Introduction
Perioperative care has been identified as an area of high cost with a wide variability in quality. Current management strategies in the perioperative setting are inconsistent with conflicting models involving multiple specialties. In 2014, the Loma Linda University Departments of Anesthesiology and Urology implemented a perioperative hospitalist service (PHS), consisting of anesthesiology-trained physicians, to co-manage patients undergoing major urologic surgery for the entirety of their perioperative period. We hypothesized that implementation of this PHS model would result in an improvement in patient recovery, in a reduction in hospital length of stay (LOS), and decrease costs of care.
Methods
As a Quality Improvement (QI) initiative, the PHS service was formed of selected anesthesiologists who received training on the core competencies for hospitalist medicine. The service was implemented following a co-management agreement with the Department of Urology for the PHS service to medically manage patients undergoing major urologic procedures, specifically prostatectomy, cystectomy, and nephrectomy. After IRB approval, the PHS impact was assessed by comparison of the two years prior, to the two years post-implementation of the PHS. The primary outcome marker was a reduction in length of stay. Secondary outcome markers included: complication rate, return of bowel function (flatus), 30-day readmission, number of consultations, reduction in direct patient costs, and bed days saved.
Results
There was no difference between groups for age, ASA, or operative time for all surgical procedures amongst the three years. Over the two years of implementation, statistically significant reductions in length of stay were demonstrated for all surgical procedures post PHS implementation (p < 0.05). Reductions of the median LOS over the 3 years for prostatectomy, nephrectomy, nephrectomy, and cystectomy were 0.33, 1.0, and 4.6, respectively. Significant reductions in complication rates and return of bowel function (flatus) were also observed for all surgical procedures post PHS implementation (Table 1). The majority of the reductions in complications were secondary to an improvement in length of ileus for all surgical procedures. Additionally, decreases in variable direct costs, total direct costs and frequency of consultations were observed. A total of 246.8 bed-days were saved during the first two years of the PHS implementation.
Conclusions
Anesthesiologists can safely function as perioperative hospitalists, significantly improving both patient recovery and throughput. We postulate that similar outcomes would result in expansion to additional surgical lines.
