The Pediatric Perioperative Surgical Home

PRESENT VARIATIONS OF THE PERIOPERATIVE SURGICAL HOME There will quite likely be multiple variations of the Perioperative Surgical Home concept, predicated upon local institutional infrastructure as well as current and yet to be identified internal and external political and economic forces.1 Two existing adult Perioperative Surgical Home variations include a Lean/Six Sigma approach to rigorously standardizing a specific surgical service line and surgical procedures2 and a robust coordination and integration of pre/intra/postoperative care and postdischarge planning, with an emphasis on preoperative management and optimization of comorbidities via a full-service preoperative assessment, consultation, and treatment clinic directed by an anesthesiologist.1 It can be argued that the local dissemination and implementation of the Enhanced Recovery after Surgerya protocols3 represent another Perioperative Surgical Home variant, one which may be more acceptable to surgeons given their (European) specialty colleagues’ integral role in these Enhanced Recovery after Surgery protocols. It is thus timely that Ferrari et al.4 make the case in this month’s issue of Anesthesia & Analgesia that the pediatric surgical population is unique enough to deserve its own concurrent variation of the Perioperative Surgical Home concept. EPIDEMIOLOGY OF PEDIATRIC CHRONIC DISEASE AND PEDIATRIC SURGERY Children with chronic health conditions and hence special health care needs are a sizable and growing segment of the U.S. pediatric population.5 A 2009–2010 national surveyb revealed that 15.1% of children <18 years of age have a special health care need. A special health care need has been defined as a chronic physical, developmental, behavioral, or emotional condition that has lasted or is expected to last 12 months or longer which results in functional limitations and/or requires health and related services beyond those generally required.6 Similar to their adult counterparts, children and adolescents with chronic health conditions and special health care needs present for surgery. During the 18-year period from 1988 to 2005, there were a total of 2,087,915 pediatric surgical admissions in the United States.7 Pediatric general surgery (including gastrointestinal) represented the highest volume specialty, followed by orthopedic and ear, nose, and throat surgery. Most of these surgeries (60.4%) occurred in urban, teaching hospitals. Although overall inpatient mortality was 0.85%, procedures with the highest mortality were craniotomies for trauma (26.3%), liver and/or intestinal transplants (11.1%), heart transplants (10.9%), and other procedures for multiple significant trauma (10.7%).7 Based on the 2009 Kids’ Inpatient Database for patients <18 years old, pediatric surgical inpatient volume in the United States was estimated to be 216,081 procedures, with the top 20 procedures accounting for >90% of cases.8 Notably, upwards of 40% of these pediatric inpatient surgical procedures were performed in adult general hospitals, even though these included predominantly appendectomy, central venous access, burn care, and cholecystectomy.8 In their accompanying editorial, “Time to Get on the Bus: Children’s Surgery and Where We Need to Go,” Barnhart et al.9 astutely observed that providing safe, high-quality surgical care is equally predicated on anesthesia and perioperative nursing, along with rapid response teams, code teams, and transfer teams, which provide a critical safety net for children in the perioperative period. A highly collaborative Pediatric Perioperative Surgical Home would provide these requisite personnel and systems. In an effort to optimally match pediatric patient needs with available infrastructure and human resources, the Task Force for Children’s Surgical Care was assembled in 2012 under the aegis of the American College of Surgeons.10 The recommendations of this task force “could [eventually] lead us to a place where surgical care for children is convenient and local when possible and guaranteed to be safe and competent when care of the child is rare and complex.”9 A facility-specific Pediatric Perioperative Surgical Home model could greatly facilitate achieving this goal. ROGERS’ DIFFUSION OF INNOVATION MODEL: EARLY ADOPTER PHASE OF THE PERIOPERATIVE SURGICAL HOME Even the most zealous present-day advocates for the Perioperative Surgical Home must admit that this new practice model is still in its infancy. Rogers’ diffusion of innovation theory holds that adoption of a new product such as the Perioperative Surgical Home is not fully synchronous but instead is a gradual process in which individuals adopt the innovation at different rates.11 Rogers defined 5 adopter categories (Table 1): Innovators, Early Adopters, Early Majority, Late Majority, and Laggards.11 Over time, the distribution of adopter categories follows a bell-shaped curve that approaches normality (Fig. 1).Table 1: Five Adopter Categories in Rogers’ Diffusion of Innovation Theory11Figure 1: New product adoption curve based on Roger’s diffusion of innovation theory (http://tomfishburne.com/2007/02/new-product-adoption.html). Licensing fee paid by author on December 8, 2014.In his extrapolation of the diffusion of innovation theory to the marketing of high-tech products, Moore12 proposed that there is often a “chasm” between the Early Adopter and Early Majority groups and their 2 seminal phases of innovation adoption (Fig. 1). Initiatives such as the American Society of Anesthesiologists Perioperative Surgical Home Learning Collaborativec may successfully aid in more readily bridging this diffusion of innovation chasm. HISTORICAL PATTERN OF DELAYED DIFFUSION OF INNOVATIONS IN PEDIATRIC HEALTH CARE Until the mid-1990s, children were often “therapeutic orphans” for whom many medications, including anesthetics, were administered off-label, without pediatric studies to guide drug labeling for clinical indications, dosing, and other therapeutic considerations.13 The 1997 U.S. Food and Drug Administration Pediatric Exclusivity Provision, and its successor, the Best Pharmaceuticals for Children Act of 2002, provided economic incentives (a 6-month patent extension) to pharmaceutical companies to conduct drug studies in children.13,14 The Pediatric Research Equity Act of 2003 further provided the U.S. Food and Drug Administration with the authority to require pediatric studies of drugs if an adult indication also exists in children.13,15 Nevertheless, an analysis of all interventional trials registered at ClinicalTrials.gov from July 2005 to September 2010 revealed only 8.3% to be pediatric trials, which had declined during the time period.16 This historical pattern of delayed diffusion of innovations in pediatric health care is being rigorously addressed by programs such as the UCLA Children’s Discovery and Innovation Institute, Nationwide Children’s Center for Innovation in Pediatric Practice, Sheikh Zayed Institute for Pediatric Surgical Innovation at Children’s National Medical Center, Center for Pediatric Innovation at Emory University, and Institute for Pediatric Innovation in Cambridge, Massachusetts. Furthermore, Boston Children’s Hospital and Children’s National Medical Center are to be commended for being inaugural members of the American Society of Anesthesiologists Perioperative Surgical Home Learning Collaborative. However, unless a more concerted effort is made now, the pediatric surgical population will again be left out, collectively “orphaned” again, as efforts are made in the adult surgical population to achieve and leverage the 3 interdependent goals of the triple aim of health care: (1) improving the individual experience of care, (2) improving the health of populations, and (3) reducing per capita costs of care.17 THE PEDIATRIC PATIENT-CENTERED AND FAMILY-CENTERED CARE MODEL The Perioperative Surgical Home fundamentally seeks to provide adult care that is more patient-centered and involves greater patient-clinician shared decision making.1 Notably, the American Academy of Pediatrics first adopted a policy statement on Family-Centered Care and the Pediatrician’s Role in 2003.18 In their subsequent collaborative 2012 report, Patient-Centered and Family-Centered Care and the Pediatrician’s Role,19 the American Academy of Pediatrics, and the Institute for Patient-Centered and Family-Centered Care intentionally sought to “more explicitly capture the importance of engaging the family and the patient in a developmentally supportive manner as essential members of the health care team.” This expanded framework recognizes that the “family is the child’s primary source of strength and support and that the child’s and the family’s perspectives and information are important in clinical decision making.”19 It is appropriate and imperative that this expanded emphasis on the patient and family in the delivery of pediatric care also occurs in the surgical setting, a laudable goal that is realistically achievable via the Pediatric Perioperative Surgical Home model espoused by Ferrari et al.4 CONCLUSIONS As defined by the Institute of Medicine,20 and in turn herein advocated for by Ferrari et al.,4 a Pediatric Perioperative Surgical Home represents a needed “health care micro system” with a specific purpose, set of patients, technologies, and practitioners, all aligned with the explicit health care requirements and concerns of the pediatric surgical population. Given the epidemiology of pediatric chronic diseases and pediatric surgery, and the resources needed to implement a Pediatric Perioperative Surgical Home, it would appear prudent that Innovators such as Ferrari et al. at Boston Children’s Hospital lead the way, followed closely by other children’s hospitals serving as fellow Innovators and then Early Adopters of this new care model. According to Rogers, there are 5 main factors that influence the adoption of an innovation such as the adult and pediatric versions of the Perioperative Surgical Home (Table 2): Relative Advantage, Compatibility, Complexity, Triability, and Observability.11 The onus remains upon the Innovators and the Early Adopters of adult and pediatric versions of this new care model to demonstrate all 5 of these factors, ideally in a reproducible, incremental manner, which fosters adoption by other individuals and groups positioned later in the diffusion of innovation continuum.Table 2: Rogers’ 5 Main Factors That Influence Adoption of an Innovation11DISCLOSURES Name: Thomas R. Vetter, MD, MPH. Contribution: This author wrote the manuscript. Attestation: Thomas R. Vetter approved the final manuscript. This manuscript was handled by: Peter J. Davis, MD.