The Perioperative Surgical Home, Enhanced Recovery After Surgery and how integration of these models may improve care for medically complex patients

Perioperative medicine is changing rapidly, and with this change comes the opportunity to improve upon current models of care delivery and integration within the health care system. Perioperative models of care are structured or conceptual arrangements for surgical patients before, during and after their surgery. Models of care such as the Perioperative Surgical Home and Enhanced Recovery After Surgery pathways are increasingly used to guide the structure of perioperative care delivery with an aim to improve patient outcomes and experience in Canadian settings. In this narrative review, we summarize the origins of these perioperative models of care. They are fundamentally different in scope and level of evidence. Both models have potential benefits and limitations to their broad implementation in our health care system. As currently developed, both models are limited in their application to patients with chronic disease. We discuss how these models of care can be used to develop integrated horizontal and vertical perioperative pathways in a Canadian setting. Such integration is a potential solution that will improve their applicability to patients with medically complex conditions and in times when health care systems are under pressure. We describe this approach using the example of patients with kidney failure receiving dialysis. La medecine perioperatoire evolue rapidement, ce qui est propice a l'amelioration des modeles de soins actuels et a leur integration au systeme de sante. Les modeles de soins perioperatoires sont des approches structurees ou conceptuelles a l'intention des patients de chirurgie avant, durant et apres leur intervention. Les modeles de soins perioperatoires, tels que les approches PSH (Perioperative Surgical Home) et ERAS (Enhanced Recovery After Surgery) sont de plus en plus utilises pour orienter la structure et la prestation des soins perioperatoires dans le but d'ameliorer les resultats et l'experience des patients dans les milieux de soins au Canada. Dans la presente syn-these narrative, nous retracons l'origine de ces modeles de soins perioperatoires. Ils sont fondamentalement differents aux plans de leur portee et de leur niveau de preuves. Mais leur deploiement a grande echelle dans nos systemes de sante comporte des avantages et des inconvenients potentiels. Dans l'etat actuel de leur developpe-ment, les 2 modeles ont une applicabilite limitee pour les patients atteints de maladies chroniques. Nous discutons de la facon dont ils peuvent etre utilises pour developper des approches horizontales et verticales integrees au contexte canadien. Cette integration est une solution envisageable qui ameliorera leur application aux patients atteints de maladies complexes, a une epoque ou les systemes de sante sont sous pression. Nous decrivons cette approche en prenant l'exemple des insuffisants renaux dialyses.
Although the field of perioperative medicine is growing and evolving, a widely accepted current definition is the 'integrated, multi-disciplinary medical care of patients from the moment of contemplation of surgery [...]