When the first health systems formed in the 1960s and 1970s, the hospital was the center of the acute care universe. If you came to have a baby or surgical procedure, you stayed for a week. Medical advances and cost pressures have gradually chipped away at lengths of stay over the decades. There has been a steady increase in outpatient procedures done at a surgery center, whether freestanding or hospital affiliated. But the concept of the hospital as the place you go for care remains deeply entrenched in the minds of the public, healthcare leaders, and policymakers.
Then came 2020 and the coronavirus pandemic.
Hospital and surgery center volumes plummeted as procedures were canceled in preparation for a potential COVID-19 surge. However, as hospitals reopened, anxious patients were slow to return not only for elective surgeries but even for life-saving emergency care.
As a result, we’re accelerating the shift to a new paradigm, blending virtual and in-person care. While surgery and anesthesia will continue to happen in hospitals and surgery centers for the foreseeable future, our specialties are also changing with the times. In this article, I share my predictions on how anesthesia care will change in the next three years.
Interestingly, the United States is the only developed nation where anesthesiologists do not routinely manage critical care. However, the pandemic may reinvigorate this practice area.
Anesthesiologists pioneered the critical care medicine (CCM) specialty by establishing the nation’s first ICU at Johns Hopkins University. Their skill with mechanical ventilation saved thousands of lives during the polio epidemics of the 1950s. During the 1980s, Stanford anesthesiologist Myer Rosenthal, MD, pioneered the multidisciplinary critical care program that has became our national model. Today, anesthesia training includes mandatory ICU rotations, and many anesthesiologists complete ICU fellowships. However, many anesthesiologists outside of academics have gravitated from CCM to operative care.
Now, in the face of a respiratory pandemic, demand for critical care anesthesiology is soaring anew. Our current model of critical care, which too often relies on specialist consults rather than dedicated intensivists, has faltered in the face of COVID-19 surges. In many cases, hospitals have relied on clinicians with minimal critical care experience to manage hundreds of patients who are struggling to breathe.
During the COVID-19 surge in New York City, each hospital designated one or two CCM physicians to supervise volunteer clinicians on the COVID wards. Critical care anesthesiologists were well-positioned to fill this role. What’s more, many general anesthesiologists used their critical care training to lead volunteer care teams in managing COVID patients. As a result, I expect to see a rise in the number and prominence of critical care anesthesiologists in the coming years.
When I was in medical school, pulse oximetry was a brand-new innovation. Fifteen years later, I paid $800 and jumped through several regulatory hoops to purchase a pulse oximeter for a family member. Since that time, portable and wearable monitoring technologies have taken a huge leap forward. Such devices can now monitor vitals like heart rhythm, blood pressure, pulse oxygen, and much more in real time.
We continue to see options for remote monitoring in multiple specialties, including obstetrics, neurology, critical care, and anesthesiology. Visual dashboards that have integrated device data allow physicians to monitor multiple patients from a tablet or laptop. Newer options focusing on both absolute and relative changes in the data can alert both physicians and nurses to deteriorating clinical situations. The addition of video even allows a remote practitioner to interact with the patient. This is especially valuable during a pandemic because it reduces face-to-face contact and allows off-site and quarantined providers to participate in care. Going forward, I expect we’ll see this used for post-op care at home.
In other developments, wearable point-of-view technologies (think GoPro cameras) have opened the door for remote supervision of surgical care. The most extreme examples involve remote surgery teams directing medics through entire operations on ships at sea or at Antarctic research stations. In the United States, remote surgical monitoring could be used to prevent risky transfers from rural and community hospitals.
Early in my career, I had a patient call our urgent care center to ask about a burn. The most frustrating part was to try to assess the degree of the burn by asking the patient to describe it. I just couldn’t get a clear picture. “Where is the sci-fi videophone from the future?” I remember joking.
Now that future is here, and it’s a growing part of anesthesiology practice.
Complex patients often undergo extensive workups (labs, stress testing, etc.) before they are considered to be optimized and appropriate candidates for surgery. Many of these tests require travel to hospitals or other locations to complete the preoperative evaluation and preparation. This can be a logistical nightmare for both patient and family. Surgery already requires at least a short time off from work and often assistance from family, and multiple preoperative visits only add to the burden.
Many facilities had already shifted to telephone interviews to acquire a patient’s history and to give them instructions. COVID-19 has allowed us to shift to telehealth. The ability to do a virtual visit provides additional information about the patient’s appearance and environment and how they interact with staff. Virtual visits also allow the patient’s family to participate in preoperative care, which is especially helpful for older patients. Video translation services are available for those with limited English proficiency.
Most pre-surgical patients must still make at least one trip to the hospital for any required lab work and in-person screenings. At present, most hospitals also test preoperative patients for COVID-19. On the plus side, patients managed via telehealth can leave immediately after their swabs and blood draws and spend far less time in the building.
The use of telehealth is leading to incremental improvements to the overall patient and provider experience and allowing us as providers to care for patients in safer, faster, and often more effective ways. It’s also opening the door to additional virtual care solutions that increase access to care and give patients more options to choose from.
Today, many surgeries are minimally invasive. The advances over the past 30 years in laparoscopic, interventional, percutaneous, and robotic procedures have resulted in less impact on the body during surgeries, and thus recovery is typically easier. As a result, more surgeries are taking place on an outpatient basis—either in the hospital itself or at ambulatory surgery centers.
The biggest challenge associated with outpatient procedures is identifying and stratifying patients’ risk for complications and determining who is best served by a hospital instead of surgery center. Patients may not be as healthy as they think they are, and physicians and advanced providers who routinely see these patients are not aware of the subtle physiologic changes that can have a profound impact on anesthesia.
Our medications and techniques have changed as well. Ultrasound has facilitated the increased use of regional blocks for pain management, decreasing the need for opioids. Medications have faster onset and faster offset, and better side-effect profiles. All of this leads to more rapid recovery, facilitating same-day surgery.
I expect that outpatient/same-day surgery will continue to increase in volume, particularly as CMS regulations now allow for outpatient total joint replacements. In addition, patients are now concerned about extended hospital stays and COVID-19 risks. We will continue to see more innovation around minimally invasive procedures and will start to see models where post-surgical care is provided in the patient’s home, likely in conjunction with telehealth.
Christine A. Doyle, MD, FASA
Thanks to advances in medical care, surgeons today are operating on older and more complex patients than ever before. It’s not unusual to perform a hip replacement on a spritely and mobile 90-year-old. The same goes for people with heart disease and other chronic conditions.
Complex patients require careful management before, during, and after a procedure. To meet these needs, more anesthesiologists are stepping into the role of perioperative care coordinator. Along with our orthopedic colleagues, we have focused on “prehabilitation”—educating and training patients on what to expect, what exercises they should be doing (and how to do them), smoking cessation, and more. The American Society of Anesthesiologists has created the Perioperative Surgical Home model, a patient-centric and team-based approach designed to improve patient care, costs, and both provider and patient satisfaction.
One factor that is actively shaping perioperative care is growing concern around brain health. Concerns about postoperative cognitive decline (POCD) have become significant. Declines in memory and executive function after even minor surgery may last for several months. As we operate on older patients, it’s become clear that many appear “normal” to family and friends, but pre-surgical cognitive testing shows that they are already suffering from some cognitive loss. The stress associated with surgery (and any other acute illness) often unmasks this, but the timing leads one to think it’s solely related to the surgery and anesthesia. With pre-surgical cognitive testing, high-risk patients can be identified and better managed with certain precautions and medication combinations.
Current events make one thing clear: Even more than before, anesthesiologists must break out of silos and participate in the entire spectrum of patient care and organized medicine. Anesthesiology will continue to be proactive, collaborative, team-based, and more than anything else, patient-centered. And the most successful groups will prove their value as perioperative and critical care coordinators.
For these reasons, our independent anesthesia group chose to join Vituity in 2016. As members of a multispecialty practice, we have the opportunity to work with our colleagues in CCM, internal medicine, and emergency medicine to transform acute care delivery for patients everywhere.
Learn more about the benefits of aligning with Vituity’s anesthesiology practice.