Anesthesiologists can take a few steps to improve the coordination of care throughout the perioperative period and should consider safety measures that will improve the preoperative process and postoperative outcomes.
“Many of you probably say, ‘I do that already,’ but there are probably some aspects that you should consider that you probably aren’t doing,” said Douglas G. Merrill, MD, MBA, professor of anesthesiology at the University of California, Irvine Medical Center, in Orange. Dr. Merrill spoke about the perioperative surgical home (PSH) and safety at “Driving Change in Ambulatory Anesthesia,” a joint meeting held by the Society for Ambulatory Anesthesia and the American Society of Anesthesiologists.
First, Dr. Merrill advised, think data. Create systems to monitor outcomes, including those of various providers, such as physicians, nurses and home health aides. As part of the monitoring process, develop a list of the outcomes to measure, including:
- post-discharge data
- pain control
- postoperative nausea and vomiting
- PACU time
- returns to the operating room
- patient satisfaction
- infection rates
- cost of on-site care
- time to return to work
- opioid use on site
“In general, most of us do not track these data, and I know it applies to most ambulatory surgery centers,” he said. “We don’t know what happens to our patients after they leave our sites.”
Once facilities begin to monitor outcomes, they can launch a regularly recurring improvement process to expedite changes. Surgeons and staff can join anesthesia providers in creating standard care pathways for their top 20 procedures, and then compare the cost of care for each provider. These providers can then standardize their own methods to a single approach. For example, Dr. Merrill and others have used the approach of asking surgical technicians to place any surgical instrument used for a case into a pink bucket at the end of the case. Central sterilization then lists the instrumentation. This allows providers to see instrumentation that they frequently put on the tray but don’t use.
Dr. Merrill suggested getting all the surgeons in a room and buying them breakfast. “It sounds simplistic, but it’s an effective tool to help folks standardize in a way that can significantly reduce the overuse of equipment and supplies, without making physicians and [operating room] teams concerned that they won’t have what they really need.”
Facilities can also improve safety by measuring the frailty of their patients, which has a large effect on short- and long-term outcomes. Dr. Merrill suggested several tests for frailty, such as grip strength, weight loss, exhaustion, low levels of physical activity and gait. Grip strength alone can predict potential risk during surgery. Beyond frailty, the assessment of mental disability, sleep apnea, nutritional decline and social networks can predict potential delirium, complications and recurrent admissions.
“Why do this? If we know ahead of time, we can do something about it,” said Dr. Merrill, who suggested presurgical nutrition programs, home nursing rehabilitation and increased contact with caregivers. “This kind of work in advance will improve outcomes post-op, which prepares us well for the potential of bundle contracting.”
Standardization Is Key
Beyond that, ambulatory surgery centers can standardize care intraoperatively by looking at the use of opioids across providers and developing a guideline that the anesthesia team agrees to follow and monitor. If two providers use regional anesthesia for one procedure and the other three providers don’t, for example, surgical colleagues will find it difficult to explain standard experience and expectations to patients. “Adherence to standardized guidelines can better predict an expected course of treatment for patients,” Dr. Merrill pointed out.
Such standardized systems and outcome measurements can help anesthesia providers explain their value to primary care providers, hospital leaders, acute rehabilitation centers and nursing facilities. As ambulatory surgery centers demonstrate positive outcomes and lower cost, they become attractive because bundled plans can anticipate postoperative care at fixed costs.
“We must participate in these conversations going forward,” he said. “In order to do this, you must know your costs and outcomes—and make a deal with potential providers based on theirs.”
Dr. Merrill noted that more research is needed about the influence of the PSH on both the quality of safety and the quality of care. Although some standardized care improves safety in some cases, ongoing research will indicate what changes matter the most for reducing infection and errors. Although data show the PSH model works, data don’t yet indicate how it works in ambulatory surgery settings.
“My suggestion is to be proactive,” Dr. Merrill said. “As these strategies increase in number and scope, you’ll be not only prepared, you will have already acted.”