Author: Michael Vlessides
The POET (PeriOperative Enhancement Team) program at Duke University Health System aims to enhance patient health preoperatively in order to improve postoperative outcomes. The program had considerable success with its initial foray into anemia management. Other areas for preoperative enhancement have since followed.
“As anesthesiologists, we have to think of ourselves as care providers in the broader continuum of health care, and preoperative optimization is an opportunity for us to do that,” said Solomon Aronson, MD, MBA, the executive vice chair of anesthesiology at Duke University Health System, in Raleigh, N.C. “Because we live in a world where more of our patients are sicker and present for surgery with suboptimal management of comorbidities, our opportunity to contribute to this broader population health landscape is very real.”
The development of the POET program began following an examination of existing surgical pathways. “I think we need to blow out the preanesthesia paradigm, whereby we assess risk and essentially take inventory of patient risk profiles. Instead, we need to do something proactive about it,” Dr. Aronson said.
The POET program is based on the belief that patients should not undergo surgery until they are in the best possible physical condition to do so, notwithstanding emergencies and urgencies. “When it comes to modifiable risk factors,” Dr. Aronson said, “that means doing everything possible to optimize the patient’s status prior to surgery.”
Postponing Cases Is Acceptable
For several reasons, Dr. Aronson and his colleagues first set their sights on preoperative anemia. The condition is common and has been shown to be an independent predictor of morbidity and mortality. “Anemia also has a direct effect on health economics,” he added.
The program includes collaboration with professionals at almost every level of the institution, including physicians, nurses, clinic directors, administration and scheduling officers.
Patients who were likely to be deemed anemic based on point-of-care testing and to potentially need transfusions were educated about their risk and sent to a preoperative anemia clinic to be fully diagnosed and treated prior to surgery.
Such a step sometimes requires postponement of surgical cases, an eventuality that necessitates an understanding among all members of the surgical team. “If we’re going to do an elective case, we agreed to do the case after we treated the patient’s chronic medical conditions,” Dr. Aronson said. “Most of our surgeons buy into that idea, and that’s really important.” Equally critical is the ability to communicate changes in plans to patients and their primary care physicians.
At Duke, the implementation of the POET anemia clinic has yielded significant improvements, although Dr. Aronson was unwilling to provide details, citing possible publication conflicts. “Ultimately, we want to look at patient-reported outcomes as well,” he said.
The benefits have led to the expansion of the program and the development of similar preoperative initiatives, including optimization clinics for diabetes, nutrition and pain. “We have a clinic to manage the elderly and frail [patients], and preoperative smoking cessation and coagulation clinics,” Dr. Aronson said. Sleep disorders also may be added.
Dr. Aronson, who originally reported his group’s preliminary findings at the 2017 annual meeting of the American Society of A nesthesiologists (abstract A2177), added, “One of the most rewarding things was getting a letter from JCAHO [the Joint Commission] that gave a specific shout-out to the POET program, declaring it a best practice.”
In the end, Dr. Aronson said the program takes a commonsense approach to surgical care. “We wouldn’t think of landing an airplane until the wheels were down. And so we shouldn’t assign an [operating room] until the patient is ready to have the surgery.”