Perioperative surgical home models and enhanced recovery after surgery

Hi there, I am Dr. Robert Bilkovski and this is the beginning of a new podcast series on the topic of perioperative safety, where we take a look at concepts that apply to improving the perioperative journey which include topics on intraoperative paralysis, the depth of sedation, nociception monitoring, intraoperative awareness, and others. More importantly principles of a “systems approach” to improving patient outcomes will be covered throughout this podcast series.

Let us begin with a discussion on the concept of the perioperative surgical home and the Enhanced Recovery After Surgery, or ERAS.

To no one’s surprise, the field of medicine is constantly changing and so too are the requirements of anesthesiology, specifically as it looks to the perioperative space. Historically, the patient undergoing surgery will encounter the anesthesiologist relatively late in current surgical pathways where important decisions regarding sedation and pain management paradigms are made, in addition to patient counseling. The latter may or may not have been the focus of the anesthesiologist. ¹

The introduction of ERAS first spawned in the 1990s out of Denmark where researchers found that fast-tracking patients undergoing sigmoid colon surgery could have hospital stays reduced from an average of ten days, down to as little as two days. ²

The principles applied in this study evolved to shape the ERAS Society which was officially created in Sweden in 2010. There are multiple ERAS guidelines that have been published since, but common themes exist, which include the patient preparatory steps before surgery (such as patient counseling, education, and lifestyle modifications) through the post-operative period and all require coordination between surgeons, anesthesiologists, dietitians, physical medicine and rehabilitation professionals, psychiatrists, psychologists, and pharmacists to name a few.

Examples of ERAS protocols include: 

1. Multimodal analgesia: Multimodal analgesia protocols commence during the initial patient's evaluation as part of the preoperative evaluation clinic appointment. The preoperative evaluation also educates patients on different modalities that will be used during surgery and obtains the necessary informed consent for interventions such as neuraxial or regional blocks. The aim of these multimodal analgesia protocols extends into the intraoperative and postoperative periods, with emphasis on opioid sparing and opioid-free regimens that can bear impact on post-operative recovery in the PACU or in the hospital.
2. Goal-directed fluid therapy: Individualized goal-directed fluid therapy is a central element of ERAS in preoperative, intraoperative, and postoperative phases with the goal being to maintain euvolemia, which is a balance between fluids lost during surgery offset by fluids administered whether that is IV fluids, blood, or other products. Risk is stratified based on surgery type, where patients undergoing major surgery and/or with risk factors will benefit from an individualized goal-directed fluid plan. Of note, favorable outcomes have been reported with use of goal-directed fluid strategies and have been shown to reduce morbidity, mortality, and lengths of stay in the ICU and hospital.³
3. Post-Operative Nausea and Vomiting Prophylaxis: Similar to multimodal analgesia, the anesthesia care team will determine the most suitable strategy during the preoperative evaluation and will also leverage risk stratification based on surgery complexity and patient comorbidities to provide the optimal care plan.

In the United States, the American Society of Anesthesiologists have defined the Perioperative Surgical Home (or PSH) which builds off of the ERAS framework. The PSH serves as a patient-centric, team-based model of care to help meet the demands of a rapidly approaching health-care paradigm emphasizing value, patient satisfaction, and a reduction in costs. The goals of the PSH are to improve patient satisfaction, improve the quality of perioperative care delivered, and reduce the cost of surgical care. A notable concern is the focus during the intraoperative period with the interplay between depth of sedation and blood pressure can result in the “triple effect” where hypotension in the presence of a low mean alveolar concentration of inhaled anesthetics combined with a low sedation level  is an ominous predictor of morbidity and mortality. ⁴

This triple effect highlighted by Sessler et al.⁴ opens the door to consider concepts such as   AoA , or Adequacy of Anesthesia, whereby continuous monitoring of the depth of sedation, nociception-antinociception balance monitoring and quantitative neuromuscular monitoring may support the anesthesiologist in driving improvements in patient outcomes.

The study conducted by Vetter helped to shine a light on the clinical and economic outcomes that could result from implementation of the PSH construct. ⁵

Their study focused on process standardization in the management of patients undergoing either total hip or total knee arthroplasty. There was a standardization of care during the transitions of care throughout the continuum from the decision for surgery, to the post-discharge phase. They coined the term “Perioperativist” who is an anesthesiologist that specializes in the management of the surgical patient through this continuum and was deployed in the study. The study was a 2-group, before-and-after study wherein each group was observed for 24 months. The main variable deployed in the “after group” was the expansion of the PSH concept. The results from this study showed both clinical and economic outcome improvements. There was a 7.5% improvement in on-time day of surgery starts and a 2.2% reduction in ICU admission rates. In addition, there was a $432 decrease in direct non-surgery costs for total hip arthroplasty and $601 for total knee arthroplasty. 

These results help lay the foundation that structured operational efficiencies in the OR lead by anesthesiologists that touch the continuum of surgical care can improve outcomes to the patient and economically. Clearly more studies are needed to continue to grow awareness and understanding of both Perioperative Surgical Home model and Enhanced Recovery After Surgery framework. ⁶

This concludes the introductory podcast in this series, be on the lookout for more content as we take aim at means to further improve patient safety and operating room efficiencies. Thanks for listening.

References:

1. Elhassan A, Elhassan I, Elhassan A, Sekar KD, Cornett EM, Urman RD, Kaye AD. Perioperative surgical home models and enhanced recovery after surgery. J Anaesthesiol Clin Pharmacol. 2019 Apr;35(Suppl 1):S46-S50. doi: 10.4103/joacp.JOACP_47_18. PMID: 31142959; PMCID: PMC6515720.
2. Kehlet, H., 1997. Multimodal approach to control postoperative pathophysiology and rehabilitation. British journal of anaesthesia, 78(5), pp.606-617
3. Rollins, K.E. and Lobo, D.N., 2016. Intraoperative goal-directed fluid therapy in elective major abdominal surgery: a meta-analysis of randomized controlled trials. Annals of surgery, 263(3), p.465
4. Sessler, D.I., Sigl, J.C., Kelley, S.D., Chamoun, N.G., Manberg, P.J., Saager, L., Kurz, A. and Greenwald, S., 2012. Hospital stay and mortality are increased in patients having a “triple low” of low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia. The Journal of the American Society of Anesthesiologists, 116(6), pp.1195-1203
5. Vetter, Thomas R. MD, MPH; Barman, Joydip PhD, MBA; Hunter, James M. Jr MD; Jones, Keith A. MD; Pittet, Jean-Francois MD. The Effect of Implementation of Preoperative and Postoperative Care Elements of a Perioperative Surgical Home Model on Outcomes in Patients Undergoing Hip Arthroplasty or Knee Arthroplasty. Anesthesia & Analgesia 124(5):p 1450-1458, May 2017. | DOI: 10.1213/ANE.0000000000001743
6. Cannesson, Maxime MD, PhD; Mahajan, Aman MD, PhD. Anesthesiology and New Models of Perioperative Care: What Will Help Move the Needle?. Anesthesia & Analgesia 124(5):p 1392-1393, May 2017. | DOI: 10.1213/ANE.0000000000001952