The explosion of computer applications has benefited the world in many aspects. It has also lulled many into a false sense of security that the computer has all the information. An unfortunately large number of patients believe that all their medical information is “in the computer,” irrespective of the area of the world they may come from and where their primary care doctor is located or the system is accessed. The name of the surgeon, the procedure to be performed, even the diagnosis is somewhere behind the screen. Especially missing is awareness by patients of which medications they are consuming and why it is important to share this information with anesthetic care providers before surgery. Indeed, many people presenting for surgery are much more familiar with the specifications of their automobiles than they are with the state of their bodies. To counter these deficits, patients should receive a document from their surgeons specifying the diagnosis and the planned surgery. They should be instructed that a list of their medications should be available during the preanesthetic interview. The internist or pharmacist who filled the prescriptions is often a good source for this information. Moreover, too few patients have been told that they have a right to the results of tests performed on them and rarely ask for copies of the findings.
At the other end of the spectrum are patients (a lesser number) who have used the computer extensively to research their condition, a situation that is welcome and usually to be encouraged, as it is certainly easier to care for a person who cares for himself. Although these informed consumers are often highly motivated, they may have gleaned their information from sources that are experimental or less reliable, prompting questions that may prove very difficult to answer or even providing inaccurate and misleading information (for example, “Don't use propofol because you will kill me, as happened to Michael Jackson”). Anxiety and misunderstanding can often be alleviated by a longer, customized discussion with the surgeon and anesthesiologist. Consent is obtained either from the surgical team, the anesthetic team, or both. Practice differs throughout the United States; in some anesthesia departments, a separate anesthesia consent is obtained and signed by the patient, whereas in others a notation is made and signed by the anesthesiologist that the risks and benefits of anesthesia and the options have been discussed and accepted by the patient. All members, including the nursing staff, are responsible to ensure that the patient or delegated proxy is aware of the surgery to be performed, the name of the surgeon, and the operated site. Multiple checklists are in existence to ensure the garnering of this information and are an integral part of the anesthetic record.
Anxiety and misunderstanding can often be alleviated by a longer, customized discussion with the surgeon and anesthesiologist.
Harking back to older times, many patients believe, often on information from doctors' offices, that the primary purpose of a preoperative evaluation is to give blood samples, undergo an electrocardiogram (EKG), and have a chest x-ray. Routine testing is generally considered to include EKG, complete blood count (CBC), urinalysis, chest x-ray, electrolyte screen, blood urea nitrogen (BUN) and creatinine (Cr), blood glucose level, type and screen, and a coagulation profile (prothrombin/partial thromboplastin time). One of the first large studies to challenge the usefulness of this routine preoperative laboratory screening was published as long ago as 1985.5 The authors assessed the value of screening 2000 preoperative patients over a 4-month period. All age groups were included. The tests ordered were much as above and included complete and differential blood cell counts, prothrombin time and partial thromboplastin time, platelet count, 6-factor automated multiple analysis, and glucose level. The authors estimated that 60% of these routinely ordered tests would not have been performed if testing had only been done for recognizable indications, and only 0.22% of these revealed abnormalities that might influence perioperative management, although no changes were made to the planned procedure. Chart review indicated that these few abnormalities were not acted on, nor did they have any adverse anesthetic or surgical consequences. Thus, the conclusions drawn more than 25 years ago were that in the absence of specific indications, routine preoperative laboratory tests contribute little to patient care, and can reasonably be eliminated. Even when an irregular result was revealed, therapy was not changed. Abnormal results were mostly ignored because the physician (or nurse manager) who had ordered the tests frequently did not read the results.
In a review article published some years later, one of the authors of the study cited above took the conclusions a little further.6 He pointed out that $40 billion a year (a figure that has now doubled) was spent in the United States on preoperative testing and evaluation, most of it a waste. Likening it to the statement “If a little epinephrine is good, more is better,” he wrote that this extra testing caused iatrogenic disease by pursuit and treatment of borderline and false-positive results, thereby increasing medicolegal risks (especially if an abnormal result is obtained and not acted upon) and decreasing the efficiency of practice. He remarked (perhaps with rather more than a little wishful thinking) that perioperative physicians could turn such inefficiency to advantage by showing patients and bureaucrats (the insurance companies and health maintenance organizations) that we can use inexpensive technology to reduce costs substantially and improve the quality of care. Unfortunately, at this point hospitals and specialists were and in some cases still are reimbursed for unnecessary testing, For example, a bill for stress testing, a study that is acknowledged by the American College of Cardiology to have restricted benefit, amounts to about $2300. A battery of tests including CBC, basic metabolic panel, chest x-ray, and EKG bills for about $1,600, not including the cost of specialist interpretation. In some instances, CMS and insurers will not reimburse for repeat testing and for tests based on age alone, placing the burden of payment on the patient. In other situations, CMS shoulders the enormous costs, almost arbitrarily. Change is slow to be realized, and further studies, both larger and more diverse, must be undertaken.
Studies that would accurately identify essential preoperative tests were devised. In one report, a protocol of administering tests only after application of certain criteria led to the performance of only 33% of “routine” tests.7 There were no adverse effects on the quality of care. These conclusions agree with the findings of the Chicago group that at least 60% of tests performed routinely preoperatively are useless as regards the need for gathering relevant information prior to an operation.5,6
Another investigation, published in 1991, evaluated the ability of preoperative laboratory testing to predict postoperative complications.8 Data collected from 520 patients undergoing elective surgery included American Society of Anesthesiologists (ASA) risk classification, body mass index, electrolyte values (including glucose), BUN/Cr values, blood counts, coagulation studies, total protein/albumin/lymphocyte count, EKG, chest x-ray, urinalysis, pulmonary function tests, type of anesthesia, and operation. The authors found that postoperative complications were strongly associated with higher ASA classification and increased duration and severity of the surgical procedure. The only preoperative tests that might, albeit not consistently, indicate postoperative complications were EKG, chest x-ray, and nutritional status. The conclusions drawn were that preoperative laboratory testing should only be undertaken for specific indications, and because patients at the extremes of life might be expected to require more serious surgical corrections and have more problems, age may be a factor to consider.
Adams and Weigelt studied 169 adults scheduled for elective hernia repair and again reviewed the usefulness of performing routine tests.9 The patients were divided into 2 groups. Group 1 had no disease except the hernia, and group 2 had evidence of another disease process. Abnormal results not predicted by history were found in 1% of group 1 patients and in 1.4% of group 2 patients (not significant). In only 2% of patients was anesthetic or surgical treatment altered by the findings. The authors felt that routine preoperative testing in this patient population was of little value. In a similar study of preoperative testing of patients prior to elective surgery, Macpherson found that the frequency of unanticipated abnormalities was too low to justify the practice pattern of routine testing10 and there was no evidence for an association between test abnormalities and perioperative morbidity. Chung et alwent further, based on analysis of 1061 patients who either had no testing or indicated preoperative testing.11 There was no increase in perioperative adverse events in either group.
Despite the evidence that routine testing is not warranted, batteries of laboratory evaluations continue to be ordered daily and patients informed that this practice is required. An earlier study from the Netherlands examined the effects of surgical- versus anesthesia-directed screening.12 More than 6000 patients were included (3122 patients for whom surgeons ordered the tests in 1991 and 3258 cases primarily directed by anesthesiologists in 1992). The percentage of patients subjected to laboratory tests, EKG, or chest x-ray decreased from 90%, 55%, and 50%, respectively, when the surgeon was in charge to 53%, 43%, and 10% when the anesthesiologist did the ordering (even when surgeons were allowed to add any tests that they felt appropriate). Admittedly, the surgeon was the first to see the patient and may have ordered more tests. Admission on the day of surgery and reduction in length of hospital stay were more likely in the group handled by anesthesiologists (day-of-surgery admission increased from 4% to 5% in 1992). There were no differences in surgical outcome between the groups. A recent but similar study showed yet again that about 50% of patients undergo unnecessary tests.13 Anesthesiologists were, on average, 60% less likely to order unnecessary tests as compared with surgeons from all specialties. However, anesthesiologists who completed training prior to 1980 were more likely to order tests that were not indicated. The authors concluded that the incidence of unnecessary testing is high despite efforts at improvement, but it may be reduced if anesthesiologists rather than surgeons order presurgical tests and consults. They warn that anesthesia groups should be cognizant of potential heterogeneity among them based on time since training. Comparison of costs, number of tests, rate of cancellation, and outcome between a group of patients for whom tests were ordered primarily by surgeons and a second group which was mainly controlled by anesthesiologists (still allowing surgeons the final say) indicated that far fewer tests were ordered by anesthesiologists. There was no increase in cancellation rate and no adverse outcome. On average, 72.5% of tests ordered by surgeons were considered not indicated by anesthesiologists.14
The incidence of unnecessary preoperative testing is high despite efforts at improvement, but it may be reduced if the presurgical tests and consults are ordered by anesthesiologists rather than surgeons.
Current guidelines at Mount Sinai Medical Center are for EKG in patients aged >50 years who are undergoing more invasive procedures, potassium levels in patients who have renal disease, blood sugar levels in all diabetics, and a pregnancy test in women of childbearing age. Other tests should be ordered when an underlying medical condition suggests that the surgery or anesthesia might be altered by an abnormal result. Blood should be typed and screened for large procedures. Chest x-ray is not required at any age. However, there is no national standardization for the amount, ordering, and timing of tests between institutions. Indeed, the guidelines at Mount Sinai Medical Center, as with many other hospitals around the United States, are often not followed.
There is no national standardization for the amount, ordering, and timing of tests between institutions. Indeed, the guidelines at Mount Sinai Medical Center, as with many other hospitals around the United States, are often not followed.
Acceptance of these protocols requires education of patients, families, surgeons, anesthesiologists, and other medical specialists. Also, patients attending a preoperative evaluation clinic should be asked to bring any recent laboratory study results. An arbitrary time frame of 6 months has been appended to the viability of these results, provided no interval change. Interpersonal collaboration might be improved by education obtained from joint conferencing and inviting speakers from different disciplines to address other specialties at grand rounds. Certainly this approach works at a grassroots level when anesthesiologists and surgeons engage in direct communication to discuss the management of a patient with a specific problem. The practice of subspecialization within anesthesia has had its critics but is valuable in that surgeons often come to rely heavily on anesthesiologists whom they know and trust to take care of their patients. The practice of including anesthesiologists in presurgical and postsurgical rounds allows better understanding for all parties and can decrease case cancellation and postoperative complications (personal experience over 25 years as director of neuroanesthesia at the Albert Einstein College of Medicine, NY).
Interpersonal collaboration might be improved by education obtained from joint conferencing and inviting speakers from different disciplines to address other specialties at grand rounds.