Surgery Co-Management Program Celebrates 10 Years of Improved Outcomes
This month (September 2022) marks the ten-year anniversary of the launch of the surgical co-management (SCM) program in the division of hospital medicine. Since its founding in 2012 by Neera Ahuja, MD, division chief of hospital medicine, it has evolved into one of the most respected models in the country for effectively delivering perioperative care to surgical patients. Perioperative medicine is a niche area of hospital medicine that focuses exclusively on pre- and post-surgical care.
“Taking care of surgical patients is like trying to keep a building steady in the middle of an earthquake,” says hospitalist Nidhi Rohatgi, MD, MS, section chief for the surgical co-management program.
The role of the surgical co-management hospitalist is to work with surgical teams currently in orthopaedics, neurosurgery, and otolaryngology–head and neck surgery to predict, prevent, or treat the medical issues that may result from surgery. A patient’s underlying medical conditions (such as cardiovascular, pulmonary, or hematological issues) need to be optimized prior to the surgery and kept stable afterwards.
“Every system and organ in the body can be affected after surgery -- not just the one that is the target of the procedure,” says Rohatgi.
“The SCM program has been tremendously successful in helping us achieve superior patient safety and patient-centered care,” notes Konstantina Stankovic, MD, PhD, FACS, chair of the department of otolaryngology – head and neck surgery. “The SCM hospitalists help to view the patients holistically, beyond what may be typical for a surgical team.”
The timing was right
Ten years ago, Ahuja was a hospitalist in the Department of Medicine. The practice then was for hospitalists to rotate through the various surgical services on a random basis. There was limited night or weekend coverage. “Not surprisingly,” she recalls, “the surgeons often didn’t know who we were, and many times did not agree with our evidence-based recommendations for their patients. More importantly, they didn’t understand what role we could play in preventing medical complications post-surgery by managing medical issues preemptively, prior to surgery.”
She decided to take action. In 2012, with the support of the Chief Medical Officer and the chairs of orthopaedics, neurosurgery, and medicine, she developed a program that would embed dedicated hospitalists in the divisions of orthopaedic surgery and neurosurgery, 24/7, and integrate the hospitalists as collaborative partners with the surgeons.
Several trends were occurring at the time that made the timing right for this approach.
First, the hospital was working to optimize length of stay and reduce post-surgical complications. Prior to 2012, surgical patients with minor medical problems were being admitted to the medicine services, and surgeons were the consultants. Under the new SCM approach, this model would be flipped, with patients admitted to the surgical services, but with proactive medical co-management available to address their complex needs in a timely manner. The goal was to reduce patients’ lengths of stay and post-surgical complication rates, while freeing up more medical beds.
Second, the 2011 Accreditation Council for Graduate Medical Education duty hours limited the time trainees could be in the hospital. Hence, surgical trainees needed to optimize their education time in the operating room (OR) doing surgery. Though they would request a hospitalist to manage a medical problem, they often did so after the medical issue had developed. “I would think if only they had called me before this problem arose, I could probably have prevented it in the first place,” says Rohatgi.
“I thought how awesome it would be if the surgeons knew the hospitalists, and we knew their practice styles, so we could have a truly supportive collaboration that benefited the patient and also aligned with the hospital’s quality goals,” Ahuja recalls. In this scenario, for example, the hospitalist would understand the surgeon’s concern about starting an anticoagulant post-operatively, which could create a risk for a surgical-site hematoma, while the surgeon would understand why the hospitalist was motivated to prevent a deep venous thrombosis.
And third, the U.S. Centers for Medicare and Medicaid Services was implementing bundled payment models for hip and knee surgeries, aiming to lower the cost of care and improve clinical quality metrics. It was the right time to implement SCM to support this work.
The outcomes speak
Once the plan was approved, Ahuja began the arduous job of recruiting six hospitalists to join the program. “We recognized we had a lot to learn,” she comments, “and that we had to earn the trust of our surgical colleagues if they were going to agree to our evidence-based guidelines for preventing post-operative complications such as atrial fibrillation, pneumonia, acute kidney injury, venous thrombosis, and many others.”
In the surgical co-management model, the SCM hospitalists review the charts of new patients admitted for surgery early in the morning. “This takes several hours,” Rohatgi notes. “We identify patients who have medical issues, such as cardiovascular disease, that might contribute to poor outcomes after surgery. Then we see the patients for whom we believe we can add value in their management and improve their post-operative outcomes.”
Within six months of all the pieces being in place, the team observed decreasing length of stay for patients in the surgical units. Within a year, they noticed that surgical house staff and nurses increasingly came to the surgical co-management hospitalist with questions. This meant appropriate preventive or treatment measures could be taken immediately before the patient’s condition worsened. And they saw favorable reactions from patients and families, who felt there was a primary care physician looking after them round the clock.
After the first year of implementing SCM, Rohatgi and Ahuja reported a 14% reduction in medical complications, in the Annals of Surgery.
Five years into the program, they reported gratifying results in the Journal of Hospital Medicine: a 3.8% per year reduction in the rate of post-surgical medical complications, and 0.3 days per year reduction in length of stay. Both outcomes were accompanied by a decrease in the cost of care.
“We also saw reductions in transfers to the intensive care unit and in readmission rates,” notes Rohatgi. Overall, the estimated cost savings per patient studied ranged from $2,642 to $4,303, due primarily to the decrease in length of stay.
Michael Gardner, MD, vice chair of the department of orthopaedic surgery and chief of the orthopaedic trauma service, praises the SCM program: “This program has been beneficial for patients and the clinical team alike.”
“Patients who are referred to us through the emergency department often have hip fractures,” says Gardner, “and it’s been documented that patients with hip fractures benefit from earlier surgery, discharge, and ambulation. Coordination of medical care with surgical care enables us to proceed with surgery more rapidly, thereby improving outcomes for these patients.”
Neurosurgeon Gordon Li, MD, comments that the SCM program is “fantastic.” He notes that “patients get far better medical care with the hospitalists than we surgeons could provide.” In addition, Li says, “the hospitalists serve a vital teaching function on the surgical units, rounding with residents and advanced practice clinicians. They’re teaching about how to manage diabetes, delirium, heart failure, and other medical issues that arise in a surgical unit. And, they have implemented protocols that minimize errors and keep all providers on the same page when managing medical issues.” Li is associate dean of academic affairs at Stanford University School of Medicine and vice chair of faculty affairs in the department of neurosurgery.
Predict. Prevent. Treat.
“The core job of the surgical co-management hospitalist is to predict, prevent, and treat,” says Rohatgi. “We’re always thinking multiple steps ahead, trying to envision what could happen during and after this particular surgery, what we could do to prevent a medical complication from happening, and, if something did happen, how to treat it fast enough so the patient doesn’t decompensate.”
She has scrubbed up with the surgeons and the anesthesiologists and observed them in the OR to get a better understanding of each surgery and how it might affect the other systems of the body. “What they do is miraculous,” she notes. “I wanted to understand the physiological changes that occur during surgery, and what the patient is going through. I didn’t want the OR to be a black box for me – I needed to understand more.”
As the program evolved and demonstrated its effectiveness, medical students, residents, physician assistants, and others began asking if they could round with the SCM hospitalists. “It is always a pleasure to see trainees grow and develop, and often become attendings here at Stanford,” Rohatgi says.
The next 10 years
Michael Lim, MD, chair of the department of neurosurgery, notes that “we feel patients get better care with co-management. The team has been great to work with.”
As the population continues to age and patient comorbidities become more complex, surgical co-management may be adopted by more hospitals. Both Ahuja and Rohatgi speak about this at national and international meetings, and at other medical centers around the country and abroad.
“People often ask me about the financial component of setting up a program,” says Rohatgi. “I tell them that though the initial financial investment may be daunting, the outcomes more than compensate for the effort.”
In a commentary published in the American Journal of Medicine in 2019, Rohatgi and Ahuja noted that “the experiential and evidence-based knowledge required to effectively manage these [surgical] patients continues to grow, as co-management hospitalists are exposed to newer specialties and the medical complexity of patients is on the rise.”
“I come to work happy, and I go home happy,” says Rohatgi. “Our SCM program is based on mutual respect and trust. That is very gratifying.”