To the Editor:
Standardizing evidence-based best practices is a key to delivering high-value, efficient care that promotes patient satisfaction. However, that standardization should not be a one-size-fits-all approach, which can have negative implications for outcomes and safety.
Preadmission Testing (PAT)
Traditionally, preadmission testing had tremendous variability. Surgical teams often would “test everyone for everything” to help prevent cancellations. Even today, overuse remains a patient safety issue. Providers often perform tests that have a low positive predictive value and, in many cases, may result in little clinical value. To avoid unnecessary testing and the complications that can result from pursuing false positive test results, lab tests should be done based on clinical indications and the positive and negative predictive values of relevant tests. PAT processes should be both standardized and tailored to the individual patient’s context and specific comorbidities. A preadmission testing system we developed four years ago at Sheridan Healthcare (now Envision Physician Services) includes a workflow to help anesthesia professionals quickly and efficiently determine a personalized list of the tests and exams needed to ensure each patient’s surgical readiness, based on surgery type, medical history, and comorbidities. This removed variability and significantly reduced unnecessary testing, false positives, and associated risks at our partner hospitals.
A thorough and streamlined process for scheduling cases appropriately to make sure all the necessary equipment and personnel are available is needed. Double-checking the availability of both equipment and personnel at least one day prior to surgery can mitigate case delays and cancellations that can affect timely patient care.
Multimodal Pain Management
Creating standardized, evidence-based processes for multimodal pain management is becoming an increasingly important way to promote patient satisfaction, throughput, and safety. The more we learn about effective ways to control acute perioperative pain using non-narcotic adjuvants, the more we can decrease the use of opioids, reducing patients’ exposure to the potentially serious adverse effects of those drugs.
Handoffs are often incomplete and/or inconsistent because of production pressure and a lack of standardization. Having every provider do a correct and complete handoff to the next provider in a standardized manner—so that, for example, every PACU or ICU nurse who receives a patient from an anesthesia provider fully understands the patient’s acute and chronic issues—may result in decreased variability and better patient outcomes.
Protecting Patients While Increasing Efficiency
Health care providers are being pushed to do everything faster, better, and less expensively. But we still need to protect our patients and make sure we’ve performed effective time-outs. In other words, we need to “slow down (when it matters!) while speeding up” to make sure that none of the things we used to do for patient safety are missed because of speed.
Standardizing our use of The Joint Commission’s Universal Protocol decreases variability and protects patients during surgery. Standardizing evidence-based best practices throughout the perioperative period and turning them into checklists or other tools for clinicians is the most efficient, consistent way to ensure that no step is missed that could jeopardize patient safety. Encouraging a culture of safety, participation, and mindfulness during these processes is critical to their success.
Adam L. Blomberg, MD, is the Chief of Anesthesiology for Memorial Regional Hospital in Hollywood, Florida, the Vice-Chief of Anesthesiology for Memorial Healthcare System, and the National Education Director for Envision Physician Services’ Anesthesia Division.
Dr. Blomberg has no conflicts of interest to declare regarding the content in this article.