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

Research Article

Austin J Anesthesia and Aalgesia. 2014;2(5): 1029.

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


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).

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