Pushing the Limits of Minimally Invasive Spine Surgery-From Preoperative to Intraoperative to Postoperative Management.

The introduction of minimally invasive surgery ushered in a new era of spine surgery by minimizing the undue iatrogenic injury, recovery time, and blood loss, among other complications, of traditional open procedures. Over time, technological advancements have further refined the care of the operative minimally invasive spine patient. Moreover, pre-, and postoperative care have also undergone significant change by way of artificial intelligence risk stratification, advanced imaging for surgical planning and patient selection, postoperative recovery pathways, and digital health solutions. Despite these advancements, challenges persist necessitating ongoing research and collaboration to further optimize patient care in minimally invasive spine surgery.

Systems of Care Delivery and Optimization in the Preoperative Arena.

Key elements of an effective preoperative process include the following: history-taking, risk assessment, shared decision making, effective interdisciplinary communication, preoperative optimization of modifiable conditions, longitudinal care coordination, contribution to population health aims, and collection of outcomes-driven metrics. Perioperative medicine tenets can be applied by health systems of all sizes and demographics to improve quality and safety.

Barriers to Implementation of Telehealth Pre-anesthesia Evaluation Visits in the Department of Veterans Affairs.

Background: Evaluations are conducted days or weeks before a scheduled surgical or invasive procedure involving anesthesia to assess patients' preprocedure condition and risk, optimize status, and prepare them for their procedure. The traditional pre-anesthesia evaluation is conducted in person, although telehealth modalities have been used for several years and have accelerated since the advent of the COVID-19 pandemic. Methods: We surveyed 109 anesthesiology services to understand the barriers and facilitators to the adoption of telephone- and video-based pre-anesthesia evaluation visits within the US Department of Veterans Affairs (VA). Results: The analysis included 55 responses from 50 facilities. Twenty-two facilities reported using both telephone and video, 11 telephone only, 5 video only, and 12 none of these modalities. For telehealth users, the ability to obtain a history of present illness, the ability to assess for comorbidities, and assess for health habits were rated highest while assessing nutritional status was lowest. Among nonusers of telehealth modalities, barriers to adoption included the inability to perform a physical examination and the inability to obtain vital signs. Respondents not using telephone cited concerns about safety, while respondents not using video also cited lack of information technology and staff support and patient-level barriers. Conclusions: We found no significant perceived advantages of video over telephone in the ability to conduct routine pre-anesthesia evaluations except for the perceived ability to assess nutritional status. Clinicians with no telehealth experience cited the inability to perform a physical examination and obtain vital signs as the most significant barriers to implementation. Future work should focus on delineating the most appropriate and valuable uses of telehealth for pre-anesthesia evaluation and/or optimization.

Recommendations From the International Consensus Conference on Anemia Management in Surgical Patients (ICCAMS).

BACKGROUND: Perioperative anemia has been associated with increased risk of red blood cell transfusion and increased morbidity and mortality after surgery. The optimal approach to the diagnosis and management of perioperative anemia is not fully established. OBJECTIVE: To develop consensus recommendations for anemia management in surgical patients. METHODS: An international expert panel reviewed the current evidence and developed recommendations using modified RAND Delphi methodology. RESULTS: The panel recommends that all patients except those undergoing minor procedures be screened for anemia before surgery. Appropriate therapy for anemia should be guided by an accurate diagnosis of the etiology. The need to proceed with surgery in some patients with anemia is expected to persist. However, early identification and effective treatment of anemia has the potential to reduce the risks associated with surgery and improve clinical outcomes. As with preoperative anemia, postoperative anemia should be treated in the perioperative period. CONCLUSIONS: Early identification and effective treatment of anemia has the potential to improve clinical outcomes in surgical patients.

Geriatric Preoperative Optimization: A Review.

This review summarizes best practices for the perioperative care of older adults as recommended by the American Geriatrics Society, American Society of Anesthesiologists, and American College of Surgeons, with practical implementation strategies that can be readily implemented in busy preoperative or primary care clinics. In addition to traditional cardiopulmonary screening, older patients should undergo a comprehensive geriatric assessment. Rapid screening tools such as the Mini-Cog, Patient Health Questionnaire-2, and Frail Non-Disabled Survey and Clinical Frailty Scale, can be performed by multiple provider types and allow for quick, accurate assessments of cognition, functional status, and frailty screening. To assess polypharmacy, online resources can help providers identify and safely taper high-risk medications. Based on preoperative assessment findings, providers can recommend targeted prehabilitation, rehabilitation, medication management, care coordination, and/or delirium prevention interventions to improve postoperative outcomes for older surgical patients. Structured goals of care discussions utilizing the question-prompt list ensures that older patients have a realistic understanding of their surgery, risks, and recovery. This preoperative workup, combined with engaging with family members and interdisciplinary teams, can improve postoperative outcomes.

Perioperative frailty: lessons learned and future directions.

PURPOSE OF REVIEW: As the surgical population ages, preoperative diagnosis and optimization of frailty becomes increasingly important. Various concepts are used to define frailty, and several tools have been validated for use in the perioperative period. This article reviews current conceptual frameworks of frailty, references current literature and provides a practical approach to the preoperative frailty assessment with a focus on potential interventions. RECENT FINDINGS: A multipronged approach toward preoperative optimization should be used in patients with frailty syndrome. Oral protein supplementation and immunonutrition therapy can reduce complications in patients with malnutrition. Initiating a preoperative physical exercise regimen may mitigate frailty. Nonpharmacologic interventions to reduce preoperative anxiety and improve mood are effective, low-cost adjuncts associated with improvement in postoperative outcomes. Engaging in shared decision making is a critical component of the preoperative evaluation of frail patients. SUMMARY: Emerging evidence suggests that frailty may be mitigated with patient-specific, multidimensional preoperative interventions, thus potentially improving postoperative outcomes in this vulnerable patient population.

Development and Performance of a Clinical Decision Support Tool to Inform Resource Utilization for Elective Operations.

Importance: Hospitals ceased most elective procedures during the height of coronavirus disease 2019 (COVID-19) infections. As hospitals begin to recommence elective procedures, it is necessary to have a means to assess how resource intensive a given case may be. Objective: To evaluate the development and performance of a clinical decision support tool to inform resource utilization for elective procedures. Design, Setting, and Participants: In this prognostic study, predictive modeling was used on retrospective electronic health records data from a large academic health system comprising 1 tertiary care hospital and 2 community hospitals of patients undergoing scheduled elective procedures from January 1, 2017, to March 1, 2020. Electronic health records data on case type, patient demographic characteristics, service utilization history, comorbidities, and medications were and abstracted and analyzed. Data were analyzed from April to June 2020. Main Outcomes and Measures: Predicitons of hospital length of stay, intensive care unit length of stay, need for mechanical ventilation, and need to be discharged to a skilled nursing facility. These predictions were generated using the random forests algorithm. Predicted probabilities were turned into risk classifications designed to give assessments of resource utilization risk. Results: Data from the electronic health records of 42 199 patients from 3 hospitals were abstracted for analysis. The median length of stay was 2.3 days (range, 1.3-4.2 days), 6416 patients (15.2%) were admitted to the intensive care unit, 1624 (3.8%) received mechanical ventilation, and 2843 (6.7%) were discharged to a skilled nursing facility. Predictive performance was strong with an area under the receiver operator characteristic ranging from 0.76 to 0.93. Sensitivity of the high-risk and medium-risk groupings was set at 95%. The negative predictive value of the low-risk grouping was 99%. We integrated the models into a daily refreshing Tableau dashboard to guide decision-making. Conclusions and Relevance: The clinical decision support tool is currently being used by surgical leadership to inform case scheduling. This work shows the importance of a learning health care environment in surgical care, using quantitative modeling to guide decision-making.

Launching a Geriatric Surgery Center: Recommendations from the Society for Perioperative Assessment and Quality Improvement.

To prepare for the increasing numbers of older adults undergoing surgery, the American College of Surgeons (ACS) has recently launched the Geriatric Surgery Verification Program with the goal of encouraging the creation of centers of geriatric surgery. Meanwhile, the Society for Perioperative Assessment and Quality Improvement (SPAQI) has published recommendations for the preoperative management of frailty, which state that teams should actively screen for frailty before surgery and that pathways, including geriatric comanagement, shared decision-making, and multimodal prehabilitation, should be embedded in routine care to help improve patient outcomes. Both SPAQI and the ACS advocate for a multidisciplinary approach to improve the value of care for older adults undergoing surgery. However, the best way to implement geriatric services in the surgical setting is yet to be determined. In this statement, we will describe the SPAQI recommendations for launching a geriatric surgery center and the process by which its value should be assessed over time.

Preoperative Assessment and Management of Patients with Pain and Anxiety Disorders.

PURPOSE OF REVIEW: This review summarizes selected recent evidence on issues important for preoperative pain evaluation. RECENT FINDINGS: Opioids, though a mainstay of postoperative pain management, are associated with both short and increasingly recognized long-term risks, including persistent opioid use. Risk factors for high levels of acute postoperative pain as well as chronic postsurgical pain may overlap, including psychological factors such as depression, anxiety, and catastrophizing. Tools to predict those at risk for poor postoperative pain outcomes are being studied. SUMMARY: Preoperative pain and psychological factors can affect postoperative pain outcomes. More work is needed in the future to develop practical interventions in the preoperative period to address these factors.

Tutorial: Development and Implementation of a Multidisciplinary Preoperative Nutrition Optimization Clinic.

Although much is known about surgical risk, little evidence exists regarding how best to proactively address preoperative risk factors to improve surgical outcomes. Preoperative malnutrition is a widely prevalent and modifiable risk factor in patients undergoing surgery. Malnutrition prior to surgery portends significantly higher postoperative mortality, morbidity, length of stay, readmission rates, and hospital costs. Unfortunately, perioperative malnutrition is poorly screened for and remains largely unrecognized and undertreated-a true "silent epidemic" in surgical care. To better address this silent epidemic of surgical nutrition risk, here we describe the rationalization, development, and implementation of a multidisciplinary, registered dietitian-driven, preoperative nutrition optimization clinic program designed to improve perioperative outcomes and reduce cost. Implementation of this novel Perioperative Enhancement Team (POET) Nutrition Clinic required a collaboration among many disciplines, as well as an identified need for multidimensional scheduling template development, data tracking systems, dashboard development, and integration of electronic health records. A structured malnutrition risk score (Perioperative Nutrition Screen score) was developed and is being validated. A structured malnutrition pathway was developed and is under study. Finally, the POET Nutrition Clinic has established a novel role for a perioperative registered dietitian as the integral point person to deliver perioperative nutrition care. We hope this structured model of perioperative nutrition assessment and optimization will allow for wide implementation and generalizability in other centers worldwide to improve recognition and treatment of perioperative nutrition risk.

Special Considerations Related to Race, Sex, Gender, and Socioeconomic Status in the Preoperative Evaluation: Part 1: Race, History of Incarceration, and Health Literacy.

Patients anticipating surgery and anesthesia often need preoperative care to reduce risk and facilitate services on the day of surgery. Preparing patients often requires extensive evaluation and coordination of care. Vulnerable, marginalized, and disenfranchised populations have special concerns, limitations, and needs. These patients may have unidentified or poorly managed comorbidities. Underrepresented minorities and transgender patients may avoid or have limited access to health care. Homelessness, limited health literacy, and incarceration hinder perioperative optimization initiatives. Identifying patients who will benefit from additional resource allocation and knowledge of their special challenges is vital to reducing disparities in health and health care.

Special Considerations Related to Race, Sex, Gender, and Socioeconomic Status in the Preoperative Evaluation: Part 2: Sex Considerations and Homeless Patients.

Patients anticipating surgery and anesthesia often need preoperative care to lower risk and facilitate services on the day of surgery. Preparing patients often requires extensive evaluation and coordination of care. Vulnerable, marginalized, and disenfranchised populations have special concerns, limitations, and needs. These patients may have unidentified or poorly managed comorbidities. Underrepresented minorities and transgender patients may avoid or have limited access to health care. Homelessness, limited health literacy, and incarceration hinder perioperative optimization initiatives. Identifying patients who will benefit from additional resource allocation and knowledge of their special challenges are vital to reducing disparities in health and health care.

Roadmap for Transforming Preoperative Assessment to Preoperative Optimization.

Preoperative assessment typically equates to evaluating and accepting the presenting condition of the patient (unless extreme) and commonly occurs only a few days before the planned surgery. While this timing enables a preoperative history and examination and mitigates unexpected findings on the day of surgery that may delay throughput, it does not allow for meaningful preoperative management of modifiable medical conditions. Evidence is limited regarding how best to balance efforts to mitigate modifiable risk factors versus the timing of surgery. Furthermore, while the concept of preoperative risk modification is not novel, evidence is lacking for successful and sustained implementation of such an interdisciplinary, collaborative program. A better understanding of perioperative care coordination and, specifically, implementing a preoperative preparation process can enhance the value of surgery and surgical population health. In this article, we describe the implementation of a collaborative preoperative clinic with the primary goal of improving patient outcomes.

Implementation of a Preoperative Anemia Clinic Utilizing a Minimal Staffing Model.

We present a process map for the implementation of a program to treat preoperative anemia utilizing 1 existing anesthesiologist in the preoperative evaluation clinic. In the first 7 months postimplementation, 342 patients were screened for anemia, 166 were diagnosed, and 107 were treated. The mean increase in hemoglobin in treated patients was ~2 g/dL (range 0-4.9 g/dL). Two patients' surgeries were delayed in favor of treatment and 3 surgical patients, who had received 2 complete iron infusions, received an intraoperative transfusion. The total revenue generated for the institution was enough to subsidize the cost of an additional anesthesiologist.

Using Time-Driven Activity-Based Costing to Demonstrate Value in Perioperative Care: Recommendations and Review from the Society for Perioperative Assessment and Quality Improvement (SPAQI).

A shift in healthcare payment models from volume toward value-based incentives will require deliberate input into systems development from both perioperative clinicians and administrators to ensure appropriate recognition of the value of all services provided-particularly ones that are not reimbursable in current fee-for-service payment models. Time-driven activity-based costing (TDABC) methodology identifies cost drivers and reduces inaccurate costing based on siloed budgets. Inaccurate costing also results from the fact that current costing methods use charges and there has been tremendous cost shifting throughout health care. High cost, high variability processes can be identified for process improvement. As payment models inevitably evolve towards value-based metrics, it will be critical to knowledgably participate in the coordination of these changes. This document provides 8 practical Recommendations from the Society for Perioperative Assessment and Quality Improvement (SPAQI) aimed at outlining the principles of TDABC, creating process maps for patient workflows, understanding payment structures, establishing physician alignment across service lines to create integrated practice units to facilitate development of evidence-based pathways for specific patient risk groups, establishing consistent care delivery, minimizing variability between physicians and departments, utilizing data analytics and information technology tools to track progress and obtain actionable data, and using TDABC to create costing transparency.

Designing and Running a Preoperative Clinic.

Value in health care has been described as quality divided by cost, where quality is the sum of patient outcomes and experience. A well-run preoperative evaluation clinic (PEC) offers many opportunities to improve the value of the care delivered to patients by reducing the associated costs and improving the quality of care. Certain patient education and medical optimization strategies initiated in the PEC clinic are linked to an improvement in patients' long-term health outcomes. When designing a PEC, it is important to address the PEC's mission and scope with all stakeholders early in the process.

A retrospective study of opioid prescribing patterns at hospital discharge in surgical patients with obstructive sleep apnea.

PURPOSE: Obstructive sleep apnea (OSA) is a risk factor for complications with postoperative opioid use, and in those patients with known or suspected OSA, minimization of postoperative opioids is recommended. We hypothesize that despite these recommendations, surgical patients with known or suspected OSA are prescribed postoperative opioids at hospital discharge at similar doses to those without OSA. METHODS: This was a retrospective analysis of the electronic health records of surgical patients from 1 November 2016 to 30 April 2017 at a single academic institution. Patients with a known diagnosis of OSA or a STOP-Bang score ≥ 5 were compared with those without OSA for the amount of postoperative discharge opioid medication using multivariable linear regression. RESULTS: Of the 17,671 patients analyzed, 1,692 (9.6%) had known or suspected OSA with 1,450 (86%) of these patients discharged on opioid medications. Of the 15,979 patients without OSA, 12,273 (77%) were discharged on opioid medications. The total median [interquartile range (IQR)] oral morphine equivalents (OME) for all patients was 150 [0-338] mg and for patients with known or suspected OSA was 160 [0-450] mg, an unadjusted comparison showing an 18% difference in OME (95% confidence interval [CI], 3% to 35%; P = 0.02). The analysis, after adjusting for confounders, showed no significant difference in the amount of opioids prescribed to OSA or non-OSA patients (8% difference in total OME; 95% CI, -6% to 25%; P = 0.26). CONCLUSION: This study shows that surgical patients at risk for OSA or confirmed OSA are prescribed opioids at similar rates and doses upon discharge despite guidelines that recommend minimizing opioid use in OSA patients. These findings indicate a need to implement different strategies to reduce the prescription of opioids to patients with OSA.