Dan Longrois and Gabriel Gurman with the collaboration of Susan de Bièvre
This question was addressed to all National Anaesthesiologist Societies (NAS) that are part of the NAS Committee (NASC) during the National Villages during Euroanaesthesia 2017 in Geneva. The question is important for the following reasons: (i) although we all understand implicitly what perioperative medicine (POM) is about, there is no commonly accepted operational definition that would allow identification of its goals, criteria of performance, quality, and definition of resources that are necessary to achieve goals and quality; (ii) because the European project and ESA need to deal with the free circulation of professionals in Europe, it would be desirable to establish common definitions, standards of care, initial training, and continuous professional development (CPD) educational tools dedicated to POM; (iii) the current situation for POM in many, if not all, countries is probably characterized by the intervention of multiple specialties (anaesthesiologists-intensivists, surgeons, other medical specialties) and POM is probably fragmented (a fragmented process of care being defined as the intervention of non-coordinated multiple specialties with resultant decreased efficacy and efficiency and eventually altered quality of care as opposed to the intervention of one coordinating specialty).
For the above-mentioned reasons, NASC and ESA initiated a structured effort to evaluate the present status of POM as viewed by the NAS that are within the NASC. A list of questions was sent to all NAS before Euroanaesthesia 2017 and the NAS were asked to answer those questions and detail them by presenting posters during the National Villages. Profs Dan Longrois and Gabriel Gurman interviewed the presenters of the posters during the National Villages.
The first question was on the “Most appropriate definition of perioperative medicine”. An example of answer is (Great Britain and Ireland, AAGBI): “A patient-centred multidisciplinary and integrated medical care starting from the moment of contemplation of surgery until full recovery”. Other definitions (Macedonia, MSA): “A comprehensive model of care in which anaesthesiologists provide medical care in a continuum of care in collaboration with surgeons and other specialties”. For the Norwegian NAF, the Romanian SRATI, the Check CSARIM, and the Austrian ÖGARI, perioperative medicine is a comprehensive perioperative model of care in which anaesthesiologists are involved.
Similar answers were provided by the Slovakian SSAIM, by the Russian RFAR, and the Portuguese SPA, for which in the comprehensive model of care anaesthesiologists act as primary physicians. Several societies (German DGAI, the Finnish SAF, the Israeli ISA) did not provide a definition but clearly identified a structured involvement of anaesthesiologists in POM. What can be concluded from the analysis of the definitions? The keywords that could be used to build a definition are as follows: a process of care that is patient-centred, that starts from the moment of contemplation of surgery and lasts until full recovery (or even later if long-term consequences of surgery/anaesthesia/complications are evaluated), that is multidisciplinary and integrated by anaesthesiologists who either coordinate or act as primary care physicians.
The second question concerned the identification of POM as a separate specialty, on the model of the hospitalists in the United States. All answers were NO to this question, probably because all NAS consider that anaesthesiologists should be the coordinating specialty of the multidisciplinary effort to provide POM. The third question was the extension of the second and concerned identified financing of POM and again the answer was NO for all NAS. The fourth question concerned the publication by the NAS of a model of POM. None of the NAS that answered has published an explicit model of POM based on the definitions provided above. Only AAGBI and the Scandinavian SSAIC have explicitly dedicated and identified as such modules for the initial training of anaesthesiologists for the practice of POM.
For CPD, all NAS have reported educational sessions specifically dedicated to POM. Several NAS collect data on POM-related events/complications. An open question concerned future challenges for the practice of POM. Several NAS identified: (i) the greater workload for the anticipated increase in the number of complex patients who will undergo ever more complex surgical procedures; (ii) the necessity of elaborating a model of POM in collaboration with the other medical/surgical disciplines; (iii) the collection of data on outcome specifically dedicated to POM. A final question concerned the perceived interest by the NAS to have an ESA-initiated model of POM. The majority of the answers were YES.
What can be drawn from this survey? First, a few methodological concerns are obvious because only approximately a third of the NAS that are part of the ESA answered and therefore we do not have the complete picture of what POM is in the countries whose NAS are part of the ESA. Second, is that the field of POM in terms of definitions, goals, training, resources, and data collection is nearly uncharted territory in many NAS. Third is that if ESA is willing to identify POM as one of its pillars (in addition to anaesthesia, intensive care medicine, pain medicine) then ESA must in priority work within the Society with all the relevant Committees and with the NAS in order to build a model of POM that can be offered (and by no reason imposed) to the NAS that are willing to adopt them; this model has to be subsequently discussed/adapted with the other Scientific Societies at the European level. The ESA-based model of POM should be built on the fact that anaesthesiologists must be the main actors/coordinators of POM because this a key element to avoid/correct fragmentation of care.
The same element of continuity/defragmentation of care is put forward by ESA concerning intensive care medicine in the perioperative context. If this model is adopted, the necessary resources and evaluation tools for efficacy and efficiency must also be defined. Fourth, the initial training and CPD educational tool for POM must be created/improved and ESA can take advantage of the experience of those NAS who already have such educational tools. Fifth, the opportunity for data collection is huge and it is imaginable that an ESA-wide platform for data collection on POM is a next necessary step to improve quality of care in POM.
I would like to take the opportunity of this article to express our gratitude to all the anaesthesiologists from the different NAS who participated to the 2017 National Villages:
Austrian Society of Anaesthesiology, Resuscitation and Intensive Care Medicine
Society of Anesthesia and Reanimation of Belgium
Bulgaria National Society
Croatian Medical Association – Croatian Society of Anesthesia and ICM
Czech Society of Anaesthesiology and Intensive Care Medicine
Estonian Society of Anaesthesiologists
Finnish Society of Anaesthesiologists
Société Française d’Anesthésie et de Réanimation
Georgian Society of Anaesthesiology and Intensive Care Medicine
German Society of Anaesthesiology and Intensive Care Medicine
Hellenic Society of Anaesthesiology
Hungarian Society of Anaesthesiology and Intensive Therapy
Icelandic Society of Anaesthesiology and Intensive Therapy
Israel Society of Anaesthesiologists
Italian Society of Anaesthesiology, Analgesia, Resuscitation and Intensive Care
Association of Kosovar Anaesthesiologist
Latvian Association of anaesthesiologists and reanimatologists
Lithuanian Society of Anaesthesiology and Intensive Care
Macedonian Society of Anaesthesiologists
Association of Anaesthesiologists of Malta
Molodovian Anaesthesiology Reanimatology
Norwegian Society for Anaesthesiology
Polish Society of Anaesthesiology & Intensive Therapy
Sociedade Portuguesa de Anestesiologia
Romanian Society of Anaesthesia & Intensive Care
Russian Federation of Anaesthesiologists and Reanimatologists
Serbian Association of Anaesthesiologists and Intensivists
Slovak Society of Anaesthesiology and Intensive Medicine
Slovenian Society of Anaesthesiology and Intensive Care Medicine
Sociedad Espanola de Anestesiologia, Reanimacion y Terapeutica del Dolor
Swedish Society of Anaesthesia and Intensive Care
Swiss Society for Anaesthesiology and Resuscitation
Turkish Society of Anesthesiology and Reanimation
Association of Anaesthesiologists of Ukraine
Association of Anaesthetists of Great Britain and Ireland
Albanian Society of Anaesthesiology and Intensive Care
Belarusian Society of Anaesthestists and Experts in Resuscitation