Implementing a Pediatric Perioperative Surgical Home Integrated Care Coordination Pathway for Laryngeal Cleft Repair

Abstract

BACKGROUND: The Pediatric Perioperative Surgical Home (PPSH) model is an integrative care model designed to provide better patient care and value by shifting focus from the patient encounter level to the overarching surgical episode of care. So far, no PPSH model has targeted a complex airway disorder. It was hypothesized that the development of a PPSH for laryngeal cleft repair would reduce the high rates of postoperative resource utilization observed in this population. METHODS: Institutional review board approval was obtained for the purpose of data collection and analysis. A multidisciplinary team of anesthesiologists, surgeons, nursing staff, information technology specialists, and finance administrators was gathered during the PPSH development phase. Standardized perioperative (preoperative, intraoperative, and postoperative) protocols were developed, with a focus on preoperative risk stratification. Patients presenting before surgery with ≥1 predefined medical comorbidity were triaged to the intensive care unit (ICU) postoperatively, while patients without severe systemic disease were triaged to a lower-acuity floor for overnight observation. The success of the PPSH protocol was defined by quality outcome and value measurements. RESULTS: The PPSH initiative included 120 patients, and the pre-PPSH period included 115 patients who underwent laryngeal cleft repair before implementation of the new process. Patients in the pre-PPSH period were reviewed and classified as ICU candidates or lower acuity floor candidates had they presented in the post-PPSH period. Among the 79 patients in the pre-PPSH period who were identified as candidates for the lower-acuity floor transfer, 70 patients (89%) were transferred to the ICU (P < .001). Retrospective analysis concluded that 143 ICU bedded days could have been avoided in the pre-PPSH group by using PPSH risk stratification. Surgery duration (P = .034) and hospital length of stay (P = .015) were found to be slightly longer in the group of pre-PPSH observation unit candidates. Rates of 30-day unplanned readmissions to the hospital were not associated with the new PPSH initiative (P = .093). No patients in either group experienced emergent postoperative intubation or other expected complications. Total hospital costs were not lower for PPSH observation unit patients as compared to pre-PPSH observation unit candidates (difference = 8%; 95% confidence interval, −7% to 23%). CONCLUSIONS: A well-defined preoperative screening protocol for patients undergoing laryngeal cleft repair can reduce postoperative ICU utilization without affecting patient safety. Further research is needed to see if these findings are applicable to other complex airway surgeries.

The virtual pediatric perioperative home, experience at a major metropolitan safety net hospital

“…Previous studies have shown significant cost reduction ($169 per episode) in adult patients undergoing total hip or knee arthroplasty 18 . As healthcare institutions move toward bundled payment models for procedures, they are more likely to benefit from perioperative surgical home programs as they reduce ICU utilization and overall length of stay 4,5,7 . Costs of care in the operating room range from $37 to $150 per minute 19‐22 .…”

“…18 As healthcare institutions move toward bundled payment models for procedures, they are more likely to benefit from perioperative surgical home programs as they reduce ICU utilization and overall length of stay. 4,5,7 Costs of care in the operating room range from $37 to $150 per minute. [19][20][21][22] If the preanesthetic evaluation of pediatric patients does not begin until the patient arrives on their day of surgery, then there is a greater likelihood that new findings by patient history may (appropriately) require lengthier investigation or same-day consultations and diagnostic testing.…”

“…Pediatric perioperative homes are associated with reduced length of stay and fewer perioperative blood transfusions in patients undergoing posterior spinal fusion, 4,5 faster discharge in patients presenting for adenoidectomy, 6 and reduced postoperative ICU utilization for patients undergoing laryngeal cleft repair. 7 By default, the physical command centers for the perioperative homes are the preanesthesia evaluation clinics housed within hospital campuses. 8 The first documented successful implementations of the pediatric perioperative home have come from freestanding children's hospitals.…”

“…High‐performance teams, systems, and clinical pathways have demonstrated measurable improvement in both pediatric ambulatory surgery and more complex surgical scenarios. Pediatric perioperative homes are associated with reduced length of stay and fewer perioperative blood transfusions in patients undergoing posterior spinal fusion, 4,5 faster discharge in patients presenting for adenoidectomy, 6 and reduced postoperative ICU utilization for patients undergoing laryngeal cleft repair 7 . By default, the physical command centers for the perioperative homes are the preanesthesia evaluation clinics housed within hospital campuses 8 …”

A Rural Community Hospital’s Perioperative Surgical Home Model Compared to a Traditional Surgical System

“…Baseline patient characteristics were collected including insurance (private or public payer) and procedure type (total hip, knee, shoulder, and unilateral knee arthroplasty aka THA, TKA, TSA, and UKA, respectively). These characteristics have shown to be closely associated with surgical outcome risks (Alvis et al, 2017;Kim et al, 2019;Leahy et al, 2019). Additionally, residence (zip code) was also collected to assess differences in surgical outcomes between patients residing in same county as the hospital and patients residing elsewhere.…”