By Dan Paloski, Communications Specialist, AHA’s Physician Leadership Forum
As hospitals and health systems look for ways to improve quality and safety while reducing costs, one new model of care, led by anesthesiologists, is doing just that. Modeled after the patient-centered medical home (PCMH), the perioperative surgical home (PSH) model coordinates a continuum of care for patients during the preoperative, intraoperative, and postoperative periods. Two anesthesiologists leading the charge for this model at their respective institutions are Zeev Kain, MD, MBA, and Arthur Boudreaux, MD.
UAB’s Perioperative Surgical Home
The PSH model came about two years ago when the American Society of Anesthesiologists (ASA) proposed it as a patient-centered surgical care model stressing continuity of care and shared decision making. Following the ASA’s lead, the University of Alabama at Birmingham (UAB) developed its own PSH model. Similar to the ASA’s proposal, Dr. Boudreaux, professor and vice chair for Quality and Patient Safety and chief of staff at University of Alabama at Birmingham Medicine, says their PSH model is built around an integrated team of anesthesiologists and mid-level practitioners who monitor patients during the preoperative, intraoperative, and postoperative phases of care. The overall goal, according to Dr. Boudreaux, is to make the surgical continuum safer, more efficient and effective, and with better outcomes for patients at a lower cost.
During the preoperative phase, after a decision has been made for surgery, patients receive a pre-anesthetic consultation and assessment. Patients are educated on what to expect during the pre-, intra-, and postoperative surgical process, and if needed, preoperative diagnostic testing and treatments are conducted.
For the intraoperative phase, those anesthesiologists working in the PSH model meet to derive consensus on whether or not to proceed with a scheduled, elective surgery. This, in turn, helps UAB avoid possible case delays and cancellations.
During the postoperative phase, an attending anesthesiologist works in tandem with mid-level practitioners to provide continuous, focused and integrated care. When a patient is ready for discharge, the team coordinates and communicates the care plan to the setting where the patient is transitioning. Throughout each phase, patient information and data is collected and stored in an electronic health record.
UC Irvine’s Joint Surgical Home
At the University of California, Irvine, Dr. Kain, professor and chair of Anesthesiology & Perioperative Care and associate dean of Clinical Operations at the School of Medicine at the University of California, Irvine, is helping to lead their own version of the PSH model. Started in 2012 and focused on joint replacements, the Joint Surgical Home model at UC Irvine involves protocols designed for preoperative admission, intraoperative care, acute postoperative care, and post discharge. The goals of this model include reducing surgical cancellations, complications, length of stay, readmissions, and costs.
According to Dr. Kain, the Joint Surgical Home model was engineered from the bottom up through collaboration with a group that consisted of all stakeholders. These included surgeons, anesthesiologists, nurses, case managers, social workers, respiratory therapists and others. The initial challenge, he says, was the discordance in approaches to care that existed between the various stakeholders. Ultimately, these groups were brought together and devised a standardized process of care for their patients. UC Irvine took advantage of the Lean Sigma approach that was introduced to that hospital a few years ago.
Results have been nothing but positive says Dr. Kain. To date, they’ve completed 155 joint replacements. Average length of stay is 2.1 days. There has been one readmission, patient and surgeon satisfaction is high, turnover time has decreased to 23 minutes, and cancellations are at 0.4%. Because of its success, Dr. Kain says they’re in the process of replicating the model for urology patients.
Who should lead?
Both Dr. Kain and Dr. Boudreaux believe anesthesiologists are ideally suited to lead this type of model since they interact with a broad spectrum of patients across numerous care settings. Dr. Boudreaux says anesthesiologists cross all paths of medicine, which gives them a broad knowledge base. They are involved in all aspects of surgical care and the different types of surgeries.
This is not to say, however, that anesthesiologists know it all. In order to strengthen the viability of this model and lead the care systems of the future, Dr. Boudreaux says anesthesiologists need to expand their core knowledge, skills, and experience in perioperative care. Dr. Kain says additional training is on the table and that physician training programs should include more time in managing surgical patients during the postoperative period. Some anesthesiologists might see this as an infringement on their traditional intraoperative role says Dr. Boudreaux, but he expects most to see it as an expansion of their scope of practice.
Minimal pushback from clinicians
Pushback from anesthesiologists has been minimal according to Dr. Kain and Dr. Boudreaux. In fact, Dr. Kain says he’s seen nothing but enthusiasm from the physicians he works with. Dr. Boudreaux says he was shocked at the positive response he received from everyone, including surgeons and hospitalists. In fact, he said the hospitalists at his institution were so overwhelmed with work that they asked when they could start using this model.
Going forward, Dr. Kain and Dr. Boudreaux feel the model can be replicated and expanded into other areas of care. In addition to starting a Urology Surgical Home, Dr. Kain says the Joint Surgical Home model is now being tried across the five UC hospitals with selected patients. At UAB, Dr. Boudreaux says they’ve expanded their model to include an anemia management program and will soon include pre-op mental status checks for older patients, in collaboration with geriatric medicine colleagues, to better manage patients at risk for postoperative delirium.
By standardizing processes, coordinating services, and managing patients through the entire continuum of care, the PSH model has shown to improve quality while reducing costs. Continued study with collection and measurement of patient data will be crucial in determining the long-term feasibility of this model of care.
Arthur Boudreaux, MD, is professor and vice chair for Quality and Patient Safety and chief of staff at University of Alabama at Birmingham Medicine. He can be reached at firstname.lastname@example.org.
Zeev Kain, MD, MBA, is professor and chair of Anesthesiology & Perioperative Care and associate dean of Clinical Operations at the School of Medicine at the University of California, Irvine. He can be reached at email@example.com.