Application of the Surgical Home Model to High Risk Patients Undergoing Major Surgery

Duraiyah Thangathurai and Peter Roffey*

Department of Anesthesiology, University of Southern California, USA

*Corresponding author: Peter Roffey, Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA

Received: April 30, 2014; Accepted: June 17, 2014; Published: June 20, 2014

Introduction

As yet, there are no studies involving the use of the surgical home model for high risk patients. The surgical home is a new patient-centered paradigm encouraged by the American Society of Anesthesiologists (ASA) aimed at improving quality of care in surgical patients, thereby reducing postoperative complications and improving cost effectiveness [1,2]. This model is a physician-led, multidisciplinary team-based system of coordinated care [2], which should improve patient outcome as well as minimize the number of days in the intensive care unit and the hospital.

According to the ASA, surgical care is associated with 65-70% of all hospital expenses [1]. Many patients in the postoperative period suffer from complications such as pneumonia, thromboembolism, hemodynamic compromise from sepsis or bleeding, and ventilatorrelated issues, all of which may result in significant disability or death and drive up costs during their hospital stay. The postoperative period is additionally fraught with morbidity and mortality due to improper coordination of care, system inefficiencies, medical errors, and a lack of awareness of patient problems.

The surgical home involves active participation of the anesthesiologist in the preoperative, intraoperative, and postoperative periods. Anesthesiologists are familiar with the management of patients with comorbid conditions and are in a position to provide appropriate care throughout each of these periods of hospital stay. The anesthesiologist's involvement in the preoperative assessment and optimization of a patient combined with intraoperative management to protect vital organ systems as well as postoperative pain relief, and assistance in ensuring postoperative stabilization should help produce a favorable outcome for the patient. Anesthesiologists are also recognized as leaders in patient safety. They possess the skills, expertise, knowledge, and ability to coordinate care with surgeons, other caretakers, and even hospital administrators. This concept is in congruence with recent recommendations by the American Association of Medical Colleges, including "Partnership for Patients" [1].

At the Keck School of Medicine of USC Norris Center, this model has already existed for nearly 25 years. In our model, the anesthesiology attendings are also ICU physicians that rotate through critical care; the team also includes residents who are receiving their training in critical care. The attending physicians also have additional training in pain management and in the intraoperative management of high risk patients.

When the surgeons screen their high risk patients, they notify the anesthesiologist several days in advance about any coexisting diseases and the surgical procedure/plan. At this time a discussion of preoperative issues in order to optimize care and understand the potential complications that can arise from a surgical point of view is discussed. After this, a preliminary plan is generated for preoperative, intraoperative, and postoperative management; this is refined when the patient is admitted and additional information is obtained from the patient and/or team members. The discussion also entails methods to reduce costs such as avoiding redundant or irrelevant lab tests, as well as an attempt for early extubation and optimal pain management in order to minimize stays in the ICU and help prevent potential complications.

After preoperative optimization, the patient's intraoperative anesthetic technique is tailored according to the patient's needs. The anesthesiologists are familiar with the surgical procedure, and if any deviations occur the surgeon is encouraged to notify the anesthesiologist. The anesthesiologist also coordinates with the blood bank regarding needs for transfusion of blood or blood products and labs. Intraoperatively, plans are refined for postoperative pain relief and early extubation, either in the operating room or the following morning. The same anesthesiologists are then involved in the patient's care in Postanesthesia Care Unit, telemetry, or ICU. In the ICU, rounds are performed jointly with the entire team so that each member is aware of the patient's conditions and a decision whether to discharge the patient from the ICU to the floor or stepdown unit is made. Additionally, multidisciplinary rounds are performed daily. If there are any potential complications, the intensivist is quickly notified. This early detection of possible complications aids in ensuring that appropriate treatment occurs early. Though there are various protocols in place, they are tailored or modified based on the needs of each patient. Patients underwent weaning criteria and followed commands prior to extubation.

Our study involved comparison of the time to extubation, number of days mechanically ventilated, ICU readmission, total hospital stay, and 30-day and one year mortality of those patientsmanaged in the surgical home model vs. those managed in a more traditional model, in which the critical care team was not involved in the intraoperative management of the patient. Special attention waspaid to time to extubation as this is a key factor in length of ICU stay as well as prevalence of postoperative complications such as ventilator-associated pneumonia. Additionally, intubated patients often require larger doses of sedatives/narcotics in order to tolerate the endotracheal tube; these medications can lead to ileus with delayed return of bowel function (Table 1).

Table 1:



Table 1:

Methods

The data from the perioperative period was entered into an IRBapproved database by anesthesia residents aided by an attending during the patients' stay [3]. This data was analyzed retrospectively. A total of 915 patients found between November 2010 and May 2012. Of these, 555 were managed in the surgical home model and 360 in the traditional model [4]. For patients that were discharged from the hospital, any subsequent death was determined by a review of the social security death index. Admission to ICU and time to discharge from both the ICU and the hospital were determined by review of electronic charts for first or last nursing documentation at location. Univariate analysis was performed with two tailed t-test for continuous data and the Fischer's exact test for categorical data. Preoperative comorbid conditions were analyzed if a prevalence of at least 1% was found. Significance was considered at p<0.05 and inclusion into the multivariate analysis at p<0.10. All analysis was performed using SPSS (v 16, IBM) on Ubutu Linux (10.04).

Results

Analysis initially examined age, body mass index, gender, and ASA score. Both groups involved a larger proportion of males to females, which was not unexpected due to the number of prostate cancer surgeries. Each of these factors was analyzed for association with mortality at thirty days and one year post-discharge from the critical care unit.

Patient data examined stage of cancer, Estimated Blood Loss (EBL), and need for massive transfusion (defined as greater than six units Packed Red Blood Cells (PRBC), half the patient's blood volume intraoperatively, or ten units PRBC in the postoperative period). A trend was noted towards surgery being more frequently performed for higher stage cancers in the surgical home group. The need for massive transfusion was used as a surrogate for the extensiveness of the surgery and gross complications. EBL and the incidence of massive transfusion did not differ between the two groups. Only comorbid conditions known preoperatively were considered and are summarized. Again, the groups were very similar, with the only statistically significant difference being atrial fibrillation. Patients were also analyzed for total number of comorbid conditions. The Mortality Probability Model III at admission was calculated for each patient to assess acuity. No statistical difference existed between the two groups (predicted mortality 6% [SD 5.4%] in surgical home patients, 5.9% [SD 6%] in traditional model patients).

Linear regression was performed with all variables which were found with a p<0.10. Four factors remained significant: oncologic stage, age, need for transfusion, and care team model. A subsequent analysis involving all data points to confirm these four factors remained significant despite the heterogeneity. Survival curves were generated with Kaplan-Meyer analysis for care team model, oncologic stage, ASA score, and oncologic stage/care team model. In order to understand the impact of the surgical home model on cost, critical care length of stay and ICU readmission, number of days mechanically ventilated, and total hospital stay were analyzed. Each was statistically significant.

With regard to early extubation, 37% of patients were extubated in the operating room in the surgical home model, vs. 25% in the traditional model. The difference continued with a shorter time to extubation (0.97 +/- 3.82 vs 1.64 +/- 5.75 days). Early extubation also facilitated a shorter stay in the ICU (2.72+/-4.67 vs 4.85 +/- 11.53 days) and minimized respiratory and hemodynamic complications associated with mechanical ventilation as well as sedative requirements. Despite this aggressive extubation strategy, the surgical home patients had a lower rate of re-intubation (1.44 vs 2.22%). This enabled a greater number of surgical home patients to be managed in a lower level of care who would have previously required admission to the ICU.

Discussion

This study represents an example of improved outcomes in highrisk patients as a result of the surgical home model and provides evidence that continuity of care has an impact on short term as well as long term mortality, time to extubation, as well as reduced cost indicators [5]. All patients in our study were taken care of by the same surgical home team postoperatively; therefore the difference lies in the intraoperative management and transition of care. The ability todevelop a comprehensive plan preoperatively and carry this through intraoperatively and into the postoperative period contributes to the outcome difference. Much attention is currently being paid to the loss of information during transition of care, both in the operating room and upon transport to the ICU, and the effect this has on the care of the patient in both of these settings. When a group of physicians is familiar with the patient and any events that occurred intraoperatively, this loss does not occur. Additionally, in the surgical home model described, the number of consults is minimized as pulmonary and cardiac services are minimized and cuts costs and prevents fragmentation of care.

While as physicians we feel that patient care should outweigh all other factors, medicine in the United States has become increasingly influenced by financial considerations. For a systems based model, this becomes increasingly important as health care systems must lay out the costs to implement a system such as the surgical home [6]. We therefore examined the impact of this model on financial issues, such as length of stay in ICU and in the hospital as well as days of mechanical ventilation. Patients in the surgical home model had less ICU days and less hospital days. There were also fewer total days of mechanical ventilation with surgical home patients.

Two potential issues with this study include the narrow patient population and its retrospective nature. Patients were rarely performed on an emergent basis. The relatively narrow number of cancer diagnoses may allow for a degree of specialization amongst the anesthesia providers and critical care nursing [7]. Additionally, these patients were not randomized to surgical home vs. traditional model of care. Further studies should continue to be performed examining the outcomes of high risk patients undergoing a wider variety of surgeries.

Conclusion

This study demonstrates that utilization of a surgical home can improve high-risk patient mortality at one year. We caution that in spite of our results, the feasibility of this model is not always possible nor outcomes applicable given the narrow patient population. Without a doubt, we can state that the increased involvement and long term planning by anesthesiologists is within the best interest of patients and improves their outcomes.

References

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Citation: Thangathurai D and Roffey P. Application of the Surgical Home Model to High Risk Patients Undergoing Major Surgery. Austin J Anesthesia and Analgesia. 2014;2(5): 1029. ISSN: 2381-893X

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