surgical patients receiving anesthesia. Here, we evaluate the instruments which have been developed and validated for measuring frailty in surgical patients and summarize frailty tools used in 110 studies linking frailty status with adverse outcomes post-surgery. Frail older people are vulnerable to geriatric syndromes, and complications such as postoperative cognitive dysfunction and delirium are explored. This review also considers how frailty, with its decline of organ function, affects the metabolism of anesthetic agents and may influence the choice of anesthetic technique in an older person. Optimal perioperative care includes the identification of frailty, a multisystem and multidisciplinary evaluation preoperatively, and discussion of treatment goals and expectations. We conclude with an overview of the emerging evidence that Comprehensive Geriatric Assessment can improve postoperative outcomes and a discussion of the models of care that have been developed to improve preoperative assessment and enhance the postoperative recovery of older surgical patients.
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Affiliation(s)
- Hui-Shan Lin
- Centre for Research in Geriatric Medicine, University of Queensland, Princess Alexandra Hospital, Brisbane, QLD, Australia,
- PA-Southside Clinical Unit, School of Clinical Medicine, The University of Queensland, Brisbane, QLD, Australia,
| | - Rebecca L McBride
- PA-Southside Clinical Unit, School of Clinical Medicine, The University of Queensland, Brisbane, QLD, Australia,
- Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Ruth E Hubbard
- Centre for Research in Geriatric Medicine, University of Queensland, Princess Alexandra Hospital, Brisbane, QLD, Australia,
- PA-Southside Clinical Unit, School of Clinical Medicine, The University of Queensland, Brisbane, QLD, Australia,
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Role of the Perioperative Surgical Home in Optimizing the Perioperative Use of Opioids. Anesth Analg 2017; 125:1653-1657. [DOI: 10.1213/ane.0000000000002280] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Mariano ER, Vetter TR, Kain ZN. The Perioperative Surgical Home Is Not Just a Name. Anesth Analg 2017; 125:1443-1445. [DOI: 10.1213/ane.0000000000002470] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Dexter F, Epstein RH, Sun EC, Lubarsky DA, Dexter EU. Readmissions to Different Hospitals After Common Surgical Procedures and Consequences for Implementation of Perioperative Surgical Home Programs. Anesth Analg 2017; 125:943-951. [DOI: 10.1213/ane.0000000000002017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Qiu C, Rinehart J, Nguyen VT, Cannesson M, Morkos A, LaPlace D, Trivedi NS, Mercado PD, Kain ZN. An Ambulatory Surgery Perioperative Surgical Home in Kaiser Permanente Settings: Practice and Outcomes. Anesth Analg 2017; 124:768-774. [PMID: 28027086 DOI: 10.1213/ane.0000000000001717] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Chunyuan Qiu
- From the *Department of Anesthesiology, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California; †Department of Anesthesiology and Perioperative Care, University of California Irvine, Orange, California; ‡Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, California; and §Department of Surgery, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California
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Cannesson M, Mahajan A. Anesthesiology and New Models of Perioperative Care: What Will Help Move the Needle? Anesth Analg 2017; 124:1392-1393. [PMID: 28426581 DOI: 10.1213/ane.0000000000001952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Maxime Cannesson
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California
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Hospitals with Briefer than Average Lengths of Stays for Common Surgical Procedures Do Not Have Greater Odds of Either Re-Admission Or Use of Short-Term Care Facilities. Anaesth Intensive Care 2017; 45:210-219. [DOI: 10.1177/0310057x1704500211] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We considered whether senior hospital managers and department chairs need to be concerned that small reductions in average hospital length of stay (LOS) may be associated with greater rates of re-admission, use of home health care, and/or transfers to short-term care facilities. The 2013 United States Nationwide Readmissions Database was used to study surgical Diagnosis Related Groups (DRG) with 1) national median LOS ≥3 days and 2) ≥10 hospitals in the database that each had ≥100 discharges for the DRG. Dependent variables were considered individually: 1) re-admission within 30 days of discharge, 2) discharge disposition to home health care, and/or 3) discharge disposition of transfer to short-term care facility (i.e., inpatient rehabilitation hospital or skilled nursing facility). While controlling for DRG, each one-day decrease in hospital median LOS was associated with an odds of re-admission nationwide of 0.95 (95% confidence interval [CI] 0.92–0.99; P=0.012), odds of disposition upon discharge being home care of 0.95 (95% CI 0.83–1.10; P=0.64), and odds of transfer to short-term care facility of 0.68 (95% CI 0.54–0.85; P=0.0008). Results were insensitive to the addition of patient-specific data. In the USA, patients at hospitals with briefer median LOS across multiple common surgical procedures did not have a greater risk for either hospital re-admission within 30 days of discharge or transfer to an inpatient rehabilitation hospital or a skilled nursing facility. The generalisable implication is that, across many surgical procedures, DRG-based financial incentives to shorten hospital stays seem not to influence post–acute care decisions.
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Tariq H, Ahmed R, Kulkarni S, Hanif S, Toolsie O, Abbas H, Chilimuri S. Development, Functioning, and Effectiveness of a Preoperative Risk Assessment Clinic. Health Serv Insights 2016; 9:1-7. [PMID: 27812286 PMCID: PMC5090289 DOI: 10.4137/hsi.s40540] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 09/25/2016] [Accepted: 09/27/2016] [Indexed: 11/05/2022] Open
Abstract
Lee first described the concept of preoperative assessment testing (PAT) clinic in 1949. An efficiently run clinic is associated with increased cost-effectiveness by lowering preoperative admission time and thus reducing the length of stay and the associated costs. The setup of the PAT clinic should be based on the needs, culture, and resources of the institution. Various models for the setup of PAT clinic have been described, including the concept of a perioperative surgical home, which is a patient-centered model designed to improve health and the delivery of health care and to reduce the cost of care. Although there are several constraints in the development of PAT clinics, with increasing awareness about the usefulness of pre-operative risk assessments, growing bodies of literature, and evidence-based guidelines, these clinics are becoming a medical necessity for the improvement of perioperative care.
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Affiliation(s)
- Hassan Tariq
- Department of Medicine, Bronx Lebanon Hospital Center, Bronx, New York, NY, USA
| | - Rafeeq Ahmed
- Department of Medicine, Bronx Lebanon Hospital Center, Bronx, New York, NY, USA
| | - Salil Kulkarni
- Department of Medicine, Bronx Lebanon Hospital Center, Bronx, New York, NY, USA
| | - Sana Hanif
- Department of Medicine, Bronx Lebanon Hospital Center, Bronx, New York, NY, USA
| | - Omesh Toolsie
- Department of Medicine, Bronx Lebanon Hospital Center, Bronx, New York, NY, USA
| | - Hafsa Abbas
- Department of Medicine, Bronx Lebanon Hospital Center, Bronx, New York, NY, USA
| | - Sridhar Chilimuri
- Department of Medicine, Bronx Lebanon Hospital Center, Bronx, New York, NY, USA
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