[Development of an Integrated Perioperative Medicine Pathway] Proceedings of the American Society for Enhanced Recovery/Evidence Based Peri-Operative Medicine 2016 Annual Congress of Enhanced Recovery and Perioperative Medicine:

Edwards, Mark, Levett, Denny, Chapman, Tristan, Jones, Imogen Fecher, Smith, Julian, Knight, John and Grocott, Michael (2016) [Development of an Integrated Perioperative Medicine Pathway] Proceedings of the American Society for Enhanced Recovery/Evidence Based Peri-Operative Medicine 2016 Annual Congress of Enhanced Recovery and Perioperative Medicine:. Perioperative Medicine, 5 (S1), [A5]. (doi:10.1186/s13741-016-0045-0).

Abstract

Background/Introduction: Perioperative medicine is the patient-centered, multidisciplinary and integrated medical care of patients from the moment of contemplation of surgery until full recovery. It builds on the Enhanced Recovery approach to capitalize on five key opportunities: collaborative decision-making, preoperative lifestyle modification, standardization of perioperative care, achieving full postoperative recovery and using data to drive quality improvement (1). We hypothesize that redesigning the perioperative pathway will add value through improved quality and reduced resource utilization. Methods: Our multidisciplinary team is developing an integrated Perioperative Medicine care pathway at a large tertiary referral University hospital. Current pathways were mapped, analyzed and redesigned with particular focus on specific factors including defining the pathway boundaries, engaging patients and time constraints. Results: Current preoperative pathways were mapped and analyzed (see: Fig 1A). Pathway redesign addressed a number of specific aims (see: Fig1B): identification of the “moment of contemplation of surgery”, early targeted preoperative information gathering through a patient-driven online system; routine physiological assessment to stratify risk early in the preoperative pathway (“patient staging”) by cardiopulmonary exercise testing; a dedicated clinic for patients at high perioperative morbidity/mortality risk, collaborative decision-making and early medical optimization; Fit4Surgery School for all patients undergoing major surgery, targeting patient education, expectation management and lifestyle optimization; standardized perioperative management based on risk strata (see: Fig 2); postoperative care team clinical ward reviews for “at-risk” patients; postoperative electronic data capture to monitor Enhanced Recovery targets, morbidity, and patient-reported outcomes. Conclusion: Perioperative medicine offers a unique opportunity to add value through improved outcomes and reduced resource utilization in patients undergoing major surgery. Extensive pathway redesign may be needed to ensure an integrated approach, maximizing the opportunities for improvements in preoperative optimization and postoperative care. Moving the evaluation of risk to a position earlier in the pre-operative pathway offers opportunities for risk mitigation, collaborative decision-making and optimization of patient health before surgery.

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Contributors

Author: Michael Grocott

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