Mark Warner, M.D.: ‘Expanding anesthesiology care into the perioperative setting makes sense financially, it makes sense clinically and it makes sense for our patients.’
Anesthesiologists have long taken the lead in improving intraoperative patient safety. However, now is the time to take the lead in improving patient safety throughout the perioperative period.
“Taking the lead in perioperative care is the right thing to do for our patients,” said Mark Warner, M.D., Annenberg Professor of Anesthesiology at the Mayo Clinic. “Expanding anesthesiology care into the perioperative setting makes sense financially, it makes sense clinically and it makes sense for our patients.”
Dr. Warner explored the development of patient safety initiatives in anesthesiology during the ASA/APSF Ellison C. Pierce Patient Safety Memorial Lecture on Saturday. No other specialty is as well equipped by training or practice to assess and improve protocols and practices to improve patient safety before, during and after surgery, he said. Anesthesia has already created and put into practice strategies to reduce anesthesia incidents.
Such strategies include improved training, education and supervision; appropriate monitoring and vigilance; recognizing the limits of being able to influence individual behavior; establishing and following preparation and inspection protocols; ensuring that all equipment performs to expectations and standards; designing and organizing better work spaces; and improving quality continuously.
Those same strategies can, and must, be put into place throughout the perioperative experience to reduce patient morbidity and mortality, improve outcomes and reduce costs, Dr. Warner said.
Anesthesiologists have already taken the lead in several areas, he said, including the assessment of penicillin allergies; preoperative evaluation and preparation, or prehabilitation; oversight of blood and blood-product transfusion; provision of pacemaker, transesophageal echo and other services; and care process redesign to eliminate unnecessary steps.
All of these programs have brought demonstrable improvement and value, Dr. Warner said. More than 90 percent of surgical patients claim an allergy to penicillin, but testing shows that true allergic reactions are rare. Most middle-aged and older patients who experienced penicillin allergies as children were actually reacting to non-drug components of early injectable formulations. They are not allergic to the antibiotic itself.
“The result of what patients believe to be penicillin allergies is all of us writing prescriptions for third-, fourth- and fifth-generation antibiotics,” he said. “We routinely use big guns when lesser weapons would work better. The more advanced the antibiotic, the greater the increase in resistant organisms and in adverse reactions to the antibiotics themselves. Testing patients for penicillin allergy would allow us to use a more appropriate antibiotic in more of our patients, improving outcomes and reducing costs.”
Prehabilitation offers similar potential benefits. Assessing patients for weight control, smoking cessation, physical conditioning and other modifiable risk factors before surgery brings a significant decrease in surgical and postsurgical complications. Prehabilitation before surgery could dramatically reduce the need for rehabilitation after surgery, Dr. Warner said.
Care redesign is another proven winner. Every additional step in the surgical process increases the potential for human error. Anesthesiologists are already accustomed to analyzing processes and redesigning them to reduce the number of steps involved in order to improve safety.
“Reducing steps in the perioperative care process is the right thing to do clinically because it improves outcomes,” Dr. Warner said. “It is the right thing to do for our patients because it makes them safer. And it is the right thing to do financially because fewer steps mean less cost.
“The Perioperative Surgical Home is cost effective. Expense reduction from fewer steps and fewer complications is both valuable and reimbursable. I strongly support expansion of anesthesia care to include perioperative care. And I propose a new motto for the Anesthesia Patient Safety Foundation: No patient undergoing an anesthetic shall be harmed in the perioperative period.”
