Episode #11 Preoperative Optimization and Patient Safety

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining us for another show.

Today, we are going to explore the APSF Newsletter archives.  For this episode and future similar shows, we will take a look at past articles that were published in the APSF Newsletter that you can find on our website. Keep in mind that things may have changed a lot since the publication of these articles, but they are of interest from our archives.

I hope you have your cup of coffee ready or you are out on an invigorating walk as we get ready to explore the past by looking at an area that is so important for patient safety, Preoperative Optimization!!  Thank you to our followers on Twitter who responded that this was a topic that they wanted to hear about on this podcast!  Great idea @APSForg! There is so much to talk about related to preoperative optimization, but for our first show on the topic we are going all the way back to 2001 to look at the relationship between patient safety and production pressure and how this informs the preoperative assessment. Perioperative medicine has changed a lot since then which will give us plenty to talk about on future shows!

Before we dive into today’s episode, we’d like to recognize Fresenius Kabi, a major corporate supporter of APSF. Fresenius Kabi has generously provided unrestricted support as well as research and educational grants to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Fresenius Kabi – we wouldn’t be able to do all that we do without you!”

For the show today, we are going to review an article from our Spring 2001 newsletter.  You can find the article from the APSF homepage and clicking on the Newsletter section in the top banner. 4^th one down is Newsletter archives.  From here, scroll down until you get to Spring 2001 and then on the left you will see the article, Patient Safety and Production Pressure: Pre-op Assessment written by Robert Morell. I will link to the article in the show notes as well. We will start here, but this whole Newsletter is filled with additional information about the relationship between patient safety and production pressure and we hope that you will check it out!

This article appeared in our newsletter almost 20 years ago, but it is still relevant today especially as we continue to see growth in outpatient procedures in patients with significant comorbidities as well as same-day admit for patients with complex medical histories for complex surgical procedures.

How many of you have met a patient with morbid obesity, diabetes, coronary artery disease, end-stage renal disease, and/or severe pulmonary disease on the morning of surgery prior to a thoracotomy, craniotomy, coronary bypass surgery, pheochromocytoma excision, major spine surgery, or joint replacement surgery? I am sure that many anesthesia professionals can attest to this happening almost daily or weekly. This frequent scenario highlights the importance of the pre-op assessment as well as the challenges related to risk identification, risk stratification, and risk reduction.  It is also important to recognize the difference between elective surgical procedures and non-elective urgent and emergent procedures.  Just because a surgery is an outpatient procedure does not always mean that it is elective such as for plastic closure of open wounds following skin cancer excision.  In the face of a non-elective procedure there may not be time for risk reduction prior to bringing the patient to the OR for a timely and necessary procedure.  When there is time prior to surgery, preoperative patient preparation may be able to include evidence-based pre-op laboratory evaluation, informed consent, patient teaching and instruction, as well as time to answer questions and alleviate concerns.  This is such an important area for anesthesiologists since preoperative optimization goes hand in hand with the expectation that they can perform these functions in the most efficient and cost-effective way in order to maximize patient and surgeon convenience.  I am sure that some of you are nodding your heads because this probably sounds familiar.  Other considerations include expense of preoperative testing, manpower for preoperative clinics as well as shortages of anesthesia providers in certain areas and decreasing overall reimbursement by Medicare and third-party payers.

There are several different ways for anesthesia departments to perform preoperative evaluation and optimization. It depends on the practice setting, location, patient populations, and surgical procedures. Some practice models may be able to first see patients in the preop holding area immediately prior to surgery, but the risk of this strategy is increased number of last minute cancelations or pressure to go to the OR with patients who may not be optimized. Other method is preop telephone calls to screen patients and decide who need further preoperative evaluation and risk reduction. As we move into more labor intensive methods, some practices have physician assistants, nurses, and nurse practitioners who screen patients and evaluate the patients in an outpatient clinic setting before their surgery. Ideally, the timing of this preop clinic visit is far enough in advance of the surgery so that patients may be completely evaluated and optimized.

In the newsletter article, Morell describes his department’s preoperative assessment clinic which was modeled after Stanford.  This preoperative assessment clinic includes a full time anesthesiologist, two physician assistants, and intern, a resident, and a nurse clinician who evaluate more than 70 patients daily, or about 16,000 patients each year which represents over 60% of their total surgical volume.  Does this sound similar to your preoperative assessment clinic?  This type of clinic is expensive and needs to be subsidized.  This cost may be offset due to the decreased number of last minute surgical cancellations leading to increased convenience and efficiency for surgeons and OR staff. Another side effect of this type of clinic is that the anesthesia faculty may develop increased expectations for patients’ evaluation and preparation before surgery.

Creating and maintaining a preoperative assessment clinic comes with several significant challenges including scheduling patients in advance of the surgery and leaving time open for add-on patients, controlling the patient flow, managing complicated patients who require several additional consultations prior to surgery and all the while keeping in mind the feasibility for patients especially if they have to travel a far distance to the hospital. One method to control patient flow is to use an appointment system with a dedicated appointment scheduler just like any other doctor’s office for scheduling appointments.  One difference may be who calls to schedule the appointment since it must be scheduled in conjunction with the schedule for the surgery. For example, it may be the surgeon’s office who calls to schedule the preop assessment clinic visit and then the preop assessment clinic can reach out to the patient to given them a preoperative questionnaire and any other additional instructions. Don’t forget that the schedule will need to keep open slots for last minute add-on patients.  The clinic may use a tiered system based on the patient’s medical history and planned surgical procedure. It is important to use evidence-based algorithms and clinical reasoning to come up with a plan for preoperative testing and consultation.  At the author’s institution, the preop clinic partnered with the department of medicine and the internal medicine residency program so that a senior medicine resident, precepted by a medicine faculty member, evaluated complex medical patients to help with the optimization and recommendations prior to surgery.

Appropriate preoperative patient assessment and optimization is so important for patient safety. Each anesthesia department and healthcare system must decide the best way to accomplish this depending on the surgeries, patients, economics, and hospital system. While this is an expensive endeavor, the benefits include patient safety first and foremost as well as increased surgical and hospital efficiency, risk management processes, and patient satisfaction. In the face of increased production pressure and increased outpatient surgery options and same-day admit surgeries, the need for appropriate preoperative assessment and optimization is even more important.

To round out this episode, we are going to take a look at a letter to the editor from October 2014 Newsletter that you can find from our Newsletter heading, then 4^th one down is the Newsletter archives, and scroll down and click on October 2014. On the left, you will see letters to the editor.  We are going to look at the letter by Adam Blomberg, MD entitled “Education Improves Patient Satisfaction and Patient Safety.” Another important component of the preoperative assessment is preoperative education and this will also yield increases in patient safety, which we are all about here at the APSF.  Blomberg writes anesthesiologists and members of the anesthesia team can have an important role for preoperative patient education and improved patient safety and satisfaction. Patients who know what to expect for surgery and anesthesia will feel more in control and may have less anxiety. Ultimately, improved patient education may help patients to view the anesthesiologist as a resource who they know and trust. In addition, by providing an overview for a patient about their options for anesthesia, it helps to set and meet expectations throughout the perioperative time period.

Now, what about patient safety? When the preoperative visit includes a medical assessment as well as an education component, there is improved communication between patients and anesthesiologists and the more we know about patients, the more we can provide anesthesia care that is safe and specific for our patients in an effective way. In addition, providing preoperative education given patient greater control over their care and leads to better outcomes.  One of the best examples of this is laterality. When patients know that their site will be marked and that the block site will be marked on the same side, then the patient can serve as an extra safe guard to make sure that everything happens on the correct side…all because they were empowered with their preoperative education and expectations.

Before we wrap up for today, I am going to review the key topics to address for preoperative patient education to improve patient safety. This is a checklist that Blomberg included in his letter to the editor.  First, it is important to provide information about the anesthesia options if there are options depending on the patient and the surgery and how these options will affect their surgery and recovery. Next, it is important to provide information about the surgical team including what role each of the caregivers will play in the patient’s surgery. Another important component is to define a clear preoperative plan for patients including understanding the importance of laboratory testing and consultation with specialists, adherence to medical management and other established guidelines such as NPO guidelines.  You want to make sure that your patients understand the fasting guidelines for liquids and solids so that there is no delay on the morning of surgery. The next step is to educate patients about the vital signs and lab results that various physicians will be monitoring throughout the perioperative time period.  Another important education component is the immediate side effects from anesthesia and surgery as well as what to expect for the recovery process.  Finally, it is important to make sure that patients have contact information for someone in the anesthesia department who they can call if they have any questions or concerns before they come to the OR for their surgery.  Blomberg leaves us with a final thought and it really highlights the relationship between patient education and safety, and I will read it now: “Educating patients and involving them in surgical structuring and standardizing communication throughout the perioperative process will provide a roadmap and encourage increased dialogue that will insure critical information is shared and confirmed, ultimately making surgical procedures safer for patients.”

That’s all the time we have for today!! Thank you so much for joining us today on this journey towards improved patient safety. If you have any questions or comments from today’s show, please email us at [email protected].

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.  Plus, you can find us on twitter @APSForg.  Follow along with us for additional patient safety information tweets!! If you are enjoying listening to this podcast, please rate us and leave us a review!! We are so excited to continue to grow our Anesthesia Patient Safety Foundation Family!

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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