Following the NorthStar

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NorthStar Anesthesia is shaking up the status quo to pursue a new standard in patient outcomes and experiences.

It’s one of the holy grails around the business of medicine: increasing patient access and quality of care—while decreasing cost. That’s precisely the disruption that NorthStar Anesthesia and President of Clinical Services Brian Woods M.D. are pursuing. They believe perioperative optimization is the way to achieve that end, and anesthesia should take the lead.

“It should seem that better care at higher quality should cost more money—if you’re looking at the direct delivery of care and quality, then yes, there’s going to be more expense. However, the real disruption of healthcare comes from the benefit of seeing, ‘Where can we reduce and eliminate inefficiencies—lost goods, lost cost, and lost time—in order to compensate for waste and thus net a reduction of total cost?’” Woods said.

Everyone in the system, especially patients and caregivers, wants better patient outcomes. Achieving them, however, requires a shakeup of the status quo. It can take re-examining the fundamentals of your practice and questioning every assumption you have. It’s no easy task, of course, but NorthStar hopes it will help lead a fundamental shift in the practice of anesthesia and perioperative medicine to create a new industry standard. While getting to perfection might not be possible, getting a lot closer certainly is.

“We’re not the single answer to the holy grail quest,” Woods said, “but this journey is one in which we believe can help hospitals and ambulatory surgery centers with—especially in these trying times. Our approach to disrupting healthcare normalcy is to partner with and invite as many people as possible to travel the journey with us.”

A New Approach to Recovery After Surgery

To make surgeries more efficient, you want to make sure the first surgery is a success. Getting things right the first time eliminates post-surgical complications, prevents the need for additional operations, and reduces morbidity and mortality. Everybody wins. This seems simple enough, but how to achieve surgical success is actually a challenging question.

Traditionally, the answer has been the following: Have patients fast to a demoralizing state of hunger prior to surgery, get them asleep and anesthetized as fast as possible, push fluids to rehydrate them from their fast, utilize a large amount of narcotics to get them through surgery, and allow them to rest and recover at their own pace.

In some centers, there’s not enough focus on optimizing the condition of the individual patient before they present for surgery. There’s insufficient focus on what can be done before the first step of care to deliver better patient outcomes and a better endpoint for these medical facilities.

“The proof is now present in multiple peer-reviewed journal articles with numerous studies to show that preoperative optimization for existing health considerations (that are unique to that patient) should be undertaken, even in the event of delaying surgery in cases that are not emergent or urgent for life-saving purposes,” Woods said.

Steps such as the optimization of a diabetic’s regimen to control blood glucose or the prolongation of time for smoking cessation before surgery can make a world of difference in their surgical outcomes and experience

But optimization of care and enhanced recovery don’t stop pre-surgery. When it comes to the use of intravenous fluids, rather than accounting just for a patient’s body weight, anesthesiologists can use goal-directed fluid therapy to individualize and optimize the amount of fluid the patient needs to maintain adequate organ perfusion and hemodynamic status.

Perhaps the most important part of surgical optimization is the management of pain. Our world is currently overwhelmed with narcotics and narcotic abuse. We must consider, “How can we deliver anesthesia without introducing to the patient such large amounts of narcotics, extremely powerful pain medications, as to induce addiction (the mental components of medication abuse) and even physical dependence (when the patient’s physical body becomes dependent on the medication dosing)?”

One way to combat narcotic addiction and overuse is by deploying multi-modal anesthesia with goal directed therapy. The multimodal approach utilizes lower doses of several different anesthetics in combination to fulfill the anesthetic needs of surgery without inducing dose amounts that trigger the side effects like nausea, disorientation after surgery, or addiction, as it relates to opioids.

Having the Conversation

Understanding these clinical topics is one thing. Changing behavior and day-to-day practice within anesthesia departments is another. So how do you navigate change and translate evidence into practice? It starts with having the conversation and building a consensus. NorthStar has learned there are four keys to having success in conversations and consensus building.

Key 1:

"Practice Management. You have to have a leadership approach that’s willing to start that conversation and invite others to contribute,” Woods said.

Key 2

Up to Date Science. You have to have basic access to the changing science and an understanding of the data to make valid, convincing scientific arguments that inspire change, whether that’s pre-op or intra-op fluids or post-op medication management.”

Woods credits partnerships with London’s Royal College of Anesthetists, Evidence Based Perioperative Medicine (EBPOM), Duke University, and Morpheus Anesthesia Consultants with connecting NorthStar with that critical information.

Key 3

Technical Measurement. “You need the technical systems in place to measure the entirety of your enterprise. For NorthStar Anesthesia that begins with our partnership with ePreop for seven years now. ePreop (now Provation) is a preop and quality documentation system we use on every anesthetic in every hospital or ASC around the country—now over 190 of those facilities and just over one million cases per year—and for every case we deliver, we measure key quality endpoints and track that nationally and submit that information to NACOR in alignment with the ASA and the Anesthesia Quality Institute. None of this ‘change the game’ conversation is possible unless you have the data to start monitoring and measuring your teams and your outcomes better.”

Finally, Key 4

Aligned Culture. You need the right culture in place to have the conversation.  NorthStar recognizes that our care is a partnership with our facilities and our surgeons, and we install a leadership accountability culture in our departments that allows this conversation to grow over time. This is not something anesthesia can simply mandate, but through partnership with our health systems, our surgeons, and our own anesthesiology departments we can make this reality,” Woods said.

Measure by Measure

 “We are finding and implementing change in as many locations as possible where we’ve turned all four of these keys on,” Woods said, “and NorthStar will continue to lay the groundwork and seek out more like-minded partners who are open to a different way of thinking and willing to go after the different results needed in healthcare today

“The intent is never to take away the individualized practice decisions from physicians and clinical caregivers,” Woods said. “But we should be at least delivering, monitoring, and then measuring what effect our choices are having on the patient’s outcomes and experience through anesthesia. If the data over the course of time does shed light on what we could do to reduce certain negative factors in their care, then we should be willing to change our practices, our behavior, and our medication delivery process to do better for our patients and for the business of perioperative medicine.”

Simply being open to change or to putting your methods to the test can go a long way toward optimizing the perioperative continuum.

“The highest outcome is not protection of ego. The highest outcome is not keeping things the way they are. The highest outcome is not doing we’ve always done just because that’s the way we like to do it. The highest priority is the patient, and so the highest outcome is that of the patients’ care and experience as they go through surgery in the perioperative period.”

Better management and measurement will ultimately improve the patient’s quality of care, making patients feel better and healthier, with the added benefit of reducing costs. Sounds disruptive and divine to us.