The Perioperative Surgical Home
©G.M. Woerlee, 2005–2019
Recent years have seen the development of the concept, and advocacy of the concept of the Perioperative Surgical Home (PSH) (see Butterworth et al, Ludbrook & Goldsman, Grocott et al, Vetter et al). The PSH is actually a recent explicit advocacy of what all physicians have known for a long time — it advocates coordination between differing groups of specialisms, so as to optimize the perioperative care of patients. The final results are better management of, or even prevention of anticipated perioperative complications, fewer unanticipated perioperative complications, shorter hospital stays, all of which mean improved patient care. For hospitals this means efficient usage of all facilities, higher turnover, and potentially more profit. PSH is not only a potential “Win-Win” for patients, physicians, and hospitals, but is revealed as a reality by recent studies. Proven advantages of the PSH are listed below.
- Accurate preoperative assessment and optimization reduces the chance, and severity of postoperative complications, as well as considerably reducing mortality (see Hall et al, Gillies et al).
- The institution of a well-functioning PSH reduces length of stay after surgery because of fewer complications (see Qiu et al)
- Postoperative complications increase the costs per surgical episide (see Selby et al, Pradarelli et al). A well-functioning PSH by reducing the chance of postoperative complications, reduces cost per patient per surgical episode (see Raphael et al)
Modern computer technology, combined with computer networks can enormously facilitate the functioning of a PSH. PANSURAS (Perioperative ANesthesia & SURgical Assessment System) is designed with the above objectives in mind, to integrate and facilitate the functioning of a PSH.
PANSURAS facilitates PSH functioning
PANSURAS is a self-learning perioperative decision support system designed as an adjunct to a hospital information system that also provides a benchmarking, audit and quality control systems, as well as a enabling “fast-track” study of drugs, techniques, and management systems. All these functions facilitate the realization of an integrated PSH.
- PANSURAS is intranet-based, (i.e. within the intranet of an institution), with a database table structure absolutely identical for all users. This means that physicians with consulting rooms at various locations, hospitals, regions, and even countries, can readily exchange information with each other, as well as use the same databases. Accordingly an anesthesiologist can assess a patient at one location, and the surgeon sees the results of this assessment at another location. Both can provide extra commentary and data. This interaction integrates by elimination of the “Island Culture” currently existing between physicians practicing different medical specialties.
- PANSURAS provides context-related information pop-ups and warnings of potential and real problems. These problems can be managed preoperatively, and the patient optimized for surgery. The simulation mode is a useful tool here to investigate the potential effects of optimization therapies, as well as for teaching.
- Recognition of problems, and potential problems is one of the features of PANSURAS. This means not only that preoperative optimization is possible, but also that planning can be made to minimize the effects of any potential, or anticipated problems.
- PANSURAS generates statistical risk percentages for multiple morbidities and mortality based upon the local socioeconomic, demographic, and medical situation. The coefficients of the predictive equations are continually calibrated for the local situation by means of a proprietry multifactorial logistic regression module where the PANSURAS system is in use. This means that surgeons and anesthesiologists can make accurate deliberations of whether a planned operation is justified or not, and discuss this with patients as indicated.
- Recognition of predicted potential morbidity and mortality enables better planning to be made for postoperative management. After operation and discharge from the recovery room, the patient goes to a part of the hospital providing the appropriate level of care — this potentially eliminates many emergency admissions to the intensive care unit.
- PANSURAS includes multiple audit and quality control tools with which the functioning of an integrated PSH can be monitored, and improved.
- The PANSURAS database is identical for all users, and also lists disorders and procedures using international ICD-10 and ICD-9 codes, so facilitating benchmarking, outcome information exchange between widely disparate users. Large amounts of standardized data from multiple institutions eliminates the need for meta-analyses which in many cases are inaccurate, as has been demonstrated in a recent study of the sometimes absent correlations between meta-analyses and controlled trials to answer the same clinical questions (see Sivakumar).
These are som of the functions with which PANSURAS is one possible solution factilitating a PSH.