Looking forward – April 2015

David B. Hoyt

David B. Hoyt, MD, FACS

Patient safety and quality care are the responsibility of every member of the operating room (OR) team, including the anesthesiologist, the nursing staff, the technicians, and, of course, the surgeon and any resident or other physician who is assisting. In an era of multidisciplinary, team-based care, all of these health care professionals work together, check each other’s actions, verify that the established protocols are being followed, and point out any possible hazards. Likewise, all specialties work together during the preoperative, perioperative, postoperative, and post-discharge stages of care to ensure that patients receive optimal care in and out of the hospital setting and to avert the possibility of complications.

More and more evidence is showing that what these health care professionals do and how they engage their patients in their own care in the perioperative phase has a significant effect on outcomes. Consequently, a great deal of attention is now being focused on the perioperative phase of care, along with what occurs intraoperatively and during recovery.

The perioperative phase of care begins with the decision for surgery and intensifies 24–48 hours before an operation. It essentially is the time when the operating team and the patient work together to ensure the patient’s safety. Perioperative care is provided in the ambulatory setting, the primary care physician’s office, the consultants’ offices, the home environment, and the hospital admitting and patient holding areas. This phase of care involves identifying risk, comorbidities, and possible drug interactions; evaluating nutritional status; counseling for smoking cessation; and ensuring that the patient will have access to appropriate postoperative care. The patient may make changes in diet and adjustments to medications for chronic conditions. Immediately before an operation, an updated patient history and physical assessment should occur and the operating team should confirm that the correct procedure is being performed on the correct site and correct patient. Surgical care bundles are established and checklists are designed to eliminate error, optimize outcomes, and reduce clinical practice variation. It is a critical phase of surgical care and should be approached with the same degree of care and attention to detail as one demonstrates at all other phases of the delivery of surgical care.

Call to action

The American College of Surgeons (ACS) has a long-standing expectation that its members will safeguard their patients’ care throughout the course of surgical treatment. The ACS Statements on Principles state, “The surgeon is responsible for the patient’s safety throughout the preoperative, operative, and postoperative period, including the responsibility for eliminating wrong-site, wrong-procedure, and wrong-patient surgery.”*

The College and other stakeholders are now developing recommendations on how best to ensure that patients receive safe, high-quality surgical care. Some of you may be familiar with the perioperative surgical home (PSH), which the American Society of Anesthesiologists (ASA) has proposed. The ASA has brought forth the PSH as a model of delivering health care throughout the patient’s entire surgical care experience—from decision making through recovery.

Under the PSH paradigm, the patient’s care would be coordinated by a director of perioperative services. The ASA suggests that a physician is best suited to this role. Application of this concept must be compatible with the surgeon’s sense of responsibility for overseeing all aspects of surgical patient care, although surgeons welcome collaborative efforts to ready patients for an operation with the anesthesiologist acting as partner. The leaders of the ACS and the ASA have been discussing perioperative care, and the ACS will continue to work with the ASA to ensure that all of the surgical patient’s needs are properly met.

ACS activities

Presently, the College is involved in a number of efforts to establish protocols for surgeons to lead the OR team and patient through the perioperative care phase. For example, the College is in the process of developing a quality manual, which, in part, outlines the surgeon’s responsibilities at each phase of surgical patient care.

The College has a Committee on Perioperative Care, which sponsors several educational sessions at the Clinical Congress. At the 2014 meeting, for example, the committee presented sessions on the relationship and role of the surgeon in designing and implementing accountable care organizations and on perioperative patient safety. This committee also has developed position statements in the past and will be issuing an updated Statement on Sharps Safety and has developed a new version of the Statement on Surgical Technology Training and Certification.

Furthermore, Sanjay Mohanty, MD, the ACS/American Geriatrics Society (AGS) James C. Thompson Geriatric Clinical Scholar, is developing a set of best practices for the perioperative care of geriatric patients. Dr. Mohanty, a general surgery resident at Henry Ford Hospital, Detroit, MI, has been using data from the ACS National Surgical Quality Improvement Program Geriatric Pilot Project to generate the guidelines.

In addition, the College’s Evidence-Based Decisions in Surgery program offers a range of clinical practice guidelines. A module specific to perioperative care is currently in development.

College Fellows also are closely involved in the work being carried out by quality collaboratives. For example, the Washington State Chapter of the ACS is part of the state’s Surgical Care Outcomes Assessment Program (SCOAP), which has established a Strong for Surgery initiative. This effort is aimed at identifying and evaluating evidence-based practices to optimize the health of patients before surgery. As of December 2014, the SCOAP Strong for Surgery program was active in 49 Washington hospitals and clinics representing 200-plus surgeons. More than 4,000 patients have been screened using the checklists and other instruments that the Strong for Surgery program has developed. Among other tools, Strong for Surgery has developed guidelines to screen for malnutrition, lists of lab tests for risk stratification, and processes for screening for supplements. Presently, Strong for Surgery is creating best practices for perioperative glucose control, generating checklists to screen for medication use, evaluating best practices for opioid minimization, and developing recommendations for preoperative smoking cessation. The College is working to bring these important programs forward.

Surgeons must lead

The delivery of perioperative care is more complex today than ever, and the evidence is mounting to show that all members of the health care profession need to be as attentive to this stage of surgical care as any other. Although surgical care has evolved from a system in which the surgeon oversees every aspect of operative readiness and care to a system in which multidisciplinary teams are working together to provide optimal care, it is still the surgeon who must be accountable for the care his or her patient receives. It is part of our contract with society as trusted health care professionals. We must never allow perioperative care to be considered someone else’s responsibility.

*American College of Surgeons. Statements on Principles. Available at: www.facs.org/about-acs/statements/stonprin. Accessed February 19, 2015.

Strong for Surgery. 2015: Looking Forward to More Remarkable Milestones. Available at: www.becertain.org/strong_for_surgery/strong_for_surgery_blog/archives/2014/12/30/2015_looking_forward_to_more_remarkable_milestones. Accessed February 24, 2015.

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