Once patients are scheduled to undergo a surgical procedure, they enter a hospital-based perioperative care model. Current perioperative practice in the US is characterized by a disjointed and fragmented approach, driven by “volume” rather than by “value”, and there is significant variability in the quality and purpose of preoperative consultations and the management of patients during the intraoperative and postoperative time periods.
At UCLA, our Division of Perioperative Medicine promotes a patient-centered, physician-led, multidisciplinary, and team-based system of coordinated care. It guides the patient through the entire surgical experience from the decision to operate until discharge home or to a post-acute care facility, and beyond.
The critical features defining our division and the way we redesign perioperative care are these:
In our perioperative medicine model, patient-centered care and shared decision-making replace perioperative physician-centered care. This model considers the patient’s preferences and values in perioperative decisions, which have been shown to be associated with better outcomes, decreased utilization, and better patient experience. One example of such an approach is the management of pain throughout the entire continuum from initial preoperative evaluation through the post-anesthesia care unit (PACU) and hospital stay, and helping the patient make a smooth transition to community-based pain medicine services whenever needed. To place the patient at the center, our team relies on strong collaboration among physician anesthesiologists, surgeons, hospitalists, nurses, pharmacists, care coordinators, social workers, nutritionists, physical therapists, and a host of other staff members.
Our perioperative medicine model seeks to create a continuum for the patient beginning with a review of the appropriateness and timing of the surgery, and ending 30 days after discharge with smooth transitions from home and back. This new care model is based on ensuring consistent, reproducible care throughout the patient’s experience, based on expanded yet flexible clinical pathways. These care pathways are standardized for most patients, and include a rigorous preoperative risk assessment and stratification that optimizes the management of any coexisting health problems. When this assessment process flags a patient as “high-risk”, modifications of the care pathway are applied as appropriate. These care pathways also include intraoperative management protocols for anesthetic, nursing, and surgical care, and a complete postoperative recovery plan.
To achieve optimal care at each phase of the continuum, our perioperative medicine model incorporates continuous improvement methodologies, including “lean management”, a long-term approach to work that systematically seeks to achieve small, incremental changes in processes to improve efficiency and quality. We also apply the principles of “six sigma” collaboration, which relies on team effort to improve performance by systematically removing waste and reducing variation. Outcomes are tracked, and clinical care is guided by electronic decision support in our EMR. Our informatics team is a key component of care redesign and coordination.
Our goal is for patients to have short waiting times and to have appointments coordinated to avoid making the preoperative experience lengthy or stressful. Once the patient is in the perioperative care pathway, the patient and family can contact perioperative physicians at any hour of the day or night. While the patient is in the hospital, our perioperative medicine team members coordinate care with their colleagues. Our electronic medical record (EMR) enables every member of the team to access the record at all times, and our intraoperative anesthesia record is integrated seamlessly with the EMR. Once the patient is discharged home, close follow-up continues as necessary, and a team-based approach is activated if a patient presents to a clinic or emergency department with any medical problem that may lead to readmission.
Our goal is to ensure that evidence-informed practices and protocols, in all phases of the perioperative process, are applied in a consistent way to all patients undergoing surgery. These protocols, along with better coordination of care, reduce variability and lead to higher quality and safety during the surgical episode of care. Where clear evidence does not exist, or conflicting data make it difficult to determine a single best practice, our team collaboratively develops cross-disciplinary agreements for the clinical plan of care. The consistency of our group mode of practice reduces the incidence of postoperative complications such as nausea, surgical site infection, hospital-acquired infection, venous thromboembolism, and acute lung injury, while fostering optimal surgery outcomes.
Henrik Kehlet, MD, PhD, a colorectal surgeon and professor from Copenhagen, Denmark, was the first to describe the concept of Enhanced Recovery After Surgery (ERAS). The ERAS protocol consists of 21 specific care practices, including reduced preoperative fasting and preoperative oral intake of carbohydrate-containing clear liquids, that are to be implemented with every surgical case. To date, ERAS protocols have been embraced by large-scale healthcare systems such as the National Health Services in the United Kingdom, and have been shown to decrease postoperative complications and shorten the length of stay in the hospital. Our perioperative medicine team incorporates many ERAS practices, yet we use a much larger conceptual framework that that includes coordination of care from the moment the decision to operate is made. We strive for minimal variation in perioperative care unless the individual patient’s condition requires it, and our goal is always to implement evidence-guided best practices for all aspects of management.