Anesthesiologists as Leaders
in Perioperative Care
Mark S. Hausman, Jr., M.D.
Chief of Staff, VA Ann Arbor Healthcare System
Assistant Dean for Veterans Affairs, University of Michigan Medical School
Assistant Professor of Anesthesiology, University of Michigan Medical School
Objectives
1. To make the case that we can do better in delivering quality and value in US healthcare
2. To review the domains of perioperative care where Anesthesiologists may be poised to lead
3. Share several examples of effective enhanced perioperative care interventions from the literature
4. Review the experience from one federal, integrated healthcare system
The US healthcare system spends
far more per capita than most
The Kaiser Family Foundation
But we are not healthier as a
population
The Kaiser Family Foundation
With more hospital admissions
for preventable diseases
The Kaiser Family Foundation
Surgical Care
• Surgical Care is represents
approximately 40% of hospital and
physician cost (500 Billion)
• When patients experience surgical
complications, the cost of care nearly
doubles (93%)
• Improving the quality of surgical care
must be a national priority
Michigan Medicine Institute for Health Policy Innovation
The US Opioid Crisis
The US Opioid Crisis
Brummett Cm, et al. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surgery 2018.
The Triple-Aim for HealthCare
Delivery and Innovation
The American Society of Anesthesiologists homepage: http://asahq.org
The Triple-Aim for HealthCare
Delivery and Innovation
The American Society of Anesthesiologists homepage: http://asahq.org
Can perioperative
care be enhanced
to achieve
progress along
one or more of
these domains?
Characteristics of Good
Perioperative Care
The American Society of Anesthesiologists homepage: http://asahq.org
Many Stakeholders Must be Engaged
around this Patient-centered Process
The American Society of Anesthesiologists homepage: http://asahq.org
Perioperative Care Pathway
The American Society of Anesthesiologists homepage: http://asahq.org
Key Elements to Enhanced
Perioperative Care
Kash, BA, Cline, BM. The Perioperative Surgical Home Interview Results from 15 Selected US programs. The American Society of Anesthesiologists
homepage: http://asahq.org: 2014.
Selected Studies
• Selected, recent and relevant studies
that demonstrate value to specific
elements of enhanced perioperative
care
• What is holding me back from
implementing this at my hospital or
medical center?
Key Elements to Enhanced
Perioperative Care
Kash, BA, Cline, BM. The Perioperative Surgical Home Interview Results from 15 Selected US programs. The American Society of Anesthesiologists
homepage: http://asahq.org: 2014.
Ferschl MB et al., Preoperative Clinic Visits Reduce Operating Room Cancellations and Delays. Anesthesiology 2006.
Key Elements to Enhanced
Perioperative Care
Kash, BA, Cline, BM. The Perioperative Surgical Home Interview Results from 15 Selected US programs. The American Society of Anesthesiologists
homepage: http://asahq.org: 2014.
Howard R, Yue Y, er al. Taking Control of Your Surgery: Impact of a Prehabiilitation Program on Major Abdominal Surgery . Journal of the American College
of Surgeons 2019.
• Michigan Surgical Health Optimization Program (MSHOP):
• Pre-surgical patients often highly compliant
• Benefit of patient-physician partnership, active participation in
care
• Previously shown to hasten return to baseline function and
associated with a reduction in postoperative complications
• This study examines clinical and economic benefit of pre-
habilitation
MSHOP Pre-habilitation
• Physical activity – walking with pedometer and target steps per day
• Pulmonary rehabilitation – IS with instructions and goals
• Nutrition optimization
• Stress reduction
• Smoking cessation
• Minimal 2 week participation
• Phone calls, text and email prompts/reminders
Howard R, Yue Y, er al. Taking Control of Your Surgery: Impact of a Prehabiilitation Program on Major Abdominal Surgery . Journal of the American College
of Surgeons 2019.
Results: Beneficial Physiological Effects,
Fewer Complications and Lower Cost
Howard R, Yue Y, er al. Taking Control of Your Surgery: Impact of a Prehabiilitation Program on Major Abdominal Surgery . Journal of the American College
of Surgeons 2019.
Key Elements to Enhanced
Perioperative Care
Kash, BA, Cline, BM. The Perioperative Surgical Home Interview Results from 15 Selected US programs. The American Society of Anesthesiologists
homepage: http://asahq.org: 2014.
Waits SA, et al. Developing An Argument for Bundled Interventions to Reduce Surgical Site Infection in Colorectal Surgery. Annals of Surgery 2014.
Bundled perioperative interventions: the more
complete the bundle, the lower incidence of SSI
Waits SA, et al. Developing An Argument for Bundled Interventions to Reduce Surgical Site Infection in Colorectal Surgery. Annals of Surgery 2014.
Key Elements to Enhanced
Perioperative Care
Kash, BA, Cline, BM. The Perioperative Surgical Home Interview Results from 15 Selected US programs. The American Society of Anesthesiologists
homepage: http://asahq.org: 2014.
Alvis B, et al. Creation and Execution of a Novel Anesthesia Perioperative Care Service at a Veterans Affairs Hospital. Anesthesia and Analgesia 2017.
Alvis, et al. PSH concept at
Tennessee Valley VA
Alvis B, et al. Creation and Execution of a Novel Anesthesia Perioperative Care Service at a Veterans Affairs Hospital. Anesthesia and Analgesia 2017.
The Tennessee Valley VA model
succeeded in LOS reduction
Alvis B, et al. Creation and Execution of a Novel Anesthesia Perioperative Care Service at a Veterans Affairs Hospital. Anesthesia and Analgesia 2017.
Enhanced
Perioperative
Care Efforts
may be
procedure
specific
Experience from the VA Ann
Arbor Healthcare System
• 142 bed tertiary
care hospital
• 69,000 uniques
• 4500-5000
surgical cases
• High surgical
complexity
Perioperative Services
Preoperative
period
Intraoperative
period
Postoperative
period
• Evidence-based pre-op
testing (laboratory,
cardiac, radiology)
• Enhanced patient
education/counseling
• Pain/opioid management
and intervention
• Patient optimization
(ambulation, IS, nutrition,
stress reduction,
smoking/alcohol
cessation)
• Standardized VTE and
antibiotic prophylaxis
• Standardized clearance
process and criteria
• Neuraxial/regional
anesthesia/analgesia
• Protocol for glycemic
control
• Evidence-based ventilator
management
• Protocol for normothermia
measures
• Goal directed fluid therapy
• Standardized antiemetic
therapy
• Evidence based, multi-
modal pain control
• Appropriate level of care
(ICU, PC, tele, floor,
ambulatory)
• Capability building
specific to level of care
• Early mobilization
• Early nutrition
• Delirium prevention
strategies
• Timely removal of
lines/catheters
• Minimize opioid
medication (multimodal
pain control)
Initiatives based on reported ERAS, MSQC, MSHOP, and ASPIRE performance data; bold = work underway
Aims for Delivery
Quality of Care Efficiency/cost
savings
Patient Experience
• Shorter LOS
• Fewer complications/better
outcomes
• Pain control
• Opioid reduction
• Reduced preoperative
testing
• Cardiology clinic
• Reduced same day
cancellation
• Reduced LOS
• Enhanced education and
engagement
• Better pain control
• Earlier return to
preoperative level of
function
• Greater trust
Implementation Efforts to
date: The PREPARE clinic• Hospitalist-Anesthesiologist staffing model
• At present see approximately 10% of pre-surgical patients (based on established triggers)• Blend of electronic consults and F2F
• Evidence based, protocol driven • Assessment and appropriate pre-surgical testing
• Early pre-habilitation
• Active management and planning • Complex pain patients (e.g. OUD/SUD/Suboxone)
• HTN, DM, HF
• Anesthesia planning
The PREPARE clinic
• Developed documentation and decision support tool that is scalable to all surgery clinics• Patient education element
• Standardized care: antibiotics, VTE, pre-operative medication management
• Results to date:• Reduction in same day cancellation
• 7.3% to 5.7% year over year
• PREPARE patients 4%, zero preventable
• Reduction in wound infection
The Acute Pain Service
Summary
• We can and must do better to improve
along the quality, efficiency and
experience spectrum
• Perioperative care is fertile ground for
meaningful process improvement
efforts, supported by evidence, which
anesthesiologists are poised to lead
• What is holding you back?
Questions and Discussion
