Authors: Jerrold H Levy MD FAHA, FCCM et al
ASA Monitor 12 2015, Vol.79, 14-16.
Over the years, we all have had the privilege of working and collaborating with many physician anesthesiologists in the United States, Europe and various other countries. In Europe, anesthesiology is a physician-focused practice and nurses function in different supporting roles; in some countries, nurse anesthesia does not exist. The United States’ use of a variety of advanced practice providers, including nurse anesthetists and physicians assistants, is the exception rather than the rule in most European systems. This, from a management perspective and political perspective, is an important major difference in Europe compared to the U.S. Non-physician anesthesiology providers were developed earlier in our clinical history to provide coverage.
The physician-centric management concept also evolved differently in the U.S. and, as a result, European anesthesiologists have an important involvement in overall medical care that extends far beyond the O.R. delivery of anesthesiology and extends into the ER and the ICU, in addition to what most U.S. physicians are involved in. The practice of both acute and chronic pain management is well-developed in the U.S. for many important considerations, including scientific and technical considerations related to nerve blocks and regional anesthesia, but also for other reasons because it often is a lucrative practice.
For many years, European anesthesiologists focused on patient blood management. They helped to foster the development of point-of-care coagulation testing and have developed transfusion and other bleeding therapy guidelines and guidance documents for perioperative management, including trauma. The ability to use specific point-of-care testing in the O.R. setting in close collaboration with central laboratories has been greatly facilitated by rules and regulations in Europe, while most coagulation testing in the U.S. has been moved to clinical laboratories.
Another important perspective of the European system is the longstanding involvement in the ICU to a greater extent than in the U.S. Since anesthesiologists in the U.S. view themselves as perioperative physicians, the ability to manage patients postoperatively is a critical component of practice, and it warrants further continuation of our involvement in the specialty of intensive care medicine. Our ability to manage acute respiratory and cardiovascular dysfunction, airway management skills, resuscitative skills, and everything we do daily in perioperative and intraoperative management helps define us and nurtures the crucial ability to be critical care physicians. The long European tradition of anesthesiologist involvement in intensive care and perioperative medicine needs to be recognized and further developed in this country, although in many U.S. centers, including ours, anesthesiologists do make important contributions as critical care physicians.
European anesthesiologists were among the first to work with surgical colleagues in a multidisciplinary environment to develop Enhanced Recovery Pathways (ERPs). ERPs have many different elements and have been shown to accelerate recovery by attenuating the stress response, leading to a reduction in length of stay, the incidence of postoperative complications and health care costs. European anesthesiologists regularly work one-on-one with the same surgeon on a weekly basis, often facilitating the ability to work as a team to introduce a new pathway. In contrast, many U.S. anesthesia practices are large and cover multiple sites. In addition, residents or nurse anesthetists often perform intraoperative decision-making. Therefore, implementing a standardized ERP is a significant undertaking requiring the education and alignment of many different anesthesia providers. There is also comparatively less potential collaboration among hospitals in the U.S. compared to Europe. In addition, unlike the National Health Service in the U.K., which implemented a national ERP within two years, there is no framework or umbrella to deliver a national program. In comparison, the U.S. is a competitive, free market system.
Many European anesthesiologists also have advanced skills in the management of perioperative hemostasis, including management of acute traumatic and surgical coagulopathies. They also work closely with physicians across many specialties in developing protocols and management for venous thromboembolic complications, including prophylaxis. The anesthesiology focused group, Group d’Interet en Hemostase Perioperatoire (GIHP), which includes Marc Samama, M.D., Ph.D., a co-author of this commentary, has been actively involved in the management of anticoagulation, bleeding and reversal in the surgical patient population. Although many of the original transfusion and coagulation management guidelines, especially for trauma, evolved from European efforts, a number of U.S. physicians are also actively involved in this work from a scientific and educational perspective. Also, management of regional anesthesia in anticoagulated patients continues to be an ongoing focus from the European perspective. With the increasing use and development of new, novel, direct oral anticoagulants, this has been particularly important in understanding and developing guidance documents and guidelines for managing patients.
It is important to note, however, that ASA has published many important guidelines for anesthesiologists. Overall, the importance of guidelines are to further evaluate, synthesize and summarize the available evidence on the area of focus, allowing for clinicians to adapt the best strategies for patient management for a specific clinical issue or problem. This should take in account the relative risk-benefit ratio for a given diagnostic, management or therapeutic approach for a particular problem. ASA and its relevant committees have done an excellent job of developing important guidelines that can be found on the ASA website.
It’s important to note that European anesthesiologists have also worked closely with other medical organizations to systematically develop guidelines and consensus statements that are important for guiding and managing clinical practice. Stefan De Hert, M.D., Ph.D., is currently the past chair of the ESA Scientific Committee. Guidelines are intended to provide better standardization of practices and potentially reduce the variability based on supporting medical evidence. They also can be used to potentially improve patient outcomes, but hospitals and administrators also use them to measure clinical performance overall. One of the major limiting factors of guidelines is their extensive length, which sometimes prevents them from being completely read. However, these important publications need to be read, understood and hopefully incorporated into clinical practice. An important example is theDeclaration on Patient Safety that was published in 2010, which provides a practical framework for both creating and implementing guidelines, but also allowing for a monitoring mechanism.
Another important set of guidelines issued recently by the ESA is the combined document with the European Society of Cardiology (ESC). These recommendations are located on the ESC website atwww.escardio.org/guidelines-surveys/esc-guidelines/about/Pages/rules-writing.aspx. Working together with cardiologists, the ESC/ESA guidelines represent an important combined position of two influential societies on a critical topic that continues to be updated at regular intervals. The American Heart Association/American College of Cardiology has also provided guidelines for perioperative management, overseen by anesthesiologist Lee Fleisher, M.D., in a combined effort from our societies (ASA and SCA) and cardiology, similar to the ESA.
In summary, the continuing collaboration from a clinical and research perspective found in many important journal activities from Anesthesiology and other journals are the result of combined U.S., European and overall world perspectives. The ongoing mutual collaboration at meetings, scientific investigations and publications have allowed the sharing of ideas, insights and perspectives that further advance our specialty, protocol-driven management and clinical care in general. The mutual collaborative efforts in the Perioperative Surgical Home occurring in Europe and the U.S. are important, as together we learn from each other to further evolve our patient care, management, and research and insight into new developments that benefit medicine, patients and the perioperative.