VOLUME 30, ISSUE 1

The practice management committee has set a goal of periodically sharing with TSA members ways to create a Perioperative Surgical Home so that every practicing anesthesiologist in Texas can effectively participate in enhanced quality based care models. This article is the first iteration of this effort to produce a PSH “menu” for TSA members.

As value-based care initiatives continue their march forward, and as the ASA’s Perioperative Surgical Home (PSH) initiative continues to gain traction, we are seeing how these two efforts can complement each other quite well. One area in which we see this synergy clearly is in the Comprehensive Care for Joint Replacement (CJR) model.

Hip and knee arthroplasty are the most common inpatient surgeries for Medicare beneficiaries. Despite their high volume, complication rates and costs vary widely. Therefore, in April 2016, CMS mandated participation in a five-year CJR pilot program in 67 metropolitan statistical areas to “hold participant hospitals financially accountable for the quality and cost of a CJR episode of care and incentivize increased coordination of care among hospitals, physicians, and post-acute care providers. The episode of care begins with an admission to a participant hospital…and ends 90 days post-discharge.”¹ Based on target vs. actual spending, hospitals may either receive additional payments from Medicare or be required to repay Medicare.

Now that hospitals are being held financially responsible for total costs of care for a three-month period, even for exacerbations of chronic conditions, they are highly motivated to engage in patient optimization efforts and to assist in bringing what is often divergent surgeon practices into more unified evidence-based protocols. As hospitals implement and optimize these programs, physician anesthesiologists are in a prime position to lead these programs, improving quality and patient outcomes while reducing cost of care and enhancing the value that their anesthesiology group brings to their hospital.

At our institution, we assembled a team that included physician anesthesiologists, orthopedic surgeons, physical therapists, and orthopedic nurses that resulted in the establishment of a CJR-specific preoperative optimization clinic. We start with patient education: a preoperative joint replacement class helps patients prepare for surgery, know what to expect perioperatively, and how to optimize recovery postoperatively.

Criteria have been established that trigger automatic referral to a primary care physician for optimization, including

• Hemoglobin < 12 (males) or < 11 (females)
• Serum potassium < 3.3 mmol/L or > 5.2 mmol/L
• Hemoglobin A1c > 7.5%.

Other screening tests include

• CBC
• MRSA screen
• ECG (if criteria are met)
• Urinalysis (if symptomatic)
• BMI
• Risk Assessment and Prediction Tool (RAPT), to predict discharge destination ²
• Venous thromboembolism risk assessment
• Depression score
• Anxiety score
• Dental screen
• Obstructive sleep apnea screen (STOP-Bang)
• Tobacco abstinence
• Alcohol intake
• Chronic narcotic use
• Lower extremity skin check

A physician anesthesiologist reviews the foregoing information and medical record of each patient 4-6 weeks prior to surgery, rather than the day before (or day of!) surgery, as was our previous practice. Any opportunities for optimization can be identified and addressed early, often without the need to postpone surgery. Referrals to other physicians, such as a cardiologist, pulmonologist, or nephrologist are made at this time. Coordination with other physicians is established, such as with a patient’s chronic pain physician for postoperative pain control.

Multimodal analgesia is started preoperatively, on the day of surgery, with celecoxib 200 mg, intravenous acetaminophen 1,000 mg, pregabalin 50 mg, and oxycodone sustained release 10 – 20 mg. Regional anesthesia for postoperative pain management includes placement of an adductor canal peripheral nerve catheter and a selective tibial nerve block. For the primary anesthetic, intrathecal anesthesia with bupivacaine is preferred unless contraindicated. A single intraoperative dose of ketamine 0.5 mg/kg is given as well.

Postoperatively, a physician anesthesiologist-led pain service, which includes nurses that specialize in acute pain management, continues to manage each patient’s pain control—certainly during the inpatient stay, but even after hospital discharge, with daily phone calls while a peripheral nerve catheter continues to provide analgesia. The hospital CJR director continues to follow all patients for 90 days postoperatively, providing care coordination and navigation of resources to provide ongoing support and education while reducing return visits to the emergency room and readmissions.

Our development of a pain committee, which is comprised of physician anesthesiologists and nurses, has allowed us to standardize this entire pathway; such standardization has, in turn, led to a consistent patient experience across multiple surgeons. A multimodal approach to pain control and the inclusion of regional anesthesia has been a critical component of this pathway.

Early results of several metrics, including pain scores, time to ambulation, distances ambulated, length of stay, readmission rates, patient satisfaction, and total cost of care are promising. Our multidisciplinary CJR team continues to meet monthly to discuss cases, outcomes, and updates to the protocol.

1. https://innovation.cms.gov/initiatives/cjr
2. Oldmeadow LB, McBurney H, Robertson VJ. Predicting risk of extended inpatient rehabilitation after hip or knee arthroplasty. J Arthroplasty 2003;18(6):775-9.