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Preset plans
At most facilities, there is variability in the overall system of care. I'm suggesting you
establish a comprehensive order set for every surgery, and change it based on the
needs of individual patients. For example, if a patient developed a peptic ulcer after
taking a non-steroidal, you uncheck that box on the preset order and avoid giving that
medication. It makes sense to do it that way; very few patients are sensitive to the
drug, so shouldn't the default involve administering a non-steroidal and changing plans
if the patient has a comorbid condition that prevents its use? The PSH model is not a
cookie-cutter approach to surgery. In fact, it's very much in line with individualized
care.
Typically, all aspects of perioperative care work in silos for the benefit of the
patient. But why shouldn't anesthesiologists and surgeons agree on how cases will be
performed, including how pain will be controlled? By reducing variability among
providers, you're reducing the likelihood of oversights occurring. The order set is stan-
dardized regardless of which surgeon will perform the case or which anesthesia
provider will work the room.
Here at UC Irvine Health, we launched the PSH model for total joint cases to great
success, which has been detailed in the journal Anesthesia & Analgesia
(osmag.net/r6NvUU). Initial planning included anesthesiologists, surgeons, nurses, phar-
macists, a physical therapist, a case manager, a social worker and information technol-
ogy experts (who helped program the health system's EMR so we could input data
and track our progress). We met weekly to launch the program and quarterly once it
was off the ground.
Thanks to the establishment of preset patient care orders created by the committee,
all patients now receive protocol-driven, standardized pain management based on a
multimodal medication regimen that begins the morning of surgery (see "UC Irvine's
Pain-Control Protocol"). Our pain management efforts focus on controlling pain
throughout the perioperative period and the avoidance of opioids to reduce lengths of
stay.
