The Perioperative Surgical Home, Enhanced Recovery After Surgery and how integration of these models may improve care for medically complex patients

Abstract

Perioperative medicine is changing rapidly, and with this change comes the opportunity to improve upon current models of care delivery and integration within the health care system. Perioperative models of care are structured or conceptual arrangements for surgical patients before, during and after their surgery. Models of care such as the Perioperative Surgical Home and Enhanced Recovery After Surgery pathways are increasingly used to guide the structure of perioperative care delivery with an aim to improve patient outcomes and experience in Canadian settings. In this narrative review, we summarize the origins of these perioperative models of care. They are fundamentally different in scope and level of evidence. Both models have potential benefits and limitations to their broad implementation in our health care system. As currently developed, both models are limited in their application to patients with chronic disease. We discuss how these models of care can be used to develop integrated horizontal and vertical perioperative pathways in a Canadian setting. Such integration is a potential solution that will improve their applicability to patients with medically complex conditions and in times when health care systems are under pressure. We describe this approach using the example of patients with kidney failure receiving dialysis.

Incremental Societal Costs of Perioperative Complications Following Adult Elective Inpatient Major Therapeutic Surgery in the State of Florida: A Seven-Year Retrospective Epidemiological Analysis

“…The most common CCSRs, which cumulatively accounted for just over half of the increase in the MS-DRG weighting factor, in descending order of the point estimates, were spine fusion, heart valve surgery, colectomy, pulmonary resection, coronary artery bypass graft, and hip and knee arthroplasty (Table 3 ). These CCSRs include the surgical procedures commonly targeted for interventions to reduce complications [ 2 - 19 ], confirming the face validity of our method of using the MS‑DRG weighting factor to measure incremental societal costs of complications. The impact of each additional case with an escalation in the MS-DRG differed greatly among the CCSRs.…”

“…There is an expanding role for anaesthesiologists to become involved in optimizing patients for surgery during the preoperative period and to participate in their postoperative care, including efforts in the United States, the United Kingdom, Canada, Australia, and New Zealand [1][2][3]. The concept of a Perioperative Surgical Home (PSH) is described by the American Society of Anesthesiologists (ASA) as including "improved operational efficiencies, decreased resource utilization, a reduction in length of stay and readmission, and a decrease in complications and mortality" [1].…”

Preoperative Medical Consultation—Questioning a Long-Standing Practice

“…Efforts at “perioperative surgical home” and “enhanced recovery after surgery” will only improve patient outcomes if they are characterized by focus, efficiency, and multidisciplinary collaboration . We oppose routine preoperative medical consultations, when there is no specific concern or indication.…”

Remote Monitoring and Artificial Intelligence: Outlook for 2050

“…The Hollywood fantasy of dragging and dropping projected icons from thin air and interacting with data this way may be closer than we imagine. The First 30 Days and Beyond: The Perioperative Surgical Home Enters Your Home Enhanced recovery protocols and perioperative surgical home concepts have been successful philosophical drivers of improved perioperative care up until now, 46 but the future will see these concepts become literal, as patients' homes become monitored settings. Despite amazing strides made by our specialty in decreasing preventable anesthetic mortality, the first 30 days following surgery account for a major source of morbidity and mortality worldwide, with approximately 5% of all surgical patients dying in the first year (and 10% in the 65 years and older age group), 47 and postoperative mortality is overall the third leading cause of death worldwide.…”