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Towards an Ideal Perioperative Continuum

The Evolution of Perioperative Care at the UT MD Anderson Cancer Center

Sunil K. Sahai, MD, FAAP, FACP, CMQ@drsunilksahai

Co-Director, The PeriOperative Evaluation & Management CenterSection Chief & Professor of Medicine

Section of Consultative MedicineDepartment of General Internal Medicine

Disclosures

• No conflict of interest disclosures to report.• No discussion of off-label medication use.• Royalties: UpToDate.com• Board Member, Society for Perioperative

Assessment and Quality Improvement (SPAQI)– Shameless Promo at end of talk!

• All failed attempts at humor are my responsibility alone, and not that of the conference organizers or the UT MD Anderson Cancer Center.

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Objectives

• Discuss the evolution of perioperative care at one cancer center in the USA

• Understand the roles of different medical providers in the ideal comprehensive perioperative medical program.

• Understand the need to clearly define phases of care and hand offs in an enhanced perioperative recovery program.

• This talk is based on the current healthcare delivery system in the USA, and as such may differ from systems in other countries represented at this conference.

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Is this your Preop Clinic?

Found on twitter, original source unknown#PeriSIG18

What is Perioperative Medicine?

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Professor Monty MythenRCoA Council Member

Chair, Perioperative Medicine ProgrammePerioperative Medicine: The Pathway to Better Surgical Care The Royal College of Anesthetists 2015www.rcoa.ac.uk/perioperativemedicine

‘Merica!• Traditional Fee for Service Model

• The more you do, the more you get paid• Perverse system, “If I don’t get paid for it, It’s not my responsibility”

• Private Insurance• Via employer or open market

• Medicare• Health care insurance for those over 65• Federally funded, state administered

• Medicaid• Health care coverage for poor, disabled, etc• State funded, state administered

• Indigent Care• The perfect system:

– Every inefficiency is someone’s revenue stream

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Traditional Roles / Timelines• Anesthesia

– Preop Holding to PACU discharge• Surgery

– Consultation to Suture Removal• Internal Medicine/Hospitalist Consultant

– Risk Assessment to Discharge• Outpatient Consultant

– What test can I bill for?• Primary Care Physicians

– What did you do to my patient?

Anesthesiology• Preop Holding/ OR/

PACU: 24 hours

Surgery• Admit to discharge: days

IMPAC• Perioperative

management: ± 30 days

Community Providers• Long term

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Who’s a Perioperative Physician?• Anyone who

– Touches– Examines– Provides Care for

• A patient in the perioperative period– Traditionally defined as before surgery and 30 days

afterwards• Can be:

– Primary Physician– Hospitalist/Internist/Family Medicine– Medical & Surgical consultants

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Know thyself• “We don’t have a perioperative problem”

– Do you just do the surgery and then the patient goes home and any post op complications are their problem?

• What kind of hospital are you?– My institution: We are not a real hospital; we are a cancer

center that just happens to have:• 650+ inpatient beds• 35+ Operating rooms• 1600+ faculty• 20,000+ employees• 20,000+ anesthetics a year• 1 Nobel Prize Winner!

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Preop Evals Today in USA• Primary Physician?

– 5 Minutes to do what?• Cardiologist?

– “Continue clopidogrel and aspirin for 14 hour brain surgery”

– No lesion goes unstented• Consulting Internist?

– The TSH is 3.5% above normal, delay surgery…• Hospital based?

– RN/Mid Level Providers– Anesthesia– Internal Medicine

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Houston, We have a Problem*

• In our current fragmented and turf war medical system, the patient suffers from– Unneeded testing– Poor communication– Safety concerns– Failure to rescue– Consultitis

• Bundled/Value based payments are coming!* Foreshadowing: With apologies to NASA, the crew of Apollo 13, & @UghHouston

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#PeriSIG18https://justoutsidethebox.deviantart.com/art/Too-many-cooks-spoil-the-broth-320209397 accessed 04/22/2018

Too many cooks

• The Perioperative Surgical Home– American Society of Anesthesiologists

• Perioperative Care Matrix– Society of Hospital Medicine

• Why can’t we all just get along?– SPAQI

http://epicrapbattlesofhistory.wikia.com/wiki/File:Star_Wars_vs_Star_Trek_by_Hapo57.jpg accessed 2/25/2018

Models of Care

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Our Story• late 1990s to 2018: Anesthesia Assessment Center (AAC)

– 80 to 120 patients a day• Quick history to make sure nothing will go bad on day ZERO

• 2004 to 2018: The Internal Medicine Perioperative Assessment Center (IMPAC) – 20 to 26 patients a day

• Focus on medical issues affecting surgery and after• Parallel processes• 2 visits, not coordinated• Asked the same information and compartmentalized it• Something called Enhanced PeriopRecovery

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Surgical Team concerned about

medical comorbidities

IMPAC Consultation

Anesthesia Assessment Center

Surgery

Cardiology ConsultationYES1NO

1The IMPAC evaluation is not mandated by institutional guidelines. The referral from the surgical team is based on the medical evaluation at the time of surgery.

Flow of referrals from Surgical Center to IMPAC

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• Without medical optimization, EPR protocols focusing on Day Minus 1, Day Zero and Day Plus 1 of surgery are not achieving their full potential.

• We need to blur the boundaries, both in terms of timelines and speciality silos.

Enhanced Perioperative Recovery

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POEM at the University of Texas MD Anderson Cancer Center

• Fall 2018: The PeriOperative Evaluation and Management Center (POEM)– Two Internists– Two Anesthesiologists– Eight Advanced Practice Practitioners– Nurses, Clinic staff, etc

• “Enter once, use many” (problem based charting)• “Single source of truth”• “If they are on a pill for it, it’s a current medical problem”

– Case Mix index• Evidence based referrals to speciality services• Evidence based perioperative testing

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POEM Patient Flow from the Surgeon’s perspective

Can I cut it out?

POEM

Surgery

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The Ideal Perioperative Continuum

• Team members– Patient and Family– Primary Care Physician / Team– Oncologist / Radiation – Surgeon– Hospital based Internal Medicine Consultants– Anesthesiology / Critical Care– Pre/Rehab Teams– Case Management / Social Work– Pharmacist – Polypharmacy– Administrative Folks (yep, them too!)

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Patient & Family

• Patient– Duh!

• Family– Advanced Care Planning

• Not just Do Not Ruscitate, but discharge to home, Long Term Acute Care, Skilled Nursing Facility, nursing home?

– Directive to Physicians– Medical Power of Attorney

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Primary Care Physician

• May know the patient the best• Wants to be involved and kept in the loop• Help with polypharmacy• May not have the expertise to map out a true

perioperative medical management plan– Knowledge of Hospital Services– Consultants– Disease specific concerns

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Oncologist

• Vitally important part of the team– Especially if neo-adjuvant chemo is planned

• In cancer care, prognosis matters• Quality of Life Issues• May be able to offer alternate treatment to

surgery

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Surgeon

• “I just want to cut”• Actually concerned about perioperative

outcomes• USA: ProPublica scorecard in the back of her

mind• American College of Surgeons is actively

focusing on the total perioperative experience

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Hospital Based Consultant

• May not know the patient, but knows the hospital

• Can actually take care of the patient in the hospital

• Knows which care teams are in place to help with care

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Anesthesiologist / Critical Care

• Again, may not know the patient, but knows the local quirks

• Last line of defense for patient safety – embrace this!

• Beginning to realize their value outside the OR– Critical Care training– High risk transitions to ICU or step down units.

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PMR & PT/OT

• Essential to the concept of full recovery• Without the Prehab, ERAS protocols are

useless:– Akin to ERAM protocols:– Enhanced Recovery After Marathons*– No matter what you do after the marathon, the

sofa surfers are not going to make it to the registration table!

– In cancer care, the “chemo couch potatoes”

*Thanks to Jay Shah, MD MDACC Urology @BladderCancerMD for the analogy

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Case Management / Social Work

• Essential to functioning in today’s environment.• How many cases cancelled just because a ride

could not be arranged?• Prolonged length of stay due to DME issues• Knows the regulatory stuff• Power or Attorney / Living Wills• Can assist with transitions of care

– LTAC, SNF, NH– Out of State Medicare!

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Pharmacist

• Polypharmacy• Beers Criteria

– It’s not about your favorite microbrew!– October 2015 list at

http://www.americangeriatrics.org/

• Inpatient/Outpatient formularies• Cost issues

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Perioperative Mission Control©• Centralized communication• Nimble and adaptable• Medical management protocols

– Enhanced Perioperative Recovery– Antiplatelet/Anticoagulation– Cardiovascular testing– Prehab

• Understanding of healthcare value– Reduction in Same Day Cancellations– Reduction in complications– Reduction in Length of stay

• Post surgical and post d/c medical management• Everyone allowed to say: GO or NO GO

Yep, I just copyrighted Perioperative Mission Control© ! All Rights Reserved: Sunil K Sahai, MD October 2015

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T-Minus: Surgical Dx

• A surgical diagnosis is made• Time to OR is T-Minus

– Hours– Days– Weeks– Months

• This is when the perioperative continuum starts and mission planning begins

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T-Minus: Months to Weeks

• Get the Golden H&P– Does the patient walk the dog, or does the dog walk

the patient?– Implanted devices

• Identify Medical Problem List• Polypharmacy / Medications• CV Risk Assessment• For each problem: optimized or not

– If not, outline plan to optimize

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The Golden H&P

• Surgical H&P: Trust, but verify• Medicine Reconciliation

– Why are you on this pill?• Ask every question on a good review of systems

– You might be surprised• “Have you ever been cut open by a doctor?”

– Just because a surgeon fixed your heart, it does not mean you no longer have heart disease

• Source documentation for cardiac stents, relevant surgeries, prolonged hospitalizations.

• Lead time to surgery for an adequate evaluation• Recognize what you need to fix, and what can wait• Don’t go on a safari

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One list to rule them all

• Before IMPAC @ UT MD Anderson Cancer Center– Problem List: Cancer, smoking

• After IMPAC– Problem List: HTN, DM, CHF, afib, hx of PE/VTE,

cardiac DES x 3 in the LAD, brain stimulator, CKD, OSA ….

• May not matter preop, but if the patient decompensates postop, having a complete H&P and a problem list is priceless.

• The all important Case Mix Index!#PeriSIG18

Prehab• The Multi-Hit hypothesis for cancer• Remember ERAM?

– The least fit have the most to gain– “Do as I say, not as I do” sksmd

• Prehab Measures– 6MWT– Hand grip– Lean Body Mass– Timed Get up and Go– Gait Assessments

• Prehab Interventions– 5 to 7 weeks ideal– Multimodal (exercise and nutrition)– Walking Stick / Cane Sahai, Curr Anesthesiol Rep DOI 10.1007/s40140-015-0121-x

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Don’t Forget

• Delirium & Fraility assessments– Hearing Aids– Glasses

• Nutrition Assessment & Optimization• Discharge Planning

– Durable Medical Equipment assessment– Post Discharge placement assessment– Stubborn Old Man Syndrome

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T-Minus: Days

• Actual Periop Medical Management– Anticoagulation management– Diabetic management

• Focus on Day Minus 3, 2, 1 details• ERAS Protocols• Set patient expectations

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Day 0• We have lift off…

http://www.artizans.com/image/KIN882/surgeon-is-totally-lost-during-surgery-color/

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Post Op Day 1• Medical consultants

– Medical Management– Critical Care / ICU

• Anesthesia– Epidurals / Regional Anesthesia and LMWH

• Surgical Team– EPR protocols– Wound assessment

• PMR and PT/OT Teams• Case Management

– Durable Medical Equipment– Post discharge placement

• Social Work– What do you mean I have to pay for a sitter?

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Post Op Day 2 - ??

• Return to Homeostasis• Step down from ICU• Transitions from Surgical Issues to Medical

Issues• Aggressive PT/OT• VTE Prophylaxis• Discharge planning• Failure to Rescue issues

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Discharge Day Minus 1

• Appointments on Same Day already made– Suture removal– Periop Clinic F/U

• Medicine Reconciliation– Inpt to Outpt Formulary

• Rehab Plan set• DME ordered and delivered• Transfer to SNF/LTAC/Nursing Home

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Day of Discharge

This slide should be blank if you have been paying attention!

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Periop Post Discharge Follow-Up• Transitions of Care• Summary of Events to primary physician• Medicine reconciliation• Compliance with Rehab Issues• Patient Education• Return to Work

– Employer direct contracting = back to work ASAP• RIOT: Return to Intended Oncologic Treatment• RILE: Return to Intended Life Experiences

Kim, B. J., et al. (2016). "The Impact of Postoperative Complications on a Timely Return to Intended Oncologic Therapy (RIOT): the Role of Enhanced Recovery in the Cancer Journey." International Anesthesiology Clinics 54(4): e33-e46.RILE concept © Sunil K Sahai, MD, January 2018

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Sunil K. Sahai, MD, FACP, FAAP, CMQThe University of Texas MD Anderson Cancer Center

ssahai@mdanderson.orgwww.perioperativecancermedicine.org

Twitter: @drsunilksahai

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Shameless Promo

http://periopmedicine.org/

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Thanks!

END OF PRESENTATION