Patient Safety and Production Pressure: Pre-Op Assessment

Robert C. Morell, MD

The past 15 years have witnessed a tremendous growth in outpatient and same-day-admit surgery. Relatively few patients are admitted to the hospital prior to the day of elective surgery. We have become increasingly tolerant of outpatients with significant co-morbidity presenting for increasingly complex surgical procedures. At many institutions patients with morbid obesity, brittle diabetes, severe coronary artery disease, end-stage renal disease, and/or severe pulmonary disease arrive on the day of their surgery for increasingly complex procedures. These may include thoracotomy, craniotomy, coronary bypass surgery, pheochromocytoma excision, and major spine or joint replacement surgery. This scenario presents tremendous challenges for preoperative assessment which include the processes of risk identification, risk stratification, and risk reduction. Not all ambulatory procedures are elective. Patients can present for plastic closure of open wounds resulting from recent excision of skin cancers. Non-elective procedures may reduce or eliminate the opportunity for risk reduction strategies. Preoperative patient preparation also includes evidence-based preoperative laboratory testing, informed consent, and patient teaching and instruction. Anesthesiologists are expected to perform all of these functions in an efficient, cost-effective fashion with primary attention to maximum patient and surgeon convenience. The expense and manpower requirements associated with delivering these necessary services are usually born by the anesthesia department, generally without reimbursement or subsidization. This burden is compounded by widespread chronic shortages of anesthesia providers and decreasing overall reimbursement by Medicare and third-party payers.

Different anesthesia departments deal with these issues in differing ways. Seeing patients in the holding room immediately prior to surgery can be a workable model for some practices, but may result in a high number of last minute cancellations or pressure to proceed with inadequately prepared patients. Other groups use telephone screening to identify subsets of patients requiring more intensive preoperative assessment or risk reduction. Still other practices utilize physician assistants, nurses, or nurse practitioners to screen or evaluate outpatients prior to their day of surgery. Our academic practice has a preoperative assessment clinic (PAC) that includes a dedicated anesthesiologist FTE, two physician assistants, one intern, one resident, and one nurse clinician who evaluate and prepare over 70 patients per day, translating into approximately 16,000 patients per year, which accounts for over 60% of our total surgical volume. Obviously, this is expensive and requires significant departmental subsidization to accomplish. What is the justification for such expenditure? This model has resulted in a significantly decreased number of last minute cancellations, increased convenience and efficiency for surgical faculty and the operating room. Ironically, it has also resulted in an increased level of expectation by the anesthesia faculty regarding preoperative patient evaluation and optimization. Our system developed in parallel and is similar to that used at Stanford.1,2

The logistics of providing such a service are significant. Challenges include accommodating add-on patients, controlling patient flow, managing complex patients requiring medical, cardiac, or pulmonary consultation, and being attentive to patient convenience, particularly for those who live far away. In order to control patient flow our clinic developed its own separate appointment system, with a dedicated appointment scheduler. This model is similar to that utilized by virtually all physician offices. The surgeon’s representative calls the PAC and establishes an appointment for the patient, who is given a preoperative questionnaire and instructional material. The scheduling grid contains open slots, which are available to accommodate last minute add-on patients.

Patients are triaged into a color-coded three tiered system based on patient co-morbidity and the planned surgical procedure. Evidence-based algorithms and reasoning are utilized to decide upon preoperative testing. No “routine” preoperative tests are required. A relationship has been developed with the internal medicine residency program to include senior level medicine residents (precepted by IM faculty) in the evaluation of complex patients with high-risk co-morbidity.

The decision to utilize this or any type of preoperative assessment paradigm is practice-dependent. Each department must analyze its own level of surgical acuity, patient demographics, economics, and hospital relationship to reach this decision. Economics play a major role in determining what resources are available for the preoperative process. It is fundamental to patient safety and clearly delineated in our practice standards and guidelines that all patients have appropriate preoperative assessment.3 HCFA regulations and compliance issues further complicate this process. Increasing pressure exists to maintain and likely expand the scope of outpatient and same-day-admit surgery. We must continue to insure safe and appropriate preoperative assessment. The cost associated with doing so will not go away. Models exist where surgical departments and/or hospital administration provide financial support for these necessary and vital aspects of patient care and patient safety. It must be recognized that dedication to our principals benefits surgical efficiency, hospital efficiency, risk management processes, patient satisfaction, and, most importantly, patient safety.

References

  1. Fischer SP. Cost-effective preoperative evaluation and testing. Chest 1999;115:96S-100S.
  2. Pollard JB, Olson L. Early outpatient preoperative anesthesia assessment: does it help to reduce operating room cancellations? Anesth Analg 1999;89:502-5.
  3. Standards of the American Society of Anesthesiologists: Basic Standards for Preanesthesia Care. In: American Society of Anesthesiologists 2001 Directory of Members. Park Ridge, IL: American Society of Anesthesiologists, 2001:493.