Perioperative ‘Surgical Home’ Reduces Complications, LOS

Timothy Geiger, M.D., talks with Melba Martin, a patient in VUMC’s High-Risk Surgical Encounter (Hi-RiSE) Optimization Clinic. (photo by John Russell)
Perioperative ‘Surgical Home’ Reduces Complications, LOS
Timothy Geiger, M.D., talks with Melba Martin, a patient in VUMC’s High-Risk Surgical Encounter (Hi-RiSE) Optimization Clinic. (photo by John Russell)
Research-backed care coordination model improves outcomes and lowers costs.

Enhanced Recovery After Surgery (ERAS) initiatives that standardize and coordinate perioperative care have been shown to improve patient recovery and decrease aggregate complications after surgery. The ERAS program at Vanderbilt University Medical Center, launched in 2014, developed out of a collaboration between surgery and anesthesiology, and now spans multiple departments.

“We realized that we could deliver higher-quality care through communication and coordination throughout the perioperative care arc,” said Timothy Geiger, M.D., director of Vanderbilt’s Colon and Rectal Surgery Program and executive medical director of the Surgery Patient Care Center. “And, we had an engaged anesthesia group that was willing to take this on.”

“We realized that we could deliver higher-quality care through communication and coordination throughout the perioperative care arc.”

As the team has continued to target more service lines for implementation, it has grown to include a project manager, health IT analytics, and a design thinking team sponsored by Scott McCarver, Chief Operating Officer.

“Vanderbilt leadership wants us to do ‘ERAS for All’,” said Matt McEvoy, M.D., professor and vice-chair for education in the Department of Anesthesiology. “If there’s a definable service line, whether it’s ambulatory or in-patient, we’re looking to collaborate to implement the principles of care standardization.”

Designing the Program

Geiger and McEvoy started designing their program by looking at all care components within colorectal surgery, matching them up to the latest evidence in perioperative care. They had two goals: improve perioperative communication and decrease unnecessary variability in order to improve patient recovery while reducing length of stay, complications, and cost.

They understood that the central component of the enhanced recovery program must be a surgical champion. In addition, key stakeholders would include anesthesiology, nursing, and pharmacy. The Vanderbilt Anesthesia Perioperative Consult Service (APCS) was established to contribute to planning the entire surgical episode through post-discharge recovery.

In a 2017 study of 1,182 colorectal surgery patients, Vanderbilt researchers found that the new ERAS program was associated with significantly reduced complication rates across a wide range of ACS NSQIP categories. It also led to a >1.5-day reduction in length of stay and reduced total hospital costs by over 20 percent for the colorectal surgery population.

Safeguarding High-risk Patients

The team more recently established the High-Risk Surgical Encounter (Hi-RiSE) Optimization Clinic, where surgical patients at higher risk of developing complications are comprehensively evaluated and interventions can be more efficiently coordinated in weeks prior to surgery.

The clinic performs structure evaluations for surgical patients at high risk for complications including delirium, adverse cardiac events, postoperative pulmonary complications, acute kidney injury and hyperglycemia. Services offered in preparation for surgery may include optimization of anemia and nutrition, as well as help with smoking cessation. This is coordinated with intraoperative and postoperative care planning to ensure patients are fully ready for a successful procedure.

“It is a cultural shift to say, ‘I’m going to hit the brakes.'”

“As surgeons, we really want to operate to fix the problem as soon as we can,” Geiger said. “It is a cultural shift to say, ‘I’m going to hit the brakes, I’m going to let the patient get ready and then we’re going to the OR.’ But being able to get high-risk patients ready for surgery makes all the difference in the world.”

Priority Service Lines

Current plans to expand the program include integrating the Vanderbilt Burn Center. “Those patients have major life-long chronic pain – beginning in the ICU,” McEvoy said. “We’re also working on benign and oncologic gynecology and finalizing protocols for C-section, thoracic, orthopaedic oncology, and geriatric hip fractures.”

In urology, the team’s “Stents and Stones” pathway for ureteroscopic stone treatment recently published in the Journal for Endourology, demonstrated excellent outcomes, increased patient satisfaction, and dramatically lowered opioid consumption after surgery.