The scope and prevalence of perioperative harm

The scope of perioperative care

Perioperative care includes the evaluation and care management during three periods: the preoperative, the peroperative (or intraoperative), and the postoperative stage. In particular, the perioperative period begins when the patient is admitted, undergoes anesthesia and surgery, and then ends when the patient is discharged. The objective of perioperative medicine is to deliver the best care in each of these three periods in order to meet the needs of patients undergoing major surgery. This can be accomplished by adopting evidence-based care pathways and safe surgery checklists.

• 1.

  Preoperative Phase

  This initial phase starts with the patient's decision to undergo surgery and ends when the patient is entering the operating room. During the preoperative period, the healthcare provider prepares the patient physically (medical history, physical examination, and medication review) and psychologically for the surgery.

  The goal of the preoperative phase is to actively promote patient engagement and shared decision-making. Although healthcare providers generally make decisions based on evidence and the patient's health, it is essential: to assess the patient's current medical status and history, to provide a clinical risk profile, and to provide patient recommendations for the entire perioperative period. Some of these recommendations include informed decisions on whether to proceed with the surgery, the choice of surgery, and the identification of risk factors and patient conditions that might require additional care or longer term care.

  This preparation can take place over a long period of time where the patient may be required to fast, undergo tests, wait for the availability of an organ for transplant, or lose weight. On the other hand, this phase can be very short where the patient is in need of an emergency surgical procedure or is facing acute trauma.

  Undergoing a surgical procedure can be a difficult and traumatic time for patients. In an effort to carefully monitor the patient's condition throughout the perioperative phases, some healthcare providers have embraced the enhanced recovery after surgery (ERAS) protocols, which are multimodal perioperative care pathways designed to achieve quick recovery after surgery. The ERAS protocols include patient education, preoperative counseling, early mobilization, oral intake of fluid, nutrition optimization, and ambulation.

  In addition to examining the clinical risks the patient may undergo, it is essential to manage the patient's anxiety levels that may result due to the long wait period before the surgery takes place or due to the sudden trauma the patient has faced. This type of anxiety can be effectively managed with constant interaction with the healthcare team, particularly the physician, surgeon, or nurse.

• 2.

  Peroperative Phase

  The peroperative or intraoperative phase includes the surgery or surgical procedure being performed. During this phase, the patient is monitored, transferred to the operating room, and prepped and undergoes anesthesia. This can include general anesthesia for complete unconsciousness, regional anesthesia, or local anesthesia to prevent pain while the patient is awake. Peroperative radiation therapy or blood salvage may also take place. This phase ends when the patient is transferred to the postanesthesia care unit also known as PACU.

  When the surgery commences, the healthcare team composed of the surgeon, the anesthesiologist, nurse, and others will closely monitor the patient's vital signs, assist the surgeon, adhere to clinical guidelines, and focus on safety procedures associated with infection prevention.

• 3.

  Postoperative Phase

  This phase begins immediately after the surgery has ended and where the patient has been transferred to the PACU. This period can either be brief or can take place over several months where the patient requires additional treatment or undergoes rehabilitation.

  The goal of this phase is to monitor and manage the patient's physical and psychological health postsurgery. The postsurgery recovery stage can include monitoring of infections, pain, temperature maintenance, mobility, urination/bowel movements, nutrition, and hydration ( Table 2.1 ).

  Table 2.1

  The scope of perioperative care.

  Steps in perioperative care	Brief description
  1. Preoperative basic health assessment and medication review	Health assessment includes: 1. Medical history: indication for surgical procedure; allergies and intolerances to medications, anesthesia, or other agents; known medical problems; surgical history; trauma; current medications; focused review of issues pertinent to the planned procedure 2. Physical examination: weight, height, and body mass index; vital signs—blood pressure, pulse (rate and regularity), respiratory rate, cardiac pulmonary, other pertinent exam
  2. Medical conditions	Cardiovascular disease, sleep apnea, diabetes mellitus, chronic medication use, nicotine cessation
  3. Antibiotic management	Antibiotic selection, prevention of Endocarditis, procedures in patients with previous total joint replacement, colorectal surgery, antibiotic administration
  4. Patient education and communication	- Understanding patient's reading level, potential visual impairments, and learning barriers - Preoperative showering and shaving, preoperative fasting recommendations
  5. Patient, procedure, and site verification	Preprocedure planning and preparation, scheduling
  6. Surgical site marking with initials	Site marking by surgeon
  7. Regional anesthesia techniques and verification process	Obtaining informed consent from the patient
  8. Patient transported to intraoperative area using checklist (reverify patient identification)	- Final verification ∗This is the last step in the preoperative area before the patient is transferred to the operating/procedure room
  9. Verify site marking/position patient/skin preparation/clipping	Skin preparation and hair removal
  10. Prior to incision—active verbal time-out	- Time-out is performed after surgeon scrubbed and gowned and just prior to beginning the procedure - Each time-out includes the following elements: patient name, procedure to be performed, site of procedure, patient position
  11. Discrepancies	If a discrepancy is identified, the surgery will not take place until the discrepancy is resolved
  12. Hard stop	If any part of the verification process was not followed or a discrepancy was identified, then the procedure will not continue until all steps of the verification process are completed and until the discrepancies have been resolved. The procedure may also be canceled and rescheduled
  13. Reverify/pause if internal laterality/implants/spine level	If procedure involves internal laterality, implants, or spine level, an intraoperative pause will be conducted
  14. Safe site implementation	The time-out is best followed with a particular person/role has the responsibility to call the time-out. The surgeon should be the one to take the lead on initiating the time-out
  15. Communication	Briefing, structured handoff for any surgical personnel changes, structured handoff process
  16. Never events	Retained foreign objects—baseline count, if counts not reconciled then perform postoperative follow-up and perform delayed wound closure/open packing, final count; and retained foreign object prevention process, patient returns to operating/procedure room for final wound closure, hard stop—perform reconciliation process, imaging if counts not reconciled, close wound
  17. Environmental	Normothermia planning and management, preventing fires in the OR/procedure room, general environmental concerns, environmental controls: operating/procedure room survey
  18. Follow-up appointments	Patients should be encouraged to schedule and keep all follow-up appointments with their surgeon and primary clinician