Peri‐operative care pathways: re‐engineering care to achieve the ‘triple aim’

Abstract

Elective surgical pathways offer a particular opportunity to plan radical change in the way care is delivered, based on patient need rather than provider convenience. Peri-operative pathway redesign enables improved patient experience of care (including quality and satisfaction), population/public health, and healthcare value (outcome per unit of currency). Among physicians with the skills to work within peri-operative medicine, anaesthetists are well positioned to lead the re-engineering of such pathways. Re-engineered pre-operative pathways open up opportunities for intervention before surgery including shared decision-making, comorbidity management and collaborative behavioural change. Individualised, risk-adapted, intra-operative interventions will drive more reliable and consistent care. Risk-adapted postoperative care, particularly around transitions of care, has a significant role in improving value through peri-operative medicine. Improved integration with primary care providers offers the potential for minimising errors around transitions of care before and after surgery, as well as maximising opportunities for population health interventions, including lifestyle modification (e.g. activity/exercise, smoking and/or alcohol cessation), pain management and sleep medicine. Systematic data collection focused on quality improvement is essential to drive continuous clinical improvement and will be enabled by technological development in predictive analytics, systems modelling and artificial intelligence.

Proposed pathway for patients undergoing enhanced recovery after spinal surgery: protocol for a systematic review

“…Many of the studies illustrating the institutional implementation of some components of ERSS have shown a significant reduction in the length of stay and consequent improved financial outcome [44,45]. Effective interventions not only provide for better outcomes for individual patients, but for more efficient use of resources in healthcare and avoidance of ineffective high-cost interventions [46]. To date, there has been no review of the merits of individual pathway elements in enhanced recovery in spinal surgery protocols.…”

Diabetes in day case general and vascular surgery: A multicentre regional audit

“…Our study would suggest that the failure to highlight the presence of diabetes in the primary care referral letter is propagated through secondary care, with the surgeon in clinic failing to pick up on the presence of diabetes. Although, the presence of diabetes is subsequently picked up in the preoperative clinic, it is not the prerogative of preoperative staff to note or request an HbA1C . Indeed, efforts subsequent to this study at Peterborough City Hospital to introduce a check box for HbA1C on the preoperative assessment paperwork were met with firm resistance from the anaesthetic team—who highlighted that this is within the remit of the responsible surgeon.…”

“…This represents an excellent example of how a preoperative pathway can unfortunately be based around provider convenience rather than patient need. The concept of re‐engineering perioperative care pathways to better serve patient needs has been recently explored and developed by Grocott et al They argue that elective surgical pathways offer the ideal opportunity to plan radical change in the way care is delivered, enabling “improved patient experience of care (including quality and satisfaction), population/public health, and healthcare value (outcome per unit of currency).” This triple aim framework, first published by the US Institute for Healthcare Improvements, is now integrated into the NHS UK 5 Year Forward View . Examples of such re‐engineered preoperative pathways include shared decision‐making, comorbidity management and collaborative behavioural change.…”

“…It is possible that the continuation of these patients towards surgery was because of unawareness of the high reading rather than a conscious decision to pro- Although, the presence of diabetes is subsequently picked up in the preoperative clinic, it is not the prerogative of preoperative staff to note or request an HbA1C. 24 Indeed, efforts subsequent to this study at Peterborough City Hospital to introduce a check box for HbA1C on the preoperative assessment paperwork were met with firm resistance from the anaesthetic team-who highlighted that this is within the remit of the responsible surgeon. Despite this, it remains true that preoperative assessment does act as "checkpoint" for patients with diabetes, at which point unacceptable HbA1C's can be noted and action taken.…”

Patient optimisation before surgery: a clear and present challenge in peri‐operative care

“…The first 10 reviews of this supplement discuss the medical and psychosocial interventions and optimisations that can be implemented pre‐operatively, and clearly document the evolution of the pre‐operative assessment clinic with a narrow remit into the collaborative pre‐operative clinic practising holistic peri‐operative medicine. However, for these interventions to be introduced in a timely manner it is necessary to rethink the classical patient pathway, and thus the review on how the patient pathway can be re‐engineered to facilitate timely intervention . As well as the need to update the elective care surgical pathway, there is the need to re‐engineer the pathway for the emergency surgical patient.…”