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Perioperative medicine

Copyright © 2006 Society of Hospital Medicine

Perioperative medicine refers to the medical evaluation and management of patients before, during and after surgical intervention. In the United States, over 44 million patients undergo non‐cardiac surgery each year. The annual cost of perioperative cardiovascular morbidity is more than $20 billion. Hospitalists perform general medical consultation preoperatively and provide postoperative medical management. Optimal care for the surgical patient is realized with a team approach that coordinates the expertise of the hospitalist and the surgical team. Hospitalists apply practice guidelines to medical consultation and can lead initiatives to improve the quality of care and patient safety in the perioperative period.

KNOWLEDGE

Hospitalists should be able to:

  • Explain the effect of anesthesia and surgical intervention on physiology.

  • Explain the goals and components of preoperative risk assessment.

  • Identify patients who require selective preoperative testing based on patient specific factors, type of surgery, and urgency of surgical procedure.

  • Describe risk factors for perioperative complications.

  • Explain risks for perioperative complications in specific patient populations.

  • Explain pharmacologic therapies that should be modified or held prior to surgery.

  • List widely accepted risk assessment tools and explain their value and limitations in patients undergoing nonvascular surgery.

  • Describe the evidence supporting prophylactic perioperative ‐blockade.

SKILLS

Hospitalists should be able to:

  • Elicit a thorough history, review the medical record and inquire about functional capacity in patients undergoing surgery.

  • Perform a targeted physical examination, focused on the cardiovascular and pulmonary systems and other systems based on patient history.

  • Perform a directed and cost effective diagnostic evaluation based on patient relevant history and physical examination findings.

  • Employ published algorithms and validated clinical scoring systems, when available, to assess and risk stratify patients.

  • Assess the urgency of the requested evaluation and provide feedback and evaluation in an appropriate timeframe.

  • Recognize medical conditions that increase risk for perioperative complications and make specific evidence based recommendations to optimize outcomes in the perioperative period.

  • Determine the perioperative medical management strategies required to address specific disease states.

  • Reassess patients for postoperative complications and make medical recommendations as indicated.

ATTITUDES

Hospitalists should be able to:

  • Communicate with patients and families to explain the hospitalist's role in their perioperative medical care, any indicated preoperative testing related to their medical conditions or risk assessment, and any adjustment of pharmacologic therapies.

  • Communicate with patients and families to explain any indicated perioperative prophylactic measures.

  • Communicate with patients and families to explain the need for follow‐up medical care post‐discharge.

  • Initiate indicated perioperative preventive strategies.

  • Recommend specific prophylactic measures, which may include ‐blockade, VTE prophylaxis, or aspiration precautions, to avoid complications in the perioperative period.

  • Serve as an advocate for patients.

  • Promote a collaborative relationship with surgical services, which includes effective communication.

  • Assess pain in perioperative patients and make recommendations for pain management when indicated.

  • Facilitate discharge planning early in the hospitalization, including communicating with the primary care provider, and presenting the patient and family with contact information for follow‐up care.

  • Utilize evidence based recommendations for the evaluation and treatment of patients in the perioperative period.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, Hospitalists should:

  • Lead, coordinate or participate in multidisciplinary efforts to develop clinical guidelines, protocols and pathways to improve the timing and quality of perioperative care from initial preoperative evaluation through all care transitions.

  • Lead, coordinate or participate in efforts to improve the efficiency and quality of care through innovative models, which may include co‐management of surgical patients in the perioperative period.

  • Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize diagnostic and management strategies for surgical patients requiring medical evaluation.

  • Lead, coordinate or participate in multidisciplinary protocols to promote the rapid identification, triage, and expeditious evaluation of patients requiring urgent operations.

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