The Future of Surgical Care – A look at the Benefits of Patient-Center Care
Perioperative Surgical Home
Most perioperative nurses would probably agree that too often, perioperative care plans are variable and fragmented. This can result in more errors and complications, longer patient stays, more readmissions, and more adverse patient outcomes.
A new clinical care delivery model is out to change this. Designed around the concept of patient-centered care, the Perioperative Surgical Home (or PSH) was created by the American Society of Anesthesiologists (ASA) to achieve the triple aim of better individual patient health, improved overall health care, and lower health care costs.
Disjointed and Disconnected
The PSH will accomplish this triple aim through continuous improvement for patients undergoing surgical procedures, according to the ASA. It guides the patient through the entire surgical experience — from the decision to have surgery until 30 days post-discharge.
“Our current healthcare delivery system is disjointed, disconnected and there’s no communication,” says Jane C.K. Fitch, M.D., ASA immediate past president. “So there’s a chance things will get overlooked and fall through the cracks, which can impact patient safety and outcomes.”
For example, the decision of the need for surgery often disconnects patients from their typical medical care. Also, surgical patients may experience lapses in care, duplication of tests and preventable harm.
The goal of the Perioperative Surgical Home is to create a better patient experience and make surgical care safer, adds Fitch, thus promoting a better medical outcome at a lower cost. The PSH model creates a unified surgical experience in which the patient’s care is coordinated by a Director of Perioperative Services, additional surgical home leadership and support personnel, all of whom constitute an interdisciplinary team.
“The Perioperative Surgical Home is a coordinated, physician-led, multidisciplinary team-based approach that focuses on placing patients at the center of care,” says Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR, CNS-CP, the director of evidence-based perioperative practice with the Association of periOperative Registered Nurses (AORN).
“It’s one way to help remedy the current costly and fragmented perioperative system of care by shared decision making between health care providers and patients and allowing a smooth transition between levels of care,” Spruce adds.
Essential Elements of PSH
According to Spruce, there are five essential elements in the PSH model:
1. Patient-centered care
Unlike the current model of physician-centered care, patient values and preferences are at the center of the PSH model, where patients participate in all decision making.
The PSH model provides continuous patient care that transitions patients from the Patient Centered Medical Home (PCMH) to the PSH and back. This helps ensure that all issues of care are handled by each team.
3. Coordination of care
The patient’s care team coordinates all phases of perioperative care. This begins in the surgeon’s office and progresses to the preadmission testing and evaluation process through all three phases of surgical care. Postoperatively, caregivers continue the care process for patients until they are discharged and clinicians continue to follow up with patients for 30 days.
4. Accessibility to care Patients should be able to contact care providers at all times. While the patient is in the hospital, providers should coordinate and integrate all care through an electronic medical record. After discharge, providers should monitor patients closely. If problems arise, PSH members should step in to coordinate the care for 30 days.
5. Commitment to quality and safety
The PSH is based on standardization to improve the quality and safety of patient care. Evidence-based clinical pathways or protocols help optimize and reduce the variability of care while improving outcomes. If evidence does not exist or is unclear, the PSH team should develop a multidisciplinary agreement for a standardized protocol.
Building a PSH Model
In 2012, the University of California Irvine School of Medicine initiated the process of building a PSH model aimed at patients undergoing total hip or knee arthroplasties. Members of the Departments of Anesthesiology & Perioperative Care and Orthopedic Surgery, along with colleagues from all perioperative hospital services, implemented a series of clinical care pathways defining and standardizing pre-, intra-, postoperative and post-discharge management.
In building its PSH model, UC Irvine formed five teams: Pre-op Admissions, Intra-op, Immediate Post-op, Post-Discharge, and Metrics. Each team reports directly to PSH leadership. Scott Engwall, M.D., of UC Irvine’s Department of Anesthesiology & Perioperative Care, lists a number of reasons why the hospital built a PSH model:
• To decrease the variability of care through evidence-based standardized practices;
• To decrease complications, length of hospital stay and the cost of care;
• To increase overall efficiency;
• To improve the quality of care and overall outcomes; and
• To improve transitions of care, surgeon satisfaction and the overall patient experience.
“It’s all about applying good evidence-based medicine and standardized practices to the surgical process,” says Engwall.
“Implementing clinical care pathways results in standardized practices in the OR in terms of how operations are performed, anesthesia is administered, pain is managed and so forth. This reduces variability and improves patient outcomes and satisfaction.”
UC Irvine’s clinical care pathways are service-line specific and patient centered to optimize outcomes, adds Engwall.
Les Garson, M.D., also of UC Irvine’s Department of Anesthesiology & Perioperative Care, points out some of the ways in which the PSH model is more streamlined than the traditional physician-centered surgical care model.
“With the traditional model, there’s minimal pre-procedure planning; variable pre-op assessment, testing and medical treatment; and a lack of standardized protocols,” says Garson. “Post-op, there’s variable support, which often leads to patient visits to the emergency room.”
“With the PSH model, everything from the decision to operate through pre-op, intra-op, post-op and post-discharge is seamlessly integrated so that protocolized care is delivered at each phase,” he adds.
According to Garson, PSH is saving UC Irvine School of Medicine about $4,000 per joint replacement case. They have reduced the average joint patient’s length of stay from 3.5 to 2.3 days, allowing the hospital to fill the bed with another patient an average of 1.2 days earlier.
Since initially adopting the PSH model for hip and knee patients in 2012, UC Irvine has expanded it to total joint replacement, orthopedic spines, orthopedic outpatient procedures (like foot and ankle, arthroscopies and hand procedures), cystectomies, and open and laparoscopic nephrectomies.
Engwall’s best advice for hospitals implementing a PSH model?
“Build a multidisciplinary team and engage the different departments that are involved,” he says. “Also, you should hardwire and monitor the pathways and re-evaluate them on an ongoing basis. Finally, be sure to involve your patients and their families in the PSH.”
Spruce says that perioperative care today is based on tradition rather than evidence.
“Perioperative services must move from practice based on tradition to practice based on evidence with a focus on quality and safety,” she says. “The PSH is a model that strives to do this.”
“PSH is beneficial because it emphasizes the patient and coordination of care from the moment the patient makes the decision to undergo surgery until 30 days after discharge,” Spruce adds. “During this time, the PSH team implements standardized evidence-based protocols that have been shown to be effective.”
“The Patient Surgical Home is the future of surgical care,” says Fitch.