One of the most positive effects of recent healthcare reform is the focus on patient-centered care and the integration of care among the variety of physicians, nurses, labs, pharmacists, and myriad other clinicians involved in a patient’s care. While almost all medical professionals can agree that greater communication among a patient’s care providers is a good thing, there are varying opinions on who should be the central point of contact in that array of professionals.
Recently, the American Society of Anesthesiologists (ASA) has proposed the idea of transforming anesthesiologists into “perioperativists” responsible for leading a patient’s multidisciplinary, comprehensive care team. As part of their concept of the Perioperative Surgical Home (PSH), the perioperativist role capitalizes on the anesthesiologist’s current involvement in surgical care from pre-operative discovery and testing through to post-operative and even post-discharge care. In this model, the perioperativist oversees the patient’s care in coordination with the surgical team. Once it has been determined that the patient needs surgery, the perioperativist will assess the patient with regard to any existing comorbidities, determine the appropriate anesthesia strategy, coordinate the surgical plan and necessary resources, and craft a post-operative care plan. The integration of care would be carried out in four phases: pre-operative, intra-operative, post-operative, and post-discharge.
A study published by Raphael et al (Perioperative Medicine [London] 2014;3:6) documents the cost-effectiveness of this approach. In the study, patients at UC-Irvine Medical Center in California who underwent total knee arthroplasty and total hip arthroplasty realized 43% and 61% savings in total per diem cost over reported benchmarks, due in large part to a reduction in hospital stay from four days to three. Assuming patients are more satisfied as length-of-stay decrease, and that the quality of care is improved as evidenced by reduced readmissions, this result aligns with the so-called “Triple Aim” of higher-quality care, reduced per capita cost, and greater patient satisfaction.
It is not surprising that anesthesiologists see themselves as the most appropriate for overseeing the continuum of surgical care. A poll taken at the 68th New York State Society of Anesthesiologists Post Graduate Assembly found that among the more than 300 attendees who responded, 94.2% felt that anesthesiologists should be OR Directors. Steven Boggs, MD, lead investigator in the survey, as well as OR director and chief of anesthesiology at James J. Peters VA Medical Center in New York City, said, “At our centers, we’ve really seen a dramatic improvement in all of the major OR productivity metrics since anesthesiology assumed the role of OR Director.”
In a differing opinion, a recent editorial in General Surgery News, written by Frederick L. Greene, MD, clinical professor of surgery at the University of North Carolina School of Medicine and medical director of Cancer Data Registry, Levine Cancer Institute, recognizes the benefit of a central point of integration for perioperative care, but argues that putting the anesthesiologist in this position sequesters the surgeon “solely into the technical phase of an operation” and that the “management of the surgical patient must not transition to non-surgical specialists because of the presumption that we have undervalued or abdicated our responsibility.” Dr. Greene said his institution had implemented a system in which a “Surgeon of the Day” managed the OR. Each day, the surgeon assigned as director would have no procedures scheduled and was responsible OR staffing and scheduling, and managing efficiency. While surgeons arguably have a credible claim to the position of OR Director, changing directors each day seems to be an invitation for inconsistency, confusion, and personal preference over protocol.
As anesthesia professionals, we at Somnia certainly see the transition to perioperativist as a natural one for anesthesiologists. An anesthesiologist’s involvement with the patient across the continuum of surgical care has given many in that role the responsibility, if not the title, already. To be sure, the role of anesthesiologist may vary widely among cases, patients, and institutions, and patient care will and should continue to be a team effort. However, every successful team needs its captain, every orchestra its maestro. We believe an objective assessment of roles and responsibilities would conclude that the anesthesiologist is best suited to that role.
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