Sharing the care: anesthesiology as part of the perioperative interdisciplinary team

Abstract

It has been more than 50 years since Beecher and Todd reported an anesthesia-related death rate of 1:1,560, which was many times greater than the now accepted anesthesia related mortality of approximately \\ 1:100,000. Unfortunately, the incidence of perioperative mortality remains much higher in comparison. In a meta-analysis for United Nations High Developed Index countries comparing pre-1970 data with that after 1990, the postoperative mortality rate decreased from 10,603 to 1,176 per million while mortality rates solely related to anesthesia declined from 357 to 34 per million. While these data illustrate a[ 30-fold difference between intraoperative and postoperative mortality, the postoperative mortality rate may be as much as 1,000 times higher if one considers mortality at 30 days. As intraoperative mortality has decreased, our attention as anesthesiologists has increasingly shifted from purely intraoperative care (or ‘‘watching closely those who sleep’’: the former motto of the Canadian Anesthesiologists’ Society) to a more comprehensive view of care that includes ‘‘Science, Vigilance and Compassion’’. Similarly, the American Society of Anesthesiologists has identified the creation of the ‘‘Perioperative Surgical Home’’ as a ‘‘patient-centric team-based model of care’’. In addition, the Canadian Cardiovascular Society published guidelines conditionally recommending a shared care approach to postoperative care in patients with elevated cardiac risk; the membership of the guidelines development panels represented a collaboration of anesthesiologists, cardiologists, general internists, and surgeons. While anesthesiologists increasingly identify themselves as perioperative physicians involved not only in conventional intraoperative care, but also in preoperative optimization and postoperative care, the team-based approach to shared care or co-management has evolved as well. Postoperative care has been traditionally provided by surgeons (and their trainees in academic institutions), or by teams of healthcare providers (i.e., shared care or comanagement) more commonly in institutions without residents. These teams may include family physicians, internists, nurse practitioners, and physician assistants. Indeed, the term ‘‘hospitalist’’ was introduced in 1996 to identify physicians who provided comprehensive inhospital care. The number of hospitalists in the United States has increased over the past two decades from less than a few hundred to over 50,000, many of whom are involved in a postoperative shared-care model. There is a need to evaluate patient outcomes associated with changing models of perioperative care. In this issue of the Journal, Mazzarello et al. report on their meta-analysis examining postoperative shared care led by physicians or nurses for patients undergoing elective or emergent inpatient non-cardiac surgeries. Their identified primary outcome was 30-day postoperative mortality, with secondary outcomes of 90-day mortality and hospital length of stay. Using a well described search strategy, only studies that included prospective standard (non-shared) care versus shared postoperative care were included. The authors excluded hip fracture patients that had been subjects of a previous systematic review examining co-management by a geriatrician with the orthopedic surgeon. That study concluded that the shared care improved mortality, both in and out of hospital, and K. E. Turner, BScPhm, MSc, MD, FRCPC (&) J. L. Parlow, MSc, MD, FRCPC Department of Anesthesiology and Perioperative Medicine, Queen’s University, 76 Stuart Street, Kingston, ON, Canada e-mail: [email protected]