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Better Outcomes And Lower Costs: The Perioperative Surgical Home

Tue, 06/03/2014 - 9:58am
Jane C.K. Fitch, M.D.

Whether it’s a knee replacement avoided for years or an urgent life-saving tumor removal, when the decision for surgery occurs, too often the patient begins a journey into a complex system of fragmented medical care. Perioperative care, which generally refers to the three phases of surgery — preoperative, intraoperative and postoperative — can be variable and fragmented. Patients can experience lapses in care, duplication of tests and preventable harm. Costs rise, complications occur, physicians and other health care team members become frustrated, and as a result the patient and family may experience an overall lower quality health care experience.

The perioperative surgical home (PSH) is an innovative practice model that has been proposed by the American Society of Anesthesiologists (ASA®) as a potential solution to improve the quality and safety of the patient experience of care, and to decrease cost.

The PSH is a patient-centered delivery system that aligns with the National Quality Strategy to achieve the triple aim of improving health, improving the delivery of health care and reducing the cost of care. These goals are met through shared decision-making and seamless continuity of care for the surgical patient, from the moment the decision to have surgery is made, all the way through recovery, discharge and beyond. Under this model, each patient will receive the right care, at the right place and the right time.

As a specialty that is constantly focused on performance improvement, the PSH model should address limitations of our current system. The surgical experience today is characterized by significant variability of care, driven by the number of patients and individual surgeon and physician anesthesiologist preference. One way to reduce variability is to treat the entire episode as one continuum of care. This continuum can be achieved by having one perioperative team that coordinates and manages all aspects of care from the minute the surgeon decides to operate until 30-days post-discharge. Under the PSH model, patient-centered care and shared decision-making at each step of the process would greatly improve our current system.

The patient may enter into the PSH through a “virtual portal” by electronic access to his or her own medical record and educational materials or a more “physical portal” where the patient can communicate with clinicians in person or electronically, or some combination of both virtual and physical entry. When the patient enters into the PSH, the physician anesthesiologist ensures that specific risk factors are assessed during the preoperative period for every patient prior to surgery. The central idea is not to “clear the patient for surgery” but rather to optimize the patient for surgery based on risk factors and evidence-based protocols. Standardization of anesthetic/nursing/surgical protocols is a critical component of the PSH, with all protocols determined in advance. Similarly, nutrition management, a recovery plan, rescue from medical complications and smooth transition of care are all part of the PSH pathway.

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