Optimizing Perioperative Care
Safety and quality have been a longstanding clinical priority at the HSS Lerner’s Children Pavilion, but those aspects of care have taken on a heightened sense of importance since the pandemic. In this interview, Lisa S. Ipp, MD, Chief of Pediatric Medicine at HSS, explains how the HSS approach to perioperative care optimizes pediatric orthopaedic patients for surgery and ensures a safe recovery.
HSS takes a nonstandard approach to the perioperative care of pediatric orthopaedic patients. At the center of our model is a team of board-certified pediatricians who assess all patients prior to an inpatient stay. In addition, patients with medical issues who are indicated for ambulatory surgery are also seen preoperatively.
Pediatric patients at HSS have their own unique set of preoperative guidelines which are different from the adult guidelines. The pediatricians work closely with a variety of subspecialists, including pediatric anesthesiologists, pediatric nurses and often a patient’s own primary care provider to optimize the patient for surgery.
At the center of our model is a team of board-certified pediatricians who assess all patients prior to an inpatient stay.
Also distinctive is that in about 99% of cases, the preoperative evaluating pediatrician is also the one who provides the postoperative care while the patient is hospitalized. This gives really nice continuity to our pediatric orthopaedic care.
We have a number of mechanisms in place to optimize our complex patients. First is an appointment that takes place right at the time of surgical indication, prior to the standard pre-surgical visit that all patients undergo several weeks before surgery. Oftentimes, this gives us four to six months before an elective procedure to gather input from as many specialists as needed. That’s when we do sleep studies, pulmonary function testing, cardiac workup, imaging and any other presurgical tests. In doing that, we’re able to get everyone on the same page for how to optimize.
this gives us four to six months before an elective procedure to gather input from as many specialists as needed.
We also have a monthly pediatric complex case panel. This is an interdisciplinary panel of orthopaedic surgeons, pediatricians, subspecialists as indicated, pediatric anesthesiologists, nurses, risk management specialists and child life specialists. Input from pediatric anesthesia is really critical at our institution. We work hand in hand with the pediatric anesthesiologists who are overseeing the incredibly difficult sedation and anesthesia in these complex patients.
Another thing that we do for complex patients is to plan proactively for the pediatric ICU. We know a complex patient is often going to need a higher level of care, so for many patients we book the bed preoperatively, even though we know they won’t always need it.
Nutritional status is one factor that tends to drive patients into that high-acuity category. Often our neuromuscular scoliosis patients come to us underweight or malnourished. They may be having difficulty at home with oral feeding, and it’s a struggle for them to maintain their weight. Because we know weight and metabolic status can impact recovery and healing, we begin following these patients early on. Many times, we send them to Weill Cornell Medicine for a GI evaluation, while other patients may come in with their own GI specialist. Occasionally we recommend a G-tube for patients who struggle with choking or swallowing.
One interesting thing we’re doing right now is a quality improvement study to send off basic nutritional screening labs on every one of our neuromuscular patients. This will include a nutrition assessment by our pediatric dietitian and a GI assessment. We have a relatively uniform approach already, but we really want to standardize it for each patient to see how that looks postoperatively.
One interesting thing we're doing right now is a quality improvement study...on every one of our neuromuscular patients.
Obstructive sleep apnea is another condition that we see in our complex patients. We’ve created guidelines to anticipate that as an issue, which involves keeping the patient in the PACU overnight for monitoring. All of our posterior spinal fusion patients also routinely remain in our PACU overnight after surgery in order to closely manage fluid shifts and pain control.
Our affiliation with Weill Cornell Medicine is critical to our ability to manage complex patients. Many of the pediatric sub-subspecialists at Weill Cornell are also credentialed physicians at HSS. It’s a robust system, and it gives us the ability to request a consult at a moment’s notice. Even if a patient has their own specialist, we will often have Weill Cornell consultants involved preoperatively in case there’s an issue postoperatively. For example, if a patient has diabetes, we always involve our Weill Cornell pediatric endocrinologists to make sure they’re aware of the issue in case a need arises postoperatively.
We have a very experienced cadre of pediatric nurses who are the backbone of our postoperative care. But because there are so many issues that can arise at this point, our pediatricians typically see patients while they are in the PACU. Fluid management is something they keep a close eye on. Pain management is of course also very important.
These approaches have helped us to reduce nausea, constipation, wooziness and other postoperative issues.
At HSS, we’re very lucky to have a dedicated pain management team that oversees the PCA and the transition to oral medicine. We’ve come a very long way in terms of reducing postoperative opioid use. We’ve begun to utilize other forms of pain control, including Toradol, ibuprofen and acetaminophen.
In particular, we’ve had great success using IV acetaminophen; we were one of the first institutions to do that. These approaches have helped us to reduce nausea, constipation, wooziness and other postoperative issues associated with opioid use. This effort has extended into postoperative prescribing as well. We’ve more than halved what we prescribe postoperatively over the past several years.