Preoperative surgical home
The American Society of Anesthesiologists (ASA) describes the perioperative surgical home model as a “patient-centric, team-based model of care created by leaders within the American Society of Anesthesiologists to help meet the demands of a rapidly approaching health care paradigm that will emphasize value, patient satisfaction, and reduced costs.” The Perioperative Surgical Home (PSH) and Enhanced Recovery After Surgery (ERAS)® initiatives were developed in different parts of the world, with similar but distinct goals. The ERAS initiative was pioneered by Kehlet et al. in Denmark (1997), with his groundbreaking work on fast-track surgery showing that most patients had recovered enough to be discharged 2 days after open sigmoid colon resections. This was at a time when the length of stay for these operations was 10 days or more in most countries. These protocols were later expanded to other surgical specialties with some resistance from the medical community, coupled with promising results. Finding that the guidelines could be implemented in a structured way with prompt improvement in results, it was subsequently decided that a major effort was needed to help spread ERAS concepts more widely alongside further development of research. This formed the basis for the ERAS Society which was created officially and registered in Sweden in 2010 (www.erassociety.org).
The PSH was proposed by the ASA and other stakeholders as an innovative, patient-centered, surgical continuity of care model that incorporates shared decision-making. The need for such a model serves to build on the gains made by the anesthesiology community in patient safety, improve coordination of care between various providers who care for patients during the perioperative period, and, finally, and to make financial sense in the bundle payment, patient outcome, and satisfaction-based reimbursement system. The initiatives stemming from different clinical needs would serve their respective purposes in a more efficient way if ERAS protocols existed within a PSH, facilitating efficient care delivery systems by coordination between providers caring for the surgical patient in the preoperative, intraoperative, early and late postoperative phases.
Overall key points of ERAS and PSH are as follows:
ERAS programs are evidence-based multimodal interventions that achieve early postoperative recovery
PSH was introduced as an organizing idea for ERAS pathways and perioperative medicine
PSH is proposed as a patient-centered, team-based system of care developed by the ASA
The goals of the PSH are to improve patient satisfaction, improve the quality of perioperative care delivered, and reduce the cost of surgical care.
Enhanced Recovery after Surgery in the Preoperative Phase of Care
Patient preparation for an upcoming surgery includes patient counseling, education, lifestyle modifications, and extends into the immediate preoperative period with newer preoperative fasting protocols. Successful implementation of these protocols requires collaborative efforts between surgeons, anesthesiologists, dieticians, physical medicine and rehabilitation professionals, psychiatrists, psychologists, and pharmacists to name a few. Since the ideal PSH contains leaders from each of these respective fields, it would be integral for timely development and continued data collection, leading to improvement of these protocols based on outcomes.
Patient Counseling and Education
Patients that are given preoperative information and/or a visit to the surgery center exhibit reduced anxiety, improved compliance with postoperative instructions, improved postoperative recovery, decreased length of stay, and improved long-term outcomes. Furthermore, preoperative psychological counseling can reduce fatigue and surgery-associated stress while also improving postoperative wound healing.