Case Presentation: A 63-year-old man with polycystic kidney disease and bilateral renal masses was seen in our dedicated Pre-Operative clinic before a bilateral nephrectomy for renal cell carcinoma. In preparation for this surgery his nephrologist had placed a referral for community hemodialysis. However, regional wait times for community dialysis chairs averaged 2-3 months necessitating prolonged hospital admissions. The Pre-Operative clinic physician, who also held roles in hospitalist medicine and hospital capacity management, conferred with the referring surgeon who provided the patient with detailed Pre-Operative counseling and risk-benefit discussion around this issue. They determined the surgery should proceed as planned. The Pre-Operative clinic physician referred this patient to our Hospital-at-Home (HaH) program prior to hospitalization, which had a pathway for patients needing dialysis to do so at the “brick and mortar” inpatient dialysis unit while waiting for a community dialysis chair. He transferred to this program on post-operative day #4 where he continued inpatient hemodialysis and was able to continue virtually working from home. He was ultimately discharged from Hospital-at-Home after 41 days once a community dialysis chair was secured.
Discussion: Perioperative medicine is far more than the act of “clearance” before surgery and at its best, presents high value and cost savings opportunities by reducing complications and other strains on the health care system. High quality perioperative care integrates multidisciplinary skill sets, decreases post-operative length of stay, improves patient experience, and improves efficiency in delivery of care. Additionally, perioperative evaluations should ideally identify and mitigate potential discharge barriers, particularly given widespread hospital bed shortages which have been exacerbated by the COVID-19 pandemic, workforce shortages, and reduced post-acute placement options. HaH programs, which have expanded to include perioperative care, are well aligned with perioperative goals by alleviating hospital capacity strain, reducing cost, reducing readmissions, maintaining quality/safety, and improving patient experience for acutely ill adults requiring hospital care.
Conclusions: Perioperative is a systems-based practice, and when done best identifies opportunities to decrease LOS by preventing medical complications, but also by proactively identifying system level discharge barriers. This case also demonstrates the value of perioperative medicine experts having active roles in hospital and systems-based practice leadership positions as perioperative medicine can be a focal point to integrate patients care across many facets of a health system.