Rural Access to Anesthesia and the Perioperative Surgical Home: Scholarship Recipient Reflection

Several years ago I underwent an operation, my fourth at the time, and although most were outpatient procedures, I merely met the anesthesiologist for five minutes before being brought into the O.R. However, things were different for my fourth operation. My understanding at the time was that the anesthesiologist was the physician with whom I would interact for a few minutes, stating any medical issues that would prove to be an obstacle during the anesthetic care and then a CRNA would stay with me in the O.R. However, during the last surgery I underwent, the anesthesiologist called and spoke with me for some time about the procedure, the anesthetic agents that would be used, to discuss any comorbidities or previous problems with anesthesia I had, and lastly to put my mind at ease about the operation. This incident stood out in my mind, as it gave me new perspective on the role the anesthesiologist has in the surgical care of a patient and how this role can be expanded upon preoperatively. However, this expansion of surgical patient care can not only be expanded upon preoperatively but also in regards to what has become known as the perioperative surgical home.

This idea would invoke the concept of having the anesthesiologist undertake the primary role in patient care throughout the perioperative surgical time frame, leading to a decrease in the disintegrated care that patients may receive from being seen by multiple different practitioners. Although this is a concept that has begun being utilized more and more in tertiary care centers, there does not seem to be as many resources in establishing this type of care in a rural setting.

This is the concept I was hoping to witness while on my rural anesthesia rotation in Crosby, MN, at Cuyuna Regional Medical Center (CRMC) with rural mentor Dr. Mark Gujer (Medical Director of Peri- operative services), as this system of care seems to be the way health care is trending towards. I was afforded the opportunity to experience the practice of anesthesia in a rural setting by the ASA Committee on Rural Access to Anesthesia Care, who had established the Rural Access to Anesthesia Scholarship program nearly 10 years ago in order to increase the exposure of medical students to rural anesthesia. My expectation entering the rotation was to gain insight into how anesthesia in a rural setting differed from anesthesia at a hospital in an urban setting, but when I arrived at CRMC I found that the level of cases did not differ greatly between the two. CRMC is a 25- bed, critical-access hospital that boasts over 1,000 employees. The operating room is staffed by two anesthesiologists, five independently practicing CRNAs (Patients are risk stratified and elevated risk patients are managed by the Anesthesiologist one on one.) and 16 board certified surgeons. Over 5,000 surgical procedures per year are done with five operating rooms and two endoscopy suites.

During my rotation I was able to see how the perioperative surgical home has been established and implemented in a rural setting, increasing the surgical volume by reduction in patient transfers to tertiary centers through physician delivered anesthesia for the most challenging patients. Since implementation of this model CRMC has demonstrated reduced the length of stay and readmission rates, and patient morbidity and mortality.

In order to establish this model, the anesthesiologists began a preoperative clinic to assess the patients undergoing more complex procedures or with multiple co morbidities. These patients are referred to the clinic by primary care physicians, surgeons and consultants such as cardiology who have learned the value of consultation with an anesthesiologist preoperatively. The clinic has cut down on the number of patients needing transfer to tertiary medical centers and allowed the time necessary for any additional testing that needed to be done, reducing any delays that could arise on the day of surgery. This also allowed the anesthesiologist time to develop a plan in order to maximize the intraoperative anesthetic management of the patient instead of gauging the patient’s comorbidities right before the case. This is the beginning of establishing a patient physician relationship that will continue from the preoperative period until discharge. At this point, the anesthesiologist develops a one-on-one relationship with the patient, and through coordinated efforts with the primary care practitioner, the patient’s care is managed pre-, intra-, and postoperatively. The rural setting facilitated the concept of one patient to one anesthesiologist providing care, further solidifying the patient physician relationship and providing comfort for the patient. Through this relationship between the anesthesiologist and the patient, the patient will feel more comfortable with his or her anesthetic care. Patients are seen virtually every day by the anesthesiologists and co-managed with the Hospitalist Service until discharge. For those patients requiring ICU care, again anesthesia continues daily rounds and provides consultative services to the Hospitalist service. In addition to this, a Community Paramedic program was initiated by the Anesthesia department to assess postdischarge care needs, through which an initial safety assessment of the home was done and scheduled visits based on need made to evaluate wound care, pain control and vital signs as well as address any other concerns. This allowed for better and more efficient patient care but was only one step in establishing the complete perioperative surgical home.

One thing that stood out in my mind during this rotation in contrast to many other anesthesia models that I have seen is that the anesthesiologists and CRNAs stay with their patients from the very beginning to the very end of their hospital care. They do not hand off their patients during a case or go on breaks. This type of care would be difficult in large busy surgical centers however it seems to work quite well in the rural setting despite being a busy surgical center. Another observation was how anesthesiologists and CRNAs can coexist in a non care team model where everyone is independent yet patients are assigned based on comorbidities and surgical complexity. This maximizes skill sets being assigned where they are best suited and gives all providers the respect they deserve and allows practicing to the extent of everyone’s training.

In establishing these programs, the perioperative surgical home can provide a more cohesive model of patient care, benefitting the hospital, the medical team and most importantly the patient. Throughout my rural access to anesthesia experience, I have been able to see this model fully implemented and the benefits of having a consistent, interconnected unit of care. The experience has reaffirmed my interest in practicing medicine in a rural setting, not only due to the need but also in viewing the efficiency, effectiveness and level of cases that the anesthesiologist has in such a setting. I strongly believe that anyone considering anesthesia as a specialty should do a rural based rotation, as it has become an invaluable experience, and I was able to see how much can truly be achieved at a rural hospital.

posted Summer 2015