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The Perioperative Surgical Home Is Not Just a Name

Mariano, Edward R. MD, MAS*†; Vetter, Thomas R. MD, MPH; Kain, Zeev N. MD, MBA, FAAP§∥¶#

doi: 10.1213/ANE.0000000000002470
Editorials: Editorial
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From the *Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California; Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas; Departments of §Anesthesiology and Perioperative Care and Medicine, University of California, Irvine, Irvine, California; Department of Child Psychiatry, Yale University, New Haven, Connecticut; and #American College of Perioperative Medicine, Irvine, California.

Accepted for publication August 2, 2017.

Funding: None.

Conflicts of Interest: See Disclosures at the end of the article.

Reprints will not be available from the authors.

Address correspondence to Edward R. Mariano, MD, MAS, Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, 3801 Miranda Ave (112A), Palo Alto, CA 94304. Address e-mail to emariano@stanford.edu.

The history of the Perioperative Surgical Home (PSH) is a short one dating back to only 2011.1 Its tenets of better coordinating and integrating the often fragmented systems of surgical care, greater patient-centeredness, and prominent leadership by anesthesiologists are novel. The PSH model has been successfully implemented in a variety of settings.2–5 However, this new model has also generated a fair amount of confusion, controversy, and even political conflict related to the challenges of expanding the anesthesiologists’ services outside the traditional operating room setting,6,7 leadership of the PSH,8,9 and even the name itself.10 Unfortunately, resulting tensions between surgeons and anesthesiologists locally and between their respective professional societies nationally may have limited the universal acceptance of the PSH as an optimal care model.

This confusion and controversy have resulted largely from the misinterpretation of what PSH is and is not. There are no guidelines to follow when establishing a PSH. To many, the PSH is viewed as a single massive undertaking, and an “all or none” change, which are very foreign to the typical anesthesiology practice. We need to back away from this global concept and demonstrate how variations of the PSH can work across the spectrum of anesthesiology and surgery practices.

Outside of the United States, and especially in Europe and the United Kingdom, the emphasis in revamping surgical care has been on “enhanced recovery” and not the PSH. One of the documented challenges with implementing enhanced recovery programs is the large number of recommendations and protocols supported by varying levels of evidence.11 Moreover, as these protocols become more complex, the level of adherence decreases12; if adherence is low, patients do not benefit. In fact, certain elements of a protocol may be more important than others in terms of improving outcomes.13 If we apply these vital lessons, the PSH is arguably best considered a modular design, building on existing best practices, with physician leadership driving continuous improvement.

That said, a lack of minimal standards and required elements has resulted in multiple anesthesiology practices declaring themselves as having a PSH model, when in reality they simply have a functioning preoperative assessment clinic, a concept established long before the PSH.14 Such a limited implementation may not realize the ultimate potential benefits of PSH, as once again, there is no clarity as to what a PSH must include. In other words, “if you’ve seen one PSH—you’ve seen one PSH.”

In addition to preoperative evaluation, anesthesiologists are routinely involved in critical care and pain medicine. Some have argued that anesthesiologists’ established expertise in the continuum of pain medicine forms the basis for the successful implementation of a PSH.15 One optimal approach to a PSH is to take advantage of existing services for the majority of patients, bridging the gaps between them, and create new services when and where necessary for specific patient groups (eg, medically complex, chronic pain, or opioid-dependent).

In this issue of Anesthesia & Analgesia, Alvis et al16 present the implementation of a PSH within the Veterans Affairs (VA) Tennessee Valley Healthcare System based in Nashville. We acknowledge their tremendous efforts undertaken starting in January 2016 and lasting several months. The potential benefits of the PSH in the care of patients within the Veterans Health Administration have been demonstrated.4,17 To launch this model at the Nashville VA, the authors describe hiring 8 registered nurse practitioners and assigning 1 full-time, critical care-trained attending anesthesiologist to the PSH for 5–7 days at a time, to cover the service 24 hours a day, 7 days a week.16 The team’s tasks include inpatient follow-up of surgical patients from 5 procedural categories to ensure adherence to enhanced recovery protocols, daily multidisciplinary rounds, follow-up telephone calls to surgical outpatients, progress note-writing and other data entry, and “bed triage” and preoperative evaluation by the attending anesthesiologist assigned to the PSH service.16

The unfortunate effect of presenting such a complex and resource-intensive model is that it may generate a response exactly the opposite of what is undoubtedly intended―instead of inspiring the implementation of a PSH, it may convince others that it cannot be done. Since most of the work described by Alvis et al16 is nonbillable, justification of the cost for this model requires demonstration of major benefits, namely, improved outcomes and/or cost-savings. However, this is difficult to evaluate as their article lacks granular details on what actually was implemented. Because rigorous statistical analyses were not performed on the data in this article,16 we cannot simply accept the estimated differences in length of stay or hospitalization. Suggested methods for evaluating the effectiveness of a new PSH model, as well as measuring and presenting outcomes, have been published previously.18–20

There are some missing elements in this article that may have allowed it to be more externally valid (generalizable). For example, Alvis et al16 provide a brief description of developing enhanced recovery pathways for 5 separate service lines, with some of their care elements and the involved stakeholders, but they do not go into sufficient detail. Providing necessary details not only represents an opportunity to examine and to critique their protocols but also is a crucial way that we can learn from such work of others. While certain elements may be institution-specific, nearly all clinical pathways can potentially be used by others as examples to develop their own versions.

Major challenges (“opportunities”) for all stakeholders involved in surgical care, not just those with an established PSH, include selecting appropriate candidates for surgery, risk stratification, optimization, prehabilitation of selected patients before elective surgery, and coordination and integration of currently disjointed services. Yet, it is not clear how these processes were established at the Nashville VA.

To clarify, risk stratification refers to identifying patients at “high risk” for intraoperative, postoperative, and postdischarge complications and devoting the majority of perioperative resources to these patients. The term optimization before surgery refers to identification of preexisting diseases (eg, diabetes, anemia, obstructive sleep apnea) and actively intervening to mitigate anticipated postoperative complications rather than applying the widely used yet inadequate, generic “clearance for surgery” approach. Optimization means that the patient has to be initially evaluated far enough in advance, even weeks before surgery, so that needed interventions can take place. Finally, prehabilitation refers to the currently infrequent consulting of a physical therapist and/or a behavioral health specialist for selected patients, smoking cessation, exercise regimen to enhance cardiopulmonary reserve, and nutritional counseling and dietary changes before surgery.21 None of these elements were described in detail by Alvis et al.16

The process of leading any clinical practice improvement project from concept design to implementation and maintenance provides knowledge that can be applied to many other practice settings.22 Physician leadership is critical, and an essential part of any PSH is developing these leaders and providing them with the tools to be successful. While perhaps the optimal PSH leader is an anesthesiologist, who can oversee all perioperative processes, this physician leader ultimately must be selected based on local circumstances. This physician leader may be an anesthesiologist, surgeon, or hospitalist in a given setting or leadership may be shared. This decision depends on the staffing, resources, and relationships available at an individual facility.

Without a system for continuous process improvement, translating new research findings into clinical practice can take 17 years or more.23 The causes of change implementation failures have been studied24–26 and generally fall into 1 of 7 categories26:

  1. Lack of awareness―Do not know evidence exists
  2. Lack of familiarity―Know evidence exists but do not know the details
  3. Lack of agreement―Do not agree with evidence-based recommendations
  4. Lack of self-efficacy―Do not think they can do it
  5. Lack of outcome expectancy―Do not think it will work
  6. Inertia―Do not want to change
  7. External barriers―Want to change but blocked by system factors

These barriers individually and collectively are difficult to overcome, and physicians are not routinely trained in system redesign and change management. We believe that change happens in environments that foster innovation and a culture of continuous improvement.

Before a PSH can be established in any setting, there is a need for well-trained physician leaders who can promote a change-oriented culture. Critical elements when implementing any PSH include robust leadership development and process improvement methods. Two examples of the latter include the iterative plan-do-study-act (also known as plan-do-check-act) cycle27 and the consolidated framework for implementation research.28 Using the consolidated framework for implementation research model, Mudumbai et al29 have shown that a PSH facilitates regular review of clinical care pathways and updating as new evidence emerges.

The physician leader in a PSH must oversee the coordination and integration of the entire continuum of surgical care, as well as be formally trained in process improvement methods to address gaps appropriately. If we use the analogy of tiling a floor―not all floor patterns are the same just as not all surgical programs are the same. When tiling a floor, certain tiles and patterns require more labor and grout while others require less. Someone has to take charge of the project and decide how much labor and materials are needed plus when and where. Not all surgical programs, and the subspecialty service lines within them, will require the same amount of daily management. The PSH is an ever-evolving process, and team members must routinely evaluate their system and its components to determine if and when it is time to make changes.

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DISCLOSURES

Name: Edward R. Mariano, MD, MAS.

Contribution: This author helped design and prepare the manuscript.

Conflicts of Interest: Dr Mariano has received unrestricted educational program funding paid to his institution from Halyard Health (Alpharetta, GA) and B. Braun (Bethlehem, PA). These companies had no input into any aspect of the present study design and implementation; data collection, analysis and interpretation, or manuscript preparation.

Name: Thomas R. Vetter, MD, MPH.

Contribution: This author helped design and prepare the manuscript.

Conflicts of Interest: None.

Name: Zeev N. Kain, MD, MBA, FAAP.

Contribution: This author helped design and prepare the manuscript.

Conflicts of Interest: Dr Kain has received unrestricted funding paid from Edwards (Edwards, Irvine, CA), Studer Group (Pensacola, FL), and the National Institutes of Child and Health Diseases to his institution from Halyard Health (Alpharetta, GA) and B. Braun (Bethlehem, PA) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) clinical trial (R01HD048935).

This manuscript was handled by: Jean-Francois Pittet, MD.

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