Risky Business

Strategic Alliance Partnership | <b>Cleveland Clinic</b>

Leaders from the Cleveland Clinic and University of Miami are using a standardized preoperative care model to reduce surgical complications.

(This article appears in the February 2011 issue of MDNG: Hospitalist)

Using a standardized preoperative care model to reduce surgical complications

By Ajay Kumar, MD, MRCP, FACP; Seema Chandra, MD; Jacek B. Cywinski, MD; and Amir Jaffer, MD

Approximately 100,000 surgeries are performed in US each day, and 36 million surgeries are performed annually. It has been estimated that the average American will have 9.2 surgeries in his or her lifetime (http://hcp.lv/ezmDBI). Although perioperative complications affect a relatively small group of surgical patients, the treatment of these conditions consumes a disproportional amount of resources; therefore, medical optimization of patients and risk stratification prior to surgery is critical in helping hospital staff to more efficiently focus resources. As the patient population has matured and become more medically complex, a number of hospitals around the country have implemented preoperative clinics with the goal of ensuring safety during the perioperative period and minimizing surgical delays and cancellations.

The preoperative clinic provides multiple services to the hospital. The main focus is on assessing perioperative risk for patients and mitigating modifiable risk factors. The “added value” of preoperative evaluation and optimization differs depending on the medical complexity of the patient and the surgical procedure; a well-designed evaluation process focuses the resources on patients with multiple comorbidities, for whom preoperative optimization and/or intervention can most effectively work to decrease perioperative risk.

Not only does the clinic risk-stratify the patients prior to surgery—thus flagging individuals who would benefit from testing, preoperative consultation, or medical optimization preoperatively, but it also serves as a clearinghouse for all surgeries to ensure compliance with regulatory agencies’ requirements. Additionally, completing necessary pre-anesthesia evaluations, history, and physicals ahead of time can help save time on the morning of surgery, potentially leading to fewer delayed cases or same-day cancellations. Finally, the preoperative clinic often introduces the patient to the surgical facility and orients them to the routines of surgery. This can play a significant role in allaying patient fears and concerns prior to surgery and improving overall satisfaction. There is, however, significant variability in the actual design of the individual preoperative clinics. In this article, we will focus on the current models at the Cleveland Clinic and the University of Miami.

Cleveland Clinic’s standardized system

At the Cleveland Clinic, we have developed a standardized system designed to reduce perioperative complications, surgical delays, and cancellations. The process utilizes the electronic medical record (EMR) to help complete a comprehensive analysis of the patient and facilitate communication among the caregivers. The emphasis on communication and teamwork provides a backbone for the patient-centered “safe system” of preoperative optimization and evaluation.

The process begins when the surgeon and patient mutually agree to proceed with surgery, followed by informed consent and a preoperative Web-based questionnaire (HealthQuest) completed by the patient either from the hospital or by logging in to a secure website from home. This information provides an initial view of the patient’s medical history and helps triage patients who need to be directed to one of our perioperative medicine experts at the Internal Medicine Preoperative Consultation and Treatment Center (IMPACT Center) and/or Preoperative Anesthesia Consultation and Evaluation Clinic (PACE Clinic). Patients deemed to be low-risk based upon the initial questionnaire are directed to operating theatre, where the pre-anesthetic assessment is completed by an anesthesiologist on the day of the surgery.

Patients arriving at either the IMPACT Center or PACE Clinic undergo comprehensive evaluations geared toward minimizing perioperative risk. The electronic assessment tool utilized in the IMPACT Center was developed by the physicians from department of hospital medicine under the leadership of Ajay Kumar, MD. The tool provides an evidence-based, comprehensive evaluation of the patient, while also collecting data for the National Surgical Quality Improvement Project (NSQIP).

Patients with multiple medical conditions schedule visits to multiple departments—including phlebotomy, electrocardiogram, and radiology—on the same day as their PACE or IMPACT visit. If additional testing is requested, tests are scheduled on the same day to create a more patient-centered preoperative process.

The PACE Clinic performs comprehensive pre-anesthetic assessments to identify conditions that potentially affect perioperative anesthetic care in the operating room, recovery room and/or intensive care unit. During the visit, the anesthetic plan is explained and discussed, which helps to greatly reduce anxiety and apprehension during the preoperative period.

Planning of postoperative pain control is another important component of the PACE Clinic evaluation; identification of patients and surgical procedures at high risk for postoperative pain allows for better utilization of advanced pain control techniques (peripheral nerve blocks, neuroaxila blocks, multimodal analgesia) and follow-up by an acute pain specialist during the postoperative period.

The geographical proximity of the anesthesia and medical consultation areas helps improve communication between two subspecialties regarding the patient’s surgical risks. The protocol-based approach of managing various conditions and treatments, medications, and patient flow during the perioperative process is agreed upon by all parties and is evidence-based. The protocols are also shared with surgical departments to create a standardized approach throughout the system.

University of Miami’s patient-centered strategy

At the University of Miami, the UHealth Preoperative Assessment Center (UPAC) was created one year ago under joint governance of the division of hospital medicine and the department of anesthesia. Like the Cleveland Clinic, the preoperative assessment process at Miami also begins at the time of the surgical visit with a questionnaire. If a patient has significant medical comorbidities, he is referred directly to UPAC, where he is seen by both a hospitalist and an anesthesiologist or CRNA. If the preoperative questionnaire was not completed or the patient was deemed to be low-risk, the patient receives a “phone screen” from one of the clinic nurses. This screening ensures that preoperative historical data is available for all patients prior to surgery, and also identifies additional patients who may benefit from an in-person evaluation prior to surgery. These data are reviewed by the UPAC anesthesiologist, and testing recommendations are made as needed (i.e. preoperative ECG or lab work) or the patient schedules an appointment for a preoperative assessment at UPAC.

The UPAC visit, similar to the PACE and IMPACT visits, is as patient-centered as possible, with phlebotomy and ECG performed on site, and same day appointments for other diagnostic testing are made when feasible. Additionally, the preoperative assessment is completed jointly by the hospitalist and the anesthesia provider using evidence-based algorithms for preoperative optimization. All completed consults are sent to the referring surgeons via EMR as well as in paper format, as some hospitals still use paper charts.

Both the IMPACT and UPAC sites extensively use EMRs to facilitate patient flow, share patient information, and improve communication among providers. Additionally, the ability to electronically flag incomplete charts helps the hospitalist track patients and complete medical documentation in a timely fashion, even when he or she is not physically at the preoperative clinic. A key advantage of the EMR is that it makes all preoperative testing and consultation results readily available to all treating physicians. Therefore, since hospitalists are often involved in the postoperative care of the higher-risk surgical patients, easy access to preoperative data helps minimizes errors and duplication of testing.

As the field of hospital medicine grows dramatically, the involvement of hospitalists in perioperative medicine has also seen a rise. Hospitalists have a unique understanding of systems-based practice at their individual facilities and, through their involvement in the preoperative clinic, they now have the ability to provide continuous care for high-risk surgical patients. The interdisciplinary nature of perioperative medicine—which requires a close collaboration between anesthesia, surgery, and medicine with a focus on evidence-based practice—is a natural fit for the hospitalist.

As perioperative medicine continues to gain interest in the academic and clinical arenas, and surgical volume continues to grow nationwide due to an aging population with multiple comorbidities, perioperative medicine will likely develop into its own specialized field in the near future. And now, hospitalists are well-positioned to be at the forefront of this emerging field.

About the authors: Seema Chandra, MD, is assistant professor of clinical medicine and Amir K. Jaffer, MD, is associate professor of medicine and the division chief of hospital medicine at the University of Miami, Leonard M. Miller School of Medicine in Miami, FL. Jacek Cywinski, MD, is medical director of PACE Clinic and assistant professor of anesthesiology at CCLCM and Cleveland Clinic and Ajay Kumar MRCP, MD, is medical director of the internal medicine preoperative center and is medical director of blood management at the department of hospital medicine at the Cleveland Clinic in Cleveland, OH.

Want to learn more about perioperative medicine? Register for the 6th Annual Perioperative Medicine Summit, which will be held March 3-5, 2011, at the Eden Roc Hotel in Miami Beach, FL. Among the many topics covered will be prophylactic strategies for venous thromboembolism, best practice strategies to reduce surgical complications, the principles of perioperative antiplatelet therapy management, and more. To register, go to http://hcp.lv/dRGwzR.