This article is a portion of a book titled "Challenges, Risks and Opportunities in Today's Spine World "edited by Stephen Hochschuler, MD, Frank Phillips, MD, and Richard Fessler, MD. You can find links to the previous chapters at the end of this article.
Over the next several weeks, we will be looking at various spine care models around the US. In the next two chapters we will be looking at the HSS model.
In the previous chapter we looked at the structure for Hospital for Special Surgery’s (HSS) non-operative management of low back pain, spine imaging and medical preoperative evaluations. In this chapter we will discuss the remaining relevant disciplines.
Anesthesia Care: Ellen Soffin MD, Dedicated Spine Anesthesiologist.
At HSS, anesthesia care teams are composed of an attending anesthesiologist, associate anesthesia providers (nurse anesthetists) and/or residents and fellows in anesthesiology. However, the spine service is attending-led, and the majority of cases are performed by a solo attending anesthesiologist. The attending anesthesiologist is present with the patient throughout the entirety of their care starting with a preoperative evaluation and ending with transfer to PACU. During the pre-anesthetic evaluation, the patient’s current state of health and the nature of the planned surgery are carefully considered. This phase of care allows the anesthesiologist to tailor a safe, effective anesthetic. We liaise closely with colleagues from medicine, radiology, the pain services and surgery to ensure all appropriate pre-operative testing is complete and the patient is optimized for surgery. Special consideration is given to the airway, particularly in cervical deformity cases. Planning for intraoperative airway management requires broad pre-operative decision making, from selection of specialized equipment, likefiberoptic or glide scope intubating tools, preparation of the patients for possible awake intubation, and referral to an otolaryngologist for consideration of a surgical airway.
Spine anesthesia at HSS differs from other orthopaedic disciplines in that regional blocks are not routinely used. The exception to this is the TAP (transverse abdominus plane) block for procedures with an anterior or lateral approach. This block has been shown to decrease the opioid requirements and improve post-operative pain control in patients undergoing antero-lateral fusion procedures. Our emphasis on opioid-sparing multimodal analgesia with regional techniques is unique to spine care at HSS and contributes to positive outcomes after surgery.
TIVA (total intravenous anesthetic) is used routinely and consists of a combination of sedatives and hypnotics, which when used in combination, lower the total requirement of any individual agent. Medicines such as dexmedetomidine hydrochloride, lidocaine, propofol, ketamine, methadone and remifentanil are the most commonly used. Titrating these compounds helps achieve hemodynamic and anesthetic goals, as well as to optimize perioperative analgesia in chronic opioid dependent patients. Dexmedetomidine hydrochloride is particularly useful as it tends to facilitate close control of blood pressure. Dexmedetomidine hydrochloride in combination with ketamine are useful in the opioid-tolerant patient to decrease opioid requirements intraoperatively. Finally, dexmedetomidine hydrochloride and ketamine are occasionally used for post-operative pain control in the opioid-tolerant patient population.
Frequently, the role of the anesthesiologist ends at the time of PACU admission. However, anesthesia care also can extend well into the postoperative period. Members of our dedicated spine care for patients admitted to the Orthopedic Special Care Unit (OSCU) for ongoing resuscitation, blood transfusion, pulmonary and ventilator management and stabilization, as needed. The acute pain service also has representation from anesthesiologists on the spine service. Pain management is a key aspect of recovery after spine surgery and is coordinated by the primary anesthesia team and the acute/chronic pain services, and ultimately transition care back to the surgical team. Our pathways of care emphasize multimodal, opioid-minimizing analgesics which enhance recovery and promote return to independence.
Surgery: Todd Albert MD, Surgeon-in-Chief.
During spine surgery there is an emphasis placed on a systematic approach to patient safety. All patients undergo a pre-induction time out prior to anesthesia with the attending anesthesiologist. Following this, a standard time out procedure is completed with introductions of all team members, identification of the patient, procedure and surgical levels as well as confirmation of preoperative medications. At this point communication is completed between the surgeon, neuromonitoring, and anesthesiologists regarding the treatment plan. Our motto is “see something, say something” highlighting the expectation that all members of the care team should speak up if they notice something that they feel requires attention. Finally, after the completion of the surgery a debrief is performed where the case is reviewed. During the debrief the plan for post-operative care including pain management is reviewed by the surgeon, fellow and anesthesiologist. At this point all team members have the opportunity to voice any special concerns for the patient. The parts of the case which went well as well as areas for improvement are briefly reviewed. The appropriate care pathway is reaffirmed based on preoperative recommendations from medical team. In this fashion, all participants are on the same page regarding the patient care plan, and communication is optimized.
Physician Assistant Spine Team: Mary-Ellen Zullo PA, Andrew Koo PA.
At HSS there is a strong physician assistant (PA) team which supports the spine service. This team is divided into specialty care groups which include a PA team responsible for preoperative history and physicals, operative assistance to surgeons and floor management. The team system allows the physician assistants develop expertise in one area of spine patient care which streamlines the patient’s course through the hospital. For example, there is a team dedicated to interviewing the patient preoperatively and acting as a final check for things which may have been missed through the extensive preop evaluation. Following this there is a dedicated team of operative PAs that works with the surgeons in the operating room and facilitate a smooth operative course. Finally, the patients are managed by a team of floor PAs experienced in post-operative spine care.
Nursing and ancillary care:
In addition to the PAs there is a robust nursing culture at HSS which focuses on customer service, safety and patient care. Patients are cared for by an individual nurse who is backed up by a team of nurses such that patient needs are always tended to immediately. In addition, patients are preemptively asked about their comfort level, if they would like to get out of bed, and what their food preferences are, etc. Nursing teams then meet as part of a multidisciplinary rounds which includes the PA teams, nursing, nutrition, and physical therapy twice a day. During these rounds, each individual patient course is discussed and changes are made as needed to ensure the most efficient and quality care.
Quality and Value Oversight: Cathy MacLean MD/PhD, Chief Value Officer.
The overarching governing principle of the spine model at HSS is based on value—that is, providing the highest quality of care at the lowest possible cost. Quality is based first on safety, but more importantly whether or not patients are actually improving. This has been measured by instituting a PROMs (patient reported outcome measures) initiative, which is controlled by a steering committee at HSS. As a part of standard of care, every patient gets two validated measures: a general health PROM (the PROM-10) and spine specific measure (i.e the Oswestry Disability Index—ODI or NDI). Every patient is measured again at 6 months. This information is fed back to providers to help improve treatment processes. Minimal clinical improvement—or the smallest change in PROMs that can indicate a successful treatment— is also being researched heavily at HSS to help use PROMs in a more informative way.
Safety is a critical component to ensuring value in spine care. This starts with the goal to perform the correct surgery the first time while keeping the chance of failure, readmission or complication low. Appropriateness of surgical procedures at HSS are based on the highest quality evidence-based medicine. In areas where literature may be lacking panels consisting of a collective group of doctors are held to determine the appropriateness of procedures. In this regard, unnecessary procedures are minimized. Safety review panels also meet regularly to discuss protocols to minimize things such as infection, thrombosis, and readmission.
The HSS spine model functions because of the collaboration between many medical practitioners and systems each doing their part to ensure the patient is treated as safely and effectively as possible. The system is a work in progress and panels of physicians and administrators are continually making changes to improve quality, safety and efficiency. HSS is a dedicated orthopaedic hospital, and while there are many different specialties, collaboration between groups are always centered on the care of the musculoskeletal system. This fosters a unique collegiality which helps drive science and improve patient outcomes.
Challenges, risks and opportunities in today's spine world