Thomas R. Vetter

The perioperative surgical home: How anesthesiology can collaboratively achieve and leverage the triple aim in health care

ORIGINS AND PARTICIPANTS OF THE PERIOPERATIVE SURGICAL HOMEGuiding Principles of the Triple Aim and the Patient-Centered Medical HomeBy 2019, an estimated 19.3% of the United States gross domestic product will be devoted to health care.1 Health care delivery and payment systems in the United States

The Perioperative Surgical Home: how can it make the case so everyone wins?

BackgroundVaried and fragmented care plans undertaken by different practitioners currently expose surgical patients to lapses in expected care, increase the chance for operational mistakes and accidents, and often result in unnecessary care. The Perioperative Surgical Home has thus been proposed by the American Society of Anesthesiologists and other stakeholders as an innovative, patient-centered, surgical continuity of care model that incorporates shared decision making. Topics central to the debate about an anesthesiology-based Perioperative Surgical Home include: holding the gains made in anesthesia-related patient safety; impacting surgical morbidity and mortality, including failure-to-rescue; achieving healthcare outcome metrics; assimilating comparative effectiveness research into the model; establishing necessary audit and data collection; a comparison with the hospitalist model of perioperative care; the perspective of the surgeon; the benefits of the Perioperative Surgical Home to the specialty of anesthesiology; and its associated healthcare economic advantages.DiscussionImproving surgical morbidity and mortality mandates a more comprehensive and integrated approach to the management of surgical patients. In their expanded capacity as the surgical patient’s “perioperativist,” anesthesiologists can play a key role in compliance with broader set of process measures, thus becoming a more vital and valuable provider from the patient, administrator, and payer perspective. The robust perioperative databases created within the Perioperative Surgical Home present new opportunities for health services and population-level research. The Perioperative Surgical Home is not intended to replace the surgeon’s patient care responsibility, but rather leverage the abilities of the entire perioperative care team in the service of the patient. To achieve this goal, it will be necessary to expand the core knowledge, skills, and experience of anesthesiologists. Anesthesiologists will need to view becoming perioperative physicians as an expansion of the specialty, rather than an abdication of their traditional intraoperative role. The Perioperative Surgical Home will need to create strategic added value for a health system and payers. This added value will strengthen the position of anesthesiologists as they navigate and negotiate in the face of finite, if not decreasing fiscal resources.SummaryBroadening the anesthesiologist’s scope of practice via the Perioperative Surgical Home may promote standardization and improve clinical outcomes and decrease resource utilization by providing greater patient-centered continuity of care throughout the preoperative, intraoperative, and postoperative periods.

A comparison of EMLA cream versus nitrous oxide for pediatric venous cannulation

STUDY OBJECTIVE To compare the analgesic and anxiolytic effects of nitrous oxide (N2O) when inhaled by face mask with those of a cutaneous application of a eutectic mixture of local anesthetics (EMLA) cream with lidocaine and prilocaine during pre-operative venous cannulation in children. DESIGN Prospective, randomized study. SETTING Outpatient presurgical area and operating rooms of a freestanding childrens hospital. PATIENTS 50 unpremedicated ASA status I and II outpatients, aged 6 to 12 years, undergoing an elective surgical procedure. INTERVENTIONS Each patient received either 70% N2O in 30% oxygen (O2) administered by face mask for 120 seconds or an application of 2.5 g of EMLA cream under an occlusive dressing for a minimum of 60 minutes. All patients then underwent a single attempt at venous cannulation in the dorsum of the hand with a 22-gauge intravenous catheter. MEASUREMENTS AND MAIN RESULTS A visual analog scale (VAS) pain score (0 to 100) was generated by the investigator and subsequently obtained from each patient immediately after the venous cannulation was completed. The pain scores generated by the investigator were significantly lower in the N2O group than the EMLA cream group (p = 0.001). When compared with the patients in the EMLA cream group, the patients in the N2O group also self-reported significantly lower VAS pain scores (p = 0.006). CONCLUSIONS N2O administered by face mask appears to provide greater anxiolysis and attendant superior analgesia for pediatric venous cannulation than a cutaneous application of EMLA cream.

Intravenous ketorolac as an adjuvant to pediatric patient-controlled analgesia with morphine

STUDY OBJECTIVE To assess the effects of a single intraoperative dose of intravenous (i.v.) ketorolac on postoperative opioid dose requirements, quality of analgesia as assessed by the patient, and frequency of opioid-related side effects during pediatric patient-controlled analgesia (PCA) with morphine. DESIGN Prospective, randomized, double-blind study. SETTING Operating rooms, postanesthesia care unit (PACU), and inpatient care units of a freestanding childrens hospital. PATIENTS 50 ASA physical status I-II orthopedic surgical patients ages 8 to 16 years. INTERVENTIONS Either 0.8 mg/kg of i.v. ketorolac or no additional analgesic was administered at the time of wound closure. After surgery, all patients were placed on PCA with morphine. MEASUREMENTS AND MAIN RESULTS Individual morphine use during the first 12 hours of PCA therapy was recorded. A visual analog scale (VAS) pain score was obtained from the patient at the time of discharge from the PACU and at 4, 8, and 12 hours postoperatively. Any vomiting, pruritus, or urinary retention occurring during the first 12 postoperative hours was noted. The morphine plus ketorolac group administered significantly less PCA with morphine during the first 12 postoperative hours than did the morphine only group (p = 0.002). The morphine plus ketorolac group also reported significantly lower overall VAS pain scores (p < 0.01). Although similar frequencies of vomiting and pruritus were observed, the morphine plus ketorolac group experienced significantly less urinary retention than did the morphine group (p = 0.02). CONCLUSION A single intraoperative dose of i.v. ketorolac appears to be opioid dose sharing, to provide superior analgesia, and to decrease the frequency of urinary retention during the first 12 hours of postoperative pediatric PCA with morphine.

The epidemiology and selective identification of children at risk for preoperative anxiety reactions.

This observational outpatient study was undertaken prospectively to assess the effect of age and gender on the frequency of childrens difficulty with preoperative parental separation and to examine five simple clinical factors as predictors of problematic preoperative behavior. Although gender had no significant effect, 2- to 6-yr-old children were more likely than children 7 to 8 yr old to exhibit problematic behavior on parental separation (P < 0.05). In 2- to 6-yr-old children, three factors were significant predictors of problematic behavior: not taking a preoperative family tour (P < 0.05), having undergone previous surgery (P < 0.05), and preoperatively displaying a dependent or withdrawn affect (P < 0.05). Instead of implementing the routine use of a sedative, optimal management seems to involve sedating only 2- to 6-yr-old children who display one or more of these significant predictive risk factors.

A primer on health-related quality of life in chronic pain medicine.

BACKGROUND:Pain is a complex and individual experience that is often difficult for patients to fully describe using a conventional pain intensity scale. Health-related quality of life is an additional metric by which to assess patients’ subjective perspective on their chronic pain experience and its adverse effect on their lives. Health-related quality of life encompasses those aspects of health and well-being valued by patients, specifically, their physical, emotional, and cognitive function, and their ability to participate in meaningful activities within their family, workplace, and community. METHODS:A methodical search of the medical literature was undertaken to identify the most commonly applied health-related quality of life measurement instruments. These measurement instruments were then assessed within the context of chronic pain medicine clinical practice and research. RESULTS:This primer provides an overview of the concept of health-related quality of life as a clinical measurement and the specific means by which to measure health-related quality of life across various cultures in adults, as well as in children and adolescents, suffering from chronic pain conditions. CONCLUSIONS:We have the ability and impetus to routinely assess adult and pediatric health-related quality of life in chronic pain medicine. However, further attention needs to be focused on overcoming barriers to the more widespread measurement of health-related quality of life. A valid preference-based, utility measure of health-related quality of life is a requirement for performing a cost-utility (cost-effectiveness) analysis and undertaking formal decision analysis modeling.

An observational study of patient versus parental perceptions of health-related quality of life in children and adolescents with a chronic pain condition: who should the clinician believe?

BackgroundPrevious pediatric studies have observed a cross-informant variance in patient self-reported health-related quality of life (HRQoL) versus parent proxy-reported HRQoL. This study assessed in older children and adolescents with a variety of chronic pain conditions: 1) the consistency and agreement between pediatric patients’ self-report and their parents’ proxy-report of their child’s HRQoL; 2) whether this patient-parent agreement is dependent on additional demographic and clinical factors; and 3) the relationship between pediatric patient HRQoL and parental reported HRQoL.MethodsThe 99 enrolled patients (mean age 13.2 years, 71% female, 81% Caucasian) and an accompanying parent completed the PedsQLTM 4.0 and 36-Item Short-Form Health Survey Version 2 (SF-36v2) at the time of their initial appointment in a pediatric chronic pain medicine clinic. Patients’ and parents’ total, physical, and psychosocial HRQoL scores were analyzed via an intra-class correlation coefficient, Spearman’s correlation coefficient, Wilcoxon signed rank test, and Bland-Altman plot. A multivariable linear regression model was used to evaluate the association between clinical and demographic variables and the difference in patient and proxy scores for the Total Scale Score on the PedsQL™.ResultsWith the exception of the psychosocial health domain, there were no statistically significant differences between pediatric patients’ self-report and their parents’ proxy-report of their child’s HRQoL. However, clinically significant patient-parent variation in pediatric HRQoL was observed. Differences in patient-parent proxy PedsQL™ Total Scale Score Scores were not significantly associated with patient age, gender, race, intensity and duration of patient’s pain, household income, parental marital status, and the parent’s own HRQoL on the SF-36v2. No significant relationship existed among patients’ self-reported HRQoL (PedsQL™), parental proxy-reports of the child’s HRQoL, and parents’ own self-reported HRQoL on the SF-36v2.ConclusionsWe observed clinically significant variation between pediatric chronic pain patients’ self-reports and their parents’ proxy-reports of their child’s HRQoL. While whenever possible the pediatric chronic pain patient’s own perspective should be directly solicited, equal attention and merit should be given to the parent’s proxy-report of HRQoL. To do otherwise will obviate the opportunity to use any discordance as the basis for a therapeutic discussion about the contributing dynamic with in parent-child dyad.

An analysis of methodologies that can be used to validate if a perioperative surgical home improves the patient-centeredness, evidence-based practice, quality, safety, and value of patient care.

Approximately 80 million inpatient and outpatient surgeries are performed annually in the United States. Widely variable and fragmented perioperative care exposes these surgical patients to lapses in expected standard of care, increases the chance for operational mistakes and accidents, results in unnecessary and potentially detrimental care, needlessly drives up costs, and adversely affects the patient healthcare experience. The American Society of Anesthesiologists and other stakeholders have proposed a more comprehensive model of perioperative care, the Perioperative Surgical Home (PSH), to improve current care of surgical patients and to meet the future demands of increased volume, quality standards, and patient-centered care. To justify implementation of this new healthcare delivery model to surgical colleagues, administrators, and patients and maintain the integrity of evidenced-based practice, the nascent PSH model must be rigorously evaluated. This special article proposes comparative effectiveness research aims or objectives and an optimal study design for the novel PSH model.

A clinical profile of a cohort of patients referred to an anesthesiology-based pediatric chronic pain medicine program

BACKGROUND: Pediatric chronic pain is very common and results in significant health care costs. Pediatric chronic pain is both an individual and a public health concern. The primary objective of this study was to generate a descriptive clinical profile of the patients referred to an anesthesiology-based pediatric chronic pain medicine program. This patient profile was intended to serve as a surrogate for a more formal population needs assessment. METHODS: A quantitative observational study design was applied. The independent study variables included the primary pain-related diagnosis, duration of pain symptoms, patient age, patient sex, insurance status, an intact biological family unit, fulltime school attendance, home schooling, and comorbid depression and/or anxiety. Using a series of previously well-validated measurement instruments, the dependent study variables included self-reported chronic pain intensity, self-reported and parent proxy-reported health-related quality of life, adverse family impact, and parental satisfaction. Study data collection occurred at the time of the first visit to the pediatric chronic pain medicine clinic but before interacting with any health care provider. RESULTS: The enrolled patients (n = 100) were predominantly adolescent females, whose chronic pain had persisted for >1 yr and whose pain was frequently accompanied by clinically significant anxiety and depression. As compared with national and state norms, a significantly disproportionate percentage had a nonintact biological family unit (P < 0.001), was not attending school fulltime (P < 0.001), and was intentionally being home-schooled (P < 0.001). Ninety-five percent of the present cohort of patients had previously been under the care of at least one other subspecialist for their chronic pain condition. The mean initial patient self-reported and initial parent proxy-reported health-related quality of life scores (PedsQL Total Score) were also significantly lower than the PedsQL Total Score values previously observed in pediatric rheumatology patients (P < 0.0001), pediatric migraine patients (P < 0.0001), and pediatric cancer patients (P < 0.0001). CONCLUSIONS: Pediatric chronic pain patients previously under the care of another subspecialist and subsequently referred to an anesthesiology-based pediatric chronic pain medicine program seemed to be experiencing significantly worse health-related quality of life. The routine assessment of chronic pain-related pediatric health-related quality of life seems feasible and worthwhile. Attention also needs to be focused on consistently addressing the strength of a patients coping mechanisms, the presence of pain-promoting versus pain-reducing parental behaviors, and preexisting parental pain and disability.

Pediatric patient-controlled analgesia with morphine versus meperidine

To assess prospectively any difference in either analgesia or side effect frequency with morphine versus meperidine, 50 patients, ages 8-16 years, were randomly assigned to receive postoperative patient-controlled analgesia (PCA) with either morphine or meperidine. A numerical rating scale pain score was obtained from each patient twice a day, and any nausea, vomiting, pruritus, or urinary retention requiring catheterization was noted. No significant difference in the incidence of side effects was noted between the morphine and meperidine groups; however, pain scores during morphine PCA were significantly less than those during meperidine PCA (P less than 0.001). These results suggest that morphine is the better opioid for pediatric PCA.