Institutional Implementation of a Collaborative Perioperative Pulmonary Hypertension Management Plan
Pullins E., Maxwell B., Kolb T.
Johns Hopkins University; Baltimore, Md.
To develop and implement a comprehensive, collaborative perioperative management plan for pulmonary hypertension (PH) patients undergoing invasive procedures requiring general anesthesia or moderate sedation.
Multiple studies have demonstrated increased rates of perioperative morbidity and mortality in patients with PH, especially those with pulmonary arterial hypertension (PAH). Despite the associated risks, there are currently no guidelines for perioperative assessment or management in PH patients. As quality of life and survival for PH patients is improved, there will likely be an increase in the number of desired and/or required procedures. We hypothesized that a collaborative approach with experts in cardiac anesthesiology (CA) might improve perioperative planning and outcomes for PH patients.
We have developed a multidisciplinary Perioperative PH Program, designed to facilitate early patient identification, provide medical optimization, and develop multidisciplinary surgical, anesthetic, and post-operative planning and training. Specific interventions included: 1) designation of a specific anesthesiology liaison for all PH patients requiring surgery; 2) expedited referrals to the Johns Hopkins PH Clinic for pre-operative assessment; 3) designated CA support for endoscopy; and 4) educational outreach to the Departments of Medicine, Anesthesia, and Surgery, as well as ICU nursing. The Perioperative PH Program was formally initiated on June 1, 2014. Data from the IRB approved Johns Hopkins PH Registry were reviewed for all patients undergoing endoscopic and surgical procedures at Johns Hopkins between January 2013 and May 2015 to determine whether cardiac anesthesia involvement increased and whether outcomes improved.
During the analysis period, 37 patients underwent 54 procedures requiring anesthesia; half of these procedures were performed prior to implementing the Perioperative PH Program, and half were performed after (n=27 in each cohort). Endoscopic (n=13 both pre- and post- 6/1/2014) and OR cases (n=14 both pre- and post- 6/1/2014) were included. While CA was involved in only 52% of all cases prior to 6/1/14, they were involved in 78% of cases after implementing the program. Among OR cases, CA involvement increased from 64.3% to 92.9%. When outcomes were compared between cases with CA and those without, there was no significant difference in the need for post-procedure hospitalization or subsequent length of stay. However, among perioperative PH patients requiring hospitalization, 30 day readmission rates decreased from 38% to 7% after implementation of the Perioperative PH program.
Implementation of a specific Perioperative PH Program led to increased CA involvement in operative and endoscopic procedures, and may be associated with reduced hospital readmission rates. Further studies are warranted to fully define the benefits of this unique collaborative relationship, and prospective registry data may provide powerful insight to clarify important predictors of perioperative risk in patients with PH.