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Qualitative Research in Perioperative Medicine

Key points Uptake of qualitative methods in perioperative medical research has been relatively slow because of some misapprehensions about these methods. Qualitative methods are most appropriate for answering “how” questions about processes as they occur in their everyday contexts. Perioperative qualitative researchers should strive for greater flexibility in their interviews and for more observation-based data collection. During data analysis, perioperative qualitative researchers should focus less on…

Equity and Perioperative Care

Key points Closing gaps in care outcomes by race, ethnicity, and other measures of health inequity must be an integral part of quality improvement. Health disparities exist in every aspect of perioperative care and medicine. Addressing health equity involves understanding the roles race and racism play in health care. Racism must be understood on an individual level and a system level. There are many actions that…

Clinical Outcomes and Measures in Perioperative Care

Key Points To improve perioperative care and safety, relevant clinical outcomes and appropriate measures must be defined. The National Quality Forum (NQF) proposed that ideal clinical measures are: Evidence-based and highlight a “performance gap.” Demonstrative of reliability and validity. Feasible to collect without undue burden (routinely generated during care delivery; available in electronic medical record). “Usable”—the measure should be able to be used for both accountability,…

Shared Decision Making

Key Points Shared decision making (SDM) is a patient-centered approach that encourages both healthcare professionals and patients to work collaboratively for the benefit of patients. Perioperative care is a collaborative multidisciplinary approach for patients contemplating surgery, and the patient's individual values and preferences should be at the center. One approach is the use and promotion of patient-facing resources, such as the “Benefits, Risks, Alternatives, and doing…

Patient-Centered Care in Perioperative Outcomes

Key points Value in health care is defined as patient-centered outcomes (PCOs) relative to the cost of achieving those outcomes. PCOs must consider the health trajectory well past discharge. Patient outcomes include that there is concordance of the expectations of the planned procedure with patient preferences, goals, and values. What Is Patient-Centered Care? Patient-centered care requires that all disciplines involved in treating a specific surgical condition…

System Thinking in Perioperative Medicine

Key Points A healthcare system can be viewed at micro, meso, or macrosystem levels. System thinking is a set of skills, behaviors, and tools that enable analysis of the processes interactions, perspectives, and boundaries of the system. Adopting a system-thinking approach provides opportunities to improve the processes and outcomes of perioperative care and extend improvement into population health for the surgical population. This chapter describes approaches…

Large-Scale Audits: Using Citizen Science to Gather High-Quality “Big Data”

Key Points Large-scale audits have been hugely successful in gathering large volumes of data in short spaces of time to inform research and quality improvement (QI) endeavors and policy development. Built on the model of “citizen science,” they harness the efforts of thousands of collaborators to approach a specific challenge, using a collaborative and cost-effective approach. Key points for success include choosing topics that are important…

Clinical Trials in Perioperative Medicine

Key points Because most improvements in perioperative care are incremental, large numbers of patients need to be studied to have adequate statistical power to detect a clinically important difference. Large, pragmatic, multicenter, randomized trials are more reliable because they provide an unbiased evaluation of specific interventions delivered across a range of healthcare settings. Large pragmatic trials therefore test for effectiveness in routine clinical practice; their results…

The Promise and Pitfalls of Big Data Studies in Perioperative Medicine

Key Points Because of a paucity of randomized controlled trial (RCT) literature in perioperative medicine, well-designed “big data” studies can fill an important void. Robust, validated perioperative registries can be the foundation of research to inform perioperative practice patterns in clinical areas for which equipoise currently exists. Consensus reporting guidelines offer a structured method to assess the quality of research and quality improvement (QI) studies using…

The Case for Improvement in Perioperative Medicine

Key Points Despite enormous strides in the reduction of intraoperative risk, the incidence of postoperative complications remains high and perioperative care is frequently fragmented. Significant variability in healthcare outcomes across different hospitals and hospital systems exists. Relatively new tools of improvement science, implementation science, and safety science should be accelerators of change and integrate into evidence-based pathways of care. Fundamental interventions include: proactive engagement in a…

What Is Perioperative Medicine and Why Do We Need It?

Key Points Perioperative medicine is the medical care of patients undergoing surgery from the moment of contemplation of surgery until full recovery. The term “perioperative care” is increasingly used instead of perioperative medicine to emphasize the multidisciplinary nature of care across the patient's surgical journey and to acknowledge the role of nonmedical healthcare professionals in delivery. Reframing the period before surgery as an active opportunity, rather…

Where Does Safety Fit In?

Key points Psychological safety is essential for learning. Safety requires safe systems, not just individuals working safely. Involving patients in their own safety improves quality of care. John F Kennedy's quote describes our patient safety journey in the National Health Service (NHS) towards understanding and proactivity, from talking about harm to talking about safer systems that provide the right care, as intended, every time and learning…

What Is Quality in Medicine and Why Do We Need to Work on It?

Key Points The ultimate goal for any clinician and healthcare system is to deliver quality care. High quality care should be: safe, effective, timely and patient-centred. Quality improvement in medicine has proven to be challenging, complex and at times difficult to sustain. In order to deliver quality in medicine, a culture shift is needed, along with recognition of time and effort needed for quality initiatives to…

Transitions From Hospital to Home

Worldwide more than 200 million surgeries are performed each year; in the United States more than 50 million inpatient procedures occur annually. In 2009, the World Health Organization demonstrated that implementation of a relatively simple day-of-surgery checklist was associated with decreased rates of postoperative complications and death. Since that time, numerous evaluations of perioperative checklists and coordinated care efforts have demonstrated significant improvements for patients. In…

Delivering Value Based Care: The UK Perspective

Introduction: Rising Demand and Resource Constraint One of the few constants throughout health-care is an inexorable rise in demand. This rise has been ongoing for many years and is driven by several factors. Across the decades, as health-care has advanced, demand has been generated by new life-saving and life-enhancing treatments, which reach patients and conditions previously untreated. For example, the total knee replacement (TKR) was first…

Improving Health-Care Quality Through Measurement

“Wherever we see systematic measurement of results in health-care–no matter what the country–we see those results improve.” Michael E. Porter, Harvard Business Review (October 2013) Extensive evidence exists demonstrating that health-care is plagued with overutilization of inappropriate services, underutilization of appropriate services, and avoidable medical errors. Over the last few decades, the emphasis on “closing the quality gap” in health-care has escalated and intensified. Furthermore, measures…

Economic Analysis of Perioperative Optimization

The goal of this chapter is to make the following points: 1. Taxpayers, employers, and employees demand that medicine deliver better value. Physicians need evidence-based medicine to establish which interventions are truly beneficial and modern management techniques to implement those interventions. 2. Perioperative interventions are investments, each with its costs and, it is hoped, its benefits. The benefits of perioperative interventions are often difficult to quantify…

Role of Palliative Care

Defining Palliative Care Palliative care is defined by the World Health Organization as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” The field of palliative medicine was developed…

Postoperative Cognitive Dysfunction and Delirium

Introduction Since the inception of anesthesia changed and expanded surgery, some patients have experienced changes in cognitive function postoperatively. Elderly patients are at higher risk of these changes in neurocognitive function, probably because of reduced cognitive reserve and increased cerebral atherosclerosis. Changes in cognitive function are associated with impaired activities of daily living, which substantially reduce the quality of life in elderly patients. Various terms are…