Preparation for elective surgery - procedures that are planned in advance rather than in response to a medical emergency - has historically required that patients undergo a series of tests to determine their medical fitness. Individuals who met an established set of criteria were considered to be “cleared for surgery.” Today, the patient’s medical readiness and comfort, as well as coordination and quality of his or her care before and after surgery, is the focus of an area of medicine known as perioperative care.
Through integrated collaboration, the prevailing culture and essential commitment at Hospital for Special Surgery (HSS) is to provide the highest quality of patient care, to achieve the best possible treatment outcomes and to assure patient satisfaction with all aspects of the patient experience. The patient’s surgeon relies on the team of physicians constituting Perioperative Services at HSS to oversee this integrated, collaborative care.
“Assessing a patient’s level of risk for a specific procedure is one of our primary objectives,” explains Linda Russell, MD, Director of Perioperative Services at HSS. “However, perioperative care also encompasses areas ranging from systematizing procedures so that every doctor involved with patient care has access to the same guidelines, to helping patients with discharge planning and returning to their homes.” Practitioners of perioperative care are also attuned to individual patient needs before, during and after surgery.
In order to assess the degree of risk associated with surgery, perioperative care specialists take into account factors including:
This information is then considered in the context of the complexity of the planned surgery to arrive at an overall estimation of risk. Some surgeries inherently carry a greater level of risk than others: a total hip replacement, for example, versus a same-day surgery to address carpal tunnel syndrome. If the patient undergoing a total hip replacement also has cardiovascular disease, the risks associated with surgery increase. Use of a computerized tool that calculates surgical risk based on specific patient health data can be part of this process. This provides patients and surgeons with an objective evaluation that may help facilitate decision making that minimizes the risk of complications, improves the quality of care and contributes to achieving the best possible surgical outcome.
By gathering detailed medical information, the perioperative team can also make recommendations about the timing of surgery. For example, people with diabetes who are found to have an elevated A1c level (a measurement of average blood glucose over a 3-month period) will be advised to postpone elective surgery until the hemoglobin A1c is reduced to an acceptable level. “An A1c level greater than 7.0 indicates that control of diabetes is not optimized, which is associated with a greater risk of infection and cardiovascular complications. We want to implement the necessary measures to assure that risk is diminished before scheduling surgery,” says Dr. Russell.
Practitioners of perioperative care also advocate for the selective and appropriate use of testing. At HSS, the Perioperative Working Group determines which tests to recommend for all patients, and which ones should be available at the specific request of the doctor providing care. “Eliminating unnecessary use of tests benefits everyone. The patient can be protected from potential risks - such as exposure to radiation that accompanies certain imaging techniques. In addition, the presurgical process is streamlined and directed to the specific tests required for each patient, which avoids unnecessary delay and expense to the patient and the insurer,” says Dr. Russell.
The Venous Thromboembolism committee at HSS focuses on another aspect of perioperative care, the prevention of deep vein thrombosis and pulmonary embolisms, dangerous blood clots that can form after surgery. This group works to identify medications that protect against this complication, and develops guidelines to regulate administration of these drugs which carry some risk of bleeding.
At HSS, during the early postoperative period, the anesthesiologist on the surgical team takes primary responsibility for the patient, essentially integrating care with the Perioperative team. To facilitate continuity of care, perioperative polices also ensure that all other physicians involved with the patient’s care follow the same HSS guidelines that cover selection of medications as well as those that dictate when drugs should be started and stopped before and after surgery.
Other quality of care and comfort issues are also important, Dr. Russell acknowledges, whether it’s ensuring that a patient who needs hypoallergenic sheets gets them or that dietary restrictions are followed. The nurse consult system at HSS provides a formalized procedure for communicating patient needs. “Responding to these requests lets patients know that we are listening and that inspires confidence,” she says.
At HSS, perioperative services have also been enhanced by the introduction of specialty nurse practitioners - registered nurses with advanced clinical training in a specific area of care. Patients with insulin-dependent diabetes, for example, are followed by a diabetes nurse practitioner. This member of the team not only stays in close touch with the endocrinologist, but sees the patient several times a day throughout their hospitalization to ensure that insulin requirements are met. “Often, the patient knows his or her own needs the best and can tell us how many units of insulin they need. The diabetes nurse practitioner is not only available and focused on this feedback, but also helps monitor the patient’s diet,” says Dr. Russell.
Similarly, patients with cardiovascular conditions benefit from the presence of a nurse practitioner trained in cardiac care. “Patients who rely on pacemakers and defibrillators must have these devices turned off prior to surgery,” notes Dr. Russell. “In the past, delays were common while we waited for the authorized individual to arrive from outside the hospital. Now, with the presence of our cardiac nurse practitioner, who was trained and supervised by cardiologists at New York Hospital, these delays have been virtually eliminated.”
A nurse practitioner trained in geriatric medicine has also joined the HSS team to reduce the risk of confusion or other central nervous system effects that some people experience following surgery. Patients at risk for these responses have been shown to benefit from interventions such as family involvement, being physically located close to the nursing station, and avoiding certain medications. The presence of the nurse practitioner is intended to ensure that these measures are in place for the patients who may need them.
In addition, a perioperative psychologist is available at HSS to help those individuals having difficulty managing anxiety associated with their impending surgery and to follow the patient through recovery.
Whether a patient is scheduled to transfer to an inpatient rehabilitation facility or to return home following surgery, perioperative services at HSS assist with the transition. This process usually starts with a preadmission phone call from a representative from the case-management team. Individuals in this department can help patients find out which services their insurance will cover, how to arrange transportation to another facility if that is necessary, and help ensure that a family member or other caregiver is available at the time of the patient’s discharge from the hospital.
In some cases, Dr. Russell and her colleagues have started working with Visiting Nurses Services in advance of admission to make sure that the patient’s home environment is safe or to recommend other arrangements as needed.
In addition to their day-to-day role in patient care at HSS, the perioperative care team is studying which initiatives are most effective in achieving positive outcomes. “Identifying which systems safely reduce length of stay in the hospital following surgery or measuring the efficacy of computerized risk calculation not only benefits HSS patients, but all surgical patients,” Dr. Russell says.
If you are already a patient at HSS and would like more information about perioperative medicine at HSS, please speak to your surgeon. If you are not currently a patient, but would like to meet with an HSS surgeon, please visit the Physician Referral Service or call 1.877.606.1555.
Summary by Nancy Novick