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

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.

Patient*innenzentrierte perioperative Versorgung: perioperative Prozessqualität, Effektivität von Schmerztherapie und Mobilisationsfortschritt nach Implementation eines Maßnahmenbündels bei Knietotalendoprothese

Zusammenfassung Hintergrund In den USA wurde das Konzept des „perioperative surgical home“ initialisiert, in dem ein teamorientiertes Vorgehen einen umfassenderen und zügigeren Heilverlauf erzielen soll. Fragestellung Evaluation des Effekts eines interdisziplinären Maßnahmenbündels (patient*innenzentrierte perioperative Versorgung, PPV) auf Aspekte der Prozessqualität unter deutschen Rahmenbedingungen. Material und Methoden Nach Einführung des PPV-Maßnahmenbündels (1. Patient*innenseminar, 2. spezifische Chirurgietechnik, 3. spezifische Anästhesietechnik, 4. Physiotherapiebeginn am Operationstag) wurden 34 Patient*innen mit elektiver Knietotalendoprothese prospektiv untersucht und mit „matched-pair“-Kontrollen verglichen. Endpunkte sind Dauer der Einleitungszeit (primär) und Krankenhausverweildauer, Ruhe- und Belastungsschmerz am 1. postoperativen Tag (numerische Analogskala), und Mobilisationsfortschritt (MBF) an den postoperativen Tagen 1, 3 und 6 (sekundär). Gruppenvergleiche wurden mit Wilcoxon-Mann-Whitney-Tests auf Nichtunterlegenheit durchgeführt. Im Fall von Nichtunterlegenheit wurde anschließend auf Überlegenheit getestet. Ergebnisse Die Einleitungszeit in der PPV-Gruppe betrug im Median 13,5 min (Kontrollgruppe: 60 min, p < 0,0001), die Krankenhausverweildauer betrug in der PPV-Gruppe 8 Tage (Kontrollgruppe: 12 Tage, p < 0,0001). Am ersten postoperativen Tag betrug die mediane Ruheschmerzstärke in der PPV-Gruppe 30 (Kontrollgruppe: 20); die Belastungsschmerzstärke war in beiden Gruppen gleich (Median 40). Die Mobilisation der Patienten*innen der PPV-Gruppe gelang an den postoperativen Tagen 1, 3 und 6 besser (jeweils p < 0,0001). Schlussfolgerung Das Konzept der patient*innenzentrierten perioperativen Versorgung (PPV) erscheint vielversprechend genug, um weitere klinische Studien zu rechtfertigen.

The Perioperative Surgical Home in Pediatrics: Improve Patient Outcomes, Decrease Cancellations, Improve HealthCare Spending and Allocation of Resources during the COVID-19 Pandemic

Cancellations or delays in surgical care for pediatric patients that present to the operating room create a great obstacle for both the physician and the patient. Perioperative outpatient management begins prior to the patient entering the hospital for the day of surgery, and many organizations practice using the perioperative surgical home (PSH), incorporating enhanced recovery concepts. This paper describes changes in standard operating procedures caused by the COVID-19 pandemic, and proposes the expansion of PSH, as a means of improving perioperative quality of care in pediatric populations.

Perioperative Surgical Home Model Improves Outcomes in Crohn’s Disease Patients Undergoing Disease-Related Surgery

Background. To evaluate Perioperative Surgical Home (PSH) practice model implementation in Crohn’s disease (CD) patients undergoing disease-related surgery. Methods. A retrospective analysis of CD patients requiring disease-related surgery in the Shanghai Ninth People’s Hospital was undertaken. Subjects were divided into a non-PSH group consisting of 49 patients (June 2016 to November 2017) and a PSH group consisting of 72 patients (December 2017 until May 2019). Conventional treatment was used for the non-PSH group, while in the PSH group, a standardized pre- and postoperative management routine was employed. The postoperative lengths of stay and incidences of postoperative complications were analyzed. Results. There were no significant differences in demographics, reasons for surgery, preoperative BMIs, and preoperative hemoglobin between the two groups (P>0.05). The overall incidence of complications in the PSH group was dramatically lower than that in the non-PSH group (26.4% vs. 44.9%, P=0.035). In the PSH group, postoperative length of stay was significantly shorter than that in the non-PSH group (11.5±5.7 vs. 9.0±6.8, P<0.001). Conclusions. The PSH conditioning routine in CD patients undergoing disease-related surgeries suggests a trend of fewer postoperative complications and shorter lengths of hospital stay. The PSH model may have clinical advantages when applied to CD patients.