Continuous Care – A Compelling Challenge and Opportunity for Anaesthesiologists

Continuous Care – A Compelling Challenge and Opportunity for Anaesthesiologists

  • Issue 73

Johannes Wacker, Chair, ESA Patient Safety and Quality Committee (PSQC)
jwac@gmx.net
Paul R. Barach, ASA Committee on Patient Safety and Education, and Wayne State University School of Medicine, Detroit, MI, USA
pbarach@gmail.com

Anaesthesiologists are involved as physicians in the care of patients in a myriad of locations – from the preoperative assessment to the perioperative and postoperative periods. 
A recent “Case Record of the Massachusetts General Hospital” published in the New England Journal of Medicine presented a 36-year-old man with opioid overdose and opioid-induced non-cardiogenic pulmonary edema.1 The patient had gone through periods of opioid addiction before hospitalization; however, he was first exposed to opioids four years earlier, when a physician prescribed hydromorphone for pain management after hand surgery.

Do we know how many of our patients have developed chronic pain, prolonged opioid disorders, or even worse after our postoperative pain treatment? Most anaesthesiologists administer or prescribe opioids on a daily basis and yet rarely manage chronic pain or are aware of their patient’s post-acute opioid concerns. Continuous care is rarely provided by anaesthesiologists throughout the hospital stay, or after discharge. Does this matter? The addictive risks of opioids should be discussed early with patients, and acute pain treatment using opioids should be as short as possible – ideally not exceeding 1-3 days.2 Continuous patient-physician relationships would likely facilitate communication and the necessarily frequent assessments. In clinical reality, however, handovers are unstructured and culture-dependent,3 often done in a superficial rather than a comprehensive manner, leading to patients being out of sight and mind of the primary anaesthesiologist.

The example of piecemeal involvement of anaesthesiologists in their patients’ postoperative pain treatment underscores the issues related to fragmented medical care in anaesthesiology. Our view on the need for a more continuous patient-physician relationship is based on limited formal evidence, but is consistent with various investigations, our personal experience, and with the established practice in some healthcare systems.4

Do you know how many of your anaesthetic patients have suffered adverse events? Regarding our example, most anaesthesiologists would probably be more likely to adapt or change their clinical practice if they were more often directly confronted with the consequences of postoperative opioid-induced adverse outcomes. More generally, while anaesthesia-specific risk is low,5 anaesthesia management significantly influences overall perioperative risk and perioperative outcomes including surgical site infections as well as respiratory, thromboembolic, ischaemic, renal, neurological, and other complications.5,6

Admittedly, some of the causes for fragmentation of care in anaesthesiology are inseparably linked to the episodic nature of our speciality. Urgent tasks have become the defining paradigm of this speciality – emergency calls, urgent anaesthetics and resuscitation, inserting vascular lines, managing unforeseen acute pain crises, etc. – all require ultra-short-term preparedness, flexibility, and an emphasis on the pressing technical aspects of saving life.

In reality, however, this paradigm of urgency reflects only a part of what anaesthesiologists actually do. Elective surgery, for example, requires careful assessment, consideration of the impact of underlying medical conditions of increasingly co-morbid patients, and anticipatory perioperative management to prevent complications. Time and attentiveness are essential to discriminate vital information from less pressing issues. It is important to be familiar with the unique clinical profile of every single patient, with the local care team, and with the hospital environment. During the process of assessing the individual risk of each patient, the physician ideally gains a clear and personalized pre-operative risk assessment of the patient – and vice versa, the patient gains an impression and an image of the physician. Together, they co-produce a perioperative diagnostic and treatment plan tailored to the patient’s individual medical profile, priorities, and experiences, guided by the professional experience of the physician.7

Surprisingly enough, patients routinely and readily give their anaesthesiologists their consent to be deprived of their consciousness; to be invasively probed with needles, tubes, and vascular lines; and to being physically manipulated by drugs, devices, and machines. They entrust their lives, autonomy, and self-determination to someone they have rarely met before. This act is only possible due to the astonishing phenomenon of human communication and trust. Despite the asymmetrical nature of this dynamic, this trust seems to be mutual: research suggests that both patients8,9 and anaesthesiologists4 prefer continuous preoperative and intraoperative patient care by the same anaesthesiologist. Established patient-physician trust is an essential therapeutic tenet of an effective perioperative microsystem.10 Unsurprisingly, increased intraoperative anaesthesia patient handovers have been found to be associated with increased complications and mortality.11,12

Despite increasing production pressures and the prevailing urgency in anaesthesia care, most anaesthesiologists can impact their practice within some limits. Even moderately enhancing continuity of care may differ significantly from a disillusioned retreat. For example, continuous care can be prioritised wherever organisationally possible. In addition, postoperative follow-up visits by the primary anaesthesiologist may enhance the resilience of the local system by checking if postoperative orders are complete and followed, and by reassessing pain scores, nausea, and signs of impending adverse events. The diversity of clinical environments requires that such visits and comparable approaches are best developed at the local level.13

Continuous rather than fragmented anaesthesiology care may contribute to perioperative value, improve patient outcomes and satisfaction, and likely enhance the professional joy and gratification of anaesthesiologists. The intuitive support of this model by many dedicated and experienced clinicians should be a reason to advocate for clinical redesign, and to stimulate research assessing the impact of continuous anaesthesia care on perioperative outcomes.

 

References

  1. Raja AS, Miller ES, Flores EJ, Wakeman SE, Eng G. Case 37-2017. A 36-Year-Old Man with Unintentional Opioid Overdose. N Engl J Med. 2017;377(22):2181-8.
  2. Shah A, Hayes C, Martin B. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use – United States, 2006-2015. MMWR Morb Mort Wkly Rep. 2017;66(10):265-9.
  3. Hesselink G, Schoonhoven L, Barach P, et al. Improving patient handovers from hospital to primary care: A systematic review. Ann Intern Med. 2012;157(6):417-28.
  4. Simini B, Bertolini G. Should same anaesthetist do preoperative anaesthetic visit and give subsequent anaesthetic? Questionnaire survey of anaesthetists. BMJ. 2003;327(7406):79.
  5. Wacker J, Staender S. The role of the anesthesiologist in perioperative patient safety. Curr Opin Anaesthesiol. 2014;27(6):649-656.
  6. Fleisher LA. Risk of Anesthesia. In: Miller RD, ed. Miller’s Anesthesia. Vol. 1. 7th ed. Philadelphia: Churchill Livingstone, Elsevier; 2010:969-999.
  7. Batalden M, Batalden P, Margolis P, et al. Coproduction of healthcare service. BMJ Qual Saf. 2016;25(7):509-17.
  8. Soltner C, Giquello JA, Monrigal-Martin C, Beydon L. Continuous care and empathic anaesthesiologist attitude in the preoperative period: impact on patient anxiety and satisfaction. BJA. 2011;106(5):680-6.
  9. Heidegger T, Saal D, Nubling M. Patient satisfaction with anaesthesia – Part 1: satisfaction as part of outcome – and what satisfies patients. Anaesthesia. 2013;68(11):1165-72.
  10. Mohr J, Batalden P, Barach P. Integrating patient safety into the clinical microsystem. Qual Saf Health Care. 2004;13(Suppl 2):ii34-ii38.
  11. Saager L, Hesler BD, You J, et al. Intraoperative transitions of anesthesia care and postoperative adverse outcomes. Anesthesiology. 2014;121(4):695-706.
  12. Hyder JA, Bohman JK, Kor DJ, et al. Anesthesia Care Transitions and Risk of Postoperative Complications. Anesth Analg. 2016;122(1):134-44.
  13. Barach P, Phelps G. Clinical sensemaking: A systematic approach to reduce the impact of normalised deviance in the medical profession. J R Soc Med. 2013;106(10):387-90.