High-Risk or Healthy, All Patients Benefit from Perioperative Care
The skyrocketing cost of health care has led health insurance providers to increasingly demand value from all providers, that is, great outcomes at ever lower costs. Surgeons provide a significant percentage of the healthcare in the US, and thus are under tremendous pressure to demonstrate “value”. Over the past 30 years, however, surgical patients have become more and more complex and fragile, and surgical outcomes very often are driven by the patient’s physiology, not the surgeon’s skill or dedication. Poorly controlled diabetes, coronary artery disease, heart failure, obesity are increasingly common in surgical patients, and these co-morbidities can derail the best efforts of highly skilled and dedicated surgeons. Preoperative management of nutritional status, anemia, diabetes, hypertension is critical to smooth recovery and a quick return to home. In addition, Enhanced Recovery After Surgery (ERAS) programs are very effective in reducing complications and shortening postoperative length of stay, and thus a better “value”. Both adequate preoperative preparation and ERAS programs, however, are time-consuming and complex. Leading hospitals are increasingly centralizing these efforts in a single clinic with staff that are familiar with the planned surgeries, know the surgeons and surgical care coordinators, and have a deep knowledge of evidence-based best practices regarding preoperative preparation of the surgical patient.
At University of Minnesota Health, the Pre-operative Assessment Clinic (PAC) has been providing this in-depth preoperative preparation for surgical patients since 2012. Over the years, the PAC has moved from a simple assessment of readiness for surgery to effective coordination of interventions required to optimize the patient. Patients with severe COPD are counseled by Complex Pulmonary Disease specialists on preoperative exercises to decrease the risk of postop respiratory complications, the CSC infusion center provides iron infusions to rapidly correct anemia and prevent the need for blood transfusions, the nurse educators provide detailed instruction around the ERAS programs, and the staff anesthesiologists review each patient to ensure no surprises (ie, cancellations) the morning of surgery. In addition, over the years, the PAC anesthesiologists have worked with individual surgeon champions to develop ERAS programs for cystectomy, for colorectal surgery, and for thoracic surgery. The graph below demonstrates the effectiveness of this multidisciplinary approach, with impressive decreases in length of stay for each program.
At this time, the PAC has been seeing the sickest patients, that is, those with severe co-morbidities at high risk for postoperative complications. The effectiveness of the ERAS programs, however, is showing that even relatively well patients benefit from a visit to the PAC. Discussions about choices of anesthesia, multimodal analgesia, and what to expect in the perioperative period prepare patients and decrease the time required for preop the morning of surgery. Capacity for patient visits is growing and will continue to increase as demand grows.