title: The Perioperative Surgical Home model facilitates change implementation in anesthetic technique within a clinical pathway for total knee arthroplasty.
abstract: BACKGROUND
  The challenge of knowledge translation in medical settings is well known, and implementing change in clinical practice can take years. For the increasing number total knee arthroplasty (TKA) patients annually, there is ample evidence to endorse neuraxial anesthesia over general anesthesia. The rate of adoption of this practice, however, is slow at the current time. We hypothesized that a Perioperative Surgical Home (PSH) model facilitates rapid change implementation in anesthesia.
  
  
  METHODS
  The PSH clinical pathways workgroup at a tertiary care Veterans Affairs hospital embarked on a 5-month process of changing the preferred anesthetic technique for patients undergoing TKA. This process involved multiple sequential steps: literature review; development of a work document; training of staff; and prospective collection of data. To assess the impact of this change, we examined data 6 months before (PRE, n=90) and after (POST) change implementation (n=128), and our primary outcome was the overall proportion of spinal anesthesia usage for each 6 month period. Secondary outcomes included minor and major complications associated with anesthetic technique.
  
  
  RESULTS
  Over a period of one year, there was an increase in the proportion of patients who received spinal anesthesia (13% vs. 63%, p<0.001). For the following year, 53-92% of TKA patients per month received spinal anesthesia. There were no differences in major complications.
  
  
  CONCLUSIONS
  Rapid and sustained change implementation in clinical anesthesia practice based on emerging evidence is feasible.
  
  
  CONCLUSIONS
  Perioperative Surgical Home model may facilitate rapid change implementation in surgical care.
  
  
  METHODS
  Cohort study, Level 2.
authors.affiliation: Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA, USA; Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Seshadri C
authors.initials: SC
authors.lastname: Mudumbai
authors.affiliation: Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA, USA; Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Tessa L
authors.initials: TL
authors.lastname: Walters
authors.affiliation: Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA, USA; Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Steven K
authors.initials: SK
authors.lastname: Howard
authors.affiliation: Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA, USA; Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: T Edward
authors.initials: TE
authors.lastname: Kim
authors.affiliation: Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA, USA; Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Gregory Milo
authors.initials: GM
authors.lastname: Lochbaum
authors.affiliation: Departments of Anesthesiology and Public Health, Weill Cornell Medical College, New York, NY, USA.
authors.forename: Stavros G
authors.initials: SG
authors.lastname: Memtsoudis
authors.affiliation: Department of Anesthesiology and Perioperative Care, University of California, Irvine, Irvine, CA, USA.
authors.forename: Zeev N
authors.initials: ZN
authors.lastname: Kain
authors.affiliation: Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA, USA; Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Alex
authors.initials: A
authors.lastname: Kou
authors.affiliation: Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: King
authors.affiliation: Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA, USA; Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: emariano@stanford.edu.
authors.forename: Edward R
authors.initials: ER
authors.lastname: Mariano
mesh_terms: D000368:Aged; D000758:Anesthesia / Q000379:methods*; D000768:Anesthesia, General; D000775:Anesthesia, Spinal; D019645:Arthroplasty, Replacement, Knee; D019091:Critical Pathways; D005260:Female; D006787:Hospitals, Veterans; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D018802:Patient-Centered Care; D019990:Perioperative Care / Q000009:adverse effects / Q000379:methods*; D011446:Prospective Studies; D012189:Retrospective Studies
keywords: Change implementation; Clinical pathway; Knee Arthroplasty; Outcomes; Perioperative Surgical Home; Spinal