Community hospitals are acutely affected by high-risk, high-cost surgical patients. Increasingly, sicker patients are choosing the hospital setting for surgery, while lower acuity, “easier” cases move to ambulatory sites like free-standing surgery centers. By focusing improvement efforts on inpatient surgery, hospitals have a chance to address many of the high-risk cases that account for 50 percent of annual health care expenditures.
Hospitals can take care of these patients more efficiently—and improve outcomes and satisfaction—by making a concerted and coordinated effort to avoid costly complications and help more of these patients return to their homes after discharge. This white paper explores a new model for surgical care—the Perioperative Surgical Home (PSH)—which is helping hospitals achieve these goals.
Traditional perioperative care tends to follow a linear pathway. That is, there is a sequence of events that must occur in a specific order for a patient to move from diagnosis to pre-operative care, surgery and then post-operative care and discharge. Although this conventional model addresses surgical care needs, it can be long and costly both to the facility and the patient.
For example, a patient who presents to the emergency department with a hip fracture may experience a care process that looks something like this:
- Emergency department physician diagnoses hip fracture and notifies hospital medicine team.
- Hospitalist admits the patient, conducts an assessment and requests a surgical consult.
- Surgeon assesses the patient and determines if she is eligible for surgery.
- Surgeon consults with the anesthesia department and schedules the procedure.
- Anesthesiologist conducts pre-operative risk assessment.
- Patient undergoes surgery.
In this scenario, it can take up to 36 hours before the pre-surgical process begins. During that time the hospital and patient incur more than a day’s worth of hospital costs while facing increased risks for infection and other complications that could be avoided with a more streamlined path to surgery and recovery.
DESIGNING THE PSH
Recognizing opportunities for improving conventional surgical care processes, several years ago the American Society of Anesthesiologists (ASA) began developing the PSH, a new, more coordinated and efficient model for perioperative care.
The ASA defines the PSH as “a patient-centric, team-based system of coordinated care that guides patients through the entire surgical experience, from the decision to undergo surgery to discharge and beyond.” It is a model that rethinks traditional surgical care pathways to identify ways they can be improved in order to:
- Increase adherence to evidence-informed guidelines
- Improve quality and safety of perioperative care
- Reduce complication and readmission rates
- Reduce surgical costs and provide superior value
- Enhance patient and family experience
In 2014 the ASA brought together 44 healthcare organizations from across the country in a learning collaborative to define, pilot and evaluate the PSH model relative to conventional perioperative care. When the collaborative completed its work in November 2015, the ASA said the effort demonstrated the PSH to be “an innovative care model with the potential to drive meaningful and lasting change in perioperative costs, outcomes and experience for patients nationwide.”
To build on those successes, the ASA launched a second iteration of the learning collaborative in April 2016 with 59 participants working on PSH strategies that are compatible with alternative payment models. The two-year collaborative is expected to complete its work in March 2018.
PSH IN ACTION
Under the PSH model, a multidisciplinary team of clinicians—typically led by anesthesiology—work together to implement new, standardized care pathways for surgical patients with the goal of providing better-coordinated and more efficient care that minimizes complications and speeds recovery.
To illustrate the PSH, consider the hip fracture case discussed above. In a PSH model, the patient may follow a care pathway that looks more like this:
- Emergency department physician confirms a hip fracture and immediately consults with the anesthesia and hospital medicine teams
- Hospitalist admits the patient while the anesthesiologist notifies the orthopedic surgeon and schedules the surgery
- Anesthesiologist conducts preoperative risk assessment
- Patient undergoes surgery
In this “rapid hip protocol,” early and increased coordination among clinicians allows for much faster time to surgery, often the same day. This equates to a lower overall length of stay, reduced risk for post-operative infection, and shortened rehabilitation time—all of which are associated with lower costs, better outcomes and improved satisfaction.
Another key PSH care pathway is called Enhanced Recovery After Surgery (ERAS). ERAS programs are designed to help surgical patients recover from surgery more quickly, safely shortening their hospital stay and helping them return to their normal routines faster.
Under ERAS, the multidisciplinary care team works together, following a set of evidence-based guidelines designed to speed recovery. Those guidelines include steps such as:
- Clear and consistent communication with patients about expectations regarding activity, diet and pain management before, during and after their hospital stay
- Minimal IV fluids, drains and nasogastric tubes
- Minimal use of narcotics
- Early reintroduction of diet
- Early ambulation
By focusing on streamlining surgery so patients recover more quickly, ERAS pathways have been shown to significantly reduce care time and post-operative complications.