INTEGRATED APPROACH It's time for anesthesiologists to adapt to patient-centered care.

Should you wait until patients enter the PACU to administer pain medications? Of course not, but many surgical facilities still fail to fight pain proactively. With the Perioperative Surgical Home (PSH) model, that won't happen. The buzz-worthy coordinated care program is based on a standardized clinical pathway created with input from all stakeholders in surgery. For example, they agree in advance on pain and nausea control regimens for each type of procedure, put the protocols in writing and implement them during every case. Launching a PSH program will put your facility on the cutting edge of care and ensure you successfully manage post-op pain and PONV, two of the biggest factors in patient satisfaction and timely discharges.

Preset plans
At most facilities, there is variability in the overall system of care. I'm suggesting you establish a comprehensive order set for every surgery, and change it based on the needs of individual patients. For example, if a patient developed a peptic ulcer after taking a non-steroidal, you uncheck that box on the preset order and avoid giving that medication. It makes sense to do it that way; very few patients are sensitive to the drug, so shouldn't the default involve administering a non-steroidal and changing plans if the patient has a comorbid condition that prevents its use? The PSH model is not a cookie-cutter approach to surgery. In fact, it's very much in line with individualized care.

Typically, all aspects of perioperative care work in silos for the benefit of the patient. But why shouldn't anesthesiologists and surgeons agree on how cases will be performed, including how pain will be controlled? By reducing variability among providers, you're reducing the likelihood of oversights occurring. The order set is standardized regardless of which surgeon will perform the case or which anesthesia provider will work the room.

Here at UC Irvine Health, we launched the PSH model for total joint cases to great success, which has been detailed in the journal Anesthesia & Analgesia (osmag.net/r6NvUU). Initial planning included anesthesiologists, surgeons, nurses, pharmacists, a physical therapist, a case manager, a social worker and information technology experts (who helped program the health system's EMR so we could input data and track our progress). We met weekly to launch the program and quarterly once it was off the ground.

Thanks to the establishment of preset patient care orders created by the committee, all patients now receive protocol-driven, standardized pain management based on a multimodal medication regimen that begins the morning of surgery (see "UC Irvine's Pain-Control Protocol"). Our pain management efforts focus on controlling pain throughout the perioperative period and the avoidance of opioids to reduce lengths of stay.

Optimizing outcomes
Anesthesiology needs to move away from a modular perioperative approach to an integrated patient care model built on better coordination throughout the entire perioperative continuum, from the minute surgeons and patients meet in clinic until 30 days after surgery. If better coordination of care is the foundation of the PSH model, reduced variability is the keystone that holds it together.

Variability related to the patient's underlying condition is good and justified. On the other hand, system variability has to be reduced, because a large body of research has shown that such variability leads to errors and increased costs. To make the PSH model work, you need a clearly defined multi-modal protocol that's addressed with patients and fully understood by the care team well before the day of surgery. The model is patient-centric. Patients receive education early on, consisting of much more than a description of the case and what to expect on the day of surgery.

In addition, all stakeholders in the perioperative process have to be included in the creation of a PSH program. That point can't be emphasized enough. Teamwork, communication, change management and process improvement are keys to making it work.

Preparing patients better for surgery is one of the most important aspects of the PSH concept. We need to move beyond clearing patients for surgery to optimizing them for best possible outcomes, which involves ensuring underlying disease — diabetes, hypertension, anemia, and frailty and delirium in the elderly — is managed as best as possible in a standardized way. That's a very different approach to focusing on how quickly you can get patients into the OR.

SAME PAGE Caregivers who use preset orders work in concert to optimize patient care.

On the same page
The PSH model is inclusive and highly collaborative. Most critical is the partnership between anesthesia providers and surgeons. It won't necessarily be easy to find common ground among your surgeons. Start by garnering agreement for the simplest common denominator. For example, I started with getting a consensus on venous thromboembolism prophylaxis, although that did take a month to achieve. Once you produce a win, surgeons will be significantly more receptive to change.

Who should lead the program? Anesthesiologists are uniquely positioned to champion the cause, because they're most interested in the management of patients before, during and after surgery. But the model has to be based on the staffing structure and resources of your facility. Identify a strong leader who's well respected by all areas of the care team, and you'll find success.

The PSH program demands you contact patients as soon as procedures are scheduled, because you need the time to optimize their care and build trust with them as they approach the day of surgery.

Quality, not quantity
Readying patients for surgery involves all aspects of surgical care, not just pain-relieving protocols. The standardized approach afforded by the PSH model will help further the movement of complex procedures involving high-acuity patients to the outpatient setting.

In addition, the secretary of the U.S. Department of Health and Human Services wants 50% of Medicare payments based on quality and value by 2018. Guess what. Everything I've outlined above hits on those key factors and can serve as a platform for adopting this model. The future of health care won't only be about how many surgeries you perform in a day. It'll be about patient-centered care and shared decision-making as we evolve from quantity of cases to quality of care.