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Keywords:

  • data accumulation;
  • interpersonal collaboration;
  • preoperative assessment;
  • preoperative testing.

Abstract

  1. Top of page
  2. Abstract
  3. PATIENTS
  4. FAMILIES
  5. PRIMARY CARE PROVIDERS
  6. SPECIALISTS
  7. ASSEMBLY AND INTERPRETATION OF INFORMATION
  8. CONCLUSION
  9. DISCLOSURES
  10. References

The enormous diversity of physician practices, including specialists, and patient requirements and comorbidities make integration of appropriate perioperative information difficult. Lack of communicating computer systems adds to the difficulty of assembling data. Meta analysis and evidence-based studies indicate that far too many tests are performed perioperatively. Guidelines for appropriate perioperative management have been formulated by several specialties. Education as to current findings and requirements should be better communicated to surgeons, consultants, and patients to improve healthcare needs and at the same time decrease costs. Means to better communication by interpersonal collaboration are outlined. Mt Sinai J Med 79:3–12, 2012.© 2012 Mount Sinai School of Medicine

“On feeling the pulse of a gentleman about twenty-one years of age, in March 1855, who had just seated himself in the chair to take chloroformI found it to be small, weak, and intermitting, and it became feeble as I was feeling it. I told the patient he would feel no pain and that he had nothing whatever to apprehend. His pulse immediately improvedNow if the inhalation had commenced without inquiry or explanation, the syncope which seemed approaching would probably have taken place, and it would have had the appearance of being caused by the chloroform, although not so in reality.”1

Although Dr Snow may not have been the first physician to evaluate the patient prior to administration of anesthesia and to communicate his findings to others (in the case above to Mr Thos. A. Rogers, a dentist), he was among the first to demonstrate the importance of physical (and psychological) examination.

The concept of preoperative outpatient evaluation is hardly new. Lee proposed an anesthetic outpatient clinic in 1949, and in 1954 Loder and Richardson analyzed 500 patients seen on an outpatient basis.2,3 In 1972, in an attempt to reduce hospital stay and cost, a preadmission evaluation clinic was initiated at the Bronx Municipal Hospital Center in New York.4 Average hospital stay for patients undergoing total abdominal hysterectomy in 1972 was 13.21 days, and for breast mass excision 6.62 days. Over 3 years, >3500 patients were seen, and the average patient hospital stay decreased by 3.9 days. Although the clinic was run through the department of anesthesia, greatly improved perioperative care was attributed to close interdepartmental cooperation, especially with medicine. No complications could be identified for patients, but the major problem of continuing the clinic was financial. In 1975 a hospital day was reimbursed at about $200 per day. A clinic visit received only $40. Thus, outpatient evaluation could cost a hospital doing 8,000 cases annually (assuming 25% were seen as outpatients initially) up to $1.6 million as beds lay fallow. Savings could be seen as a benefit mainly to patients in terms of less lost work time and greater efficiency. Nevertheless, as ambulatory surgery grew, times changed and with them the need for preadmission assessment. Hospitals with enormous bed sizes (often >2000) were forced to downsize. Ambulatory surgical admissions changed from close to 0% to almost 75%. Reimbursement was restructured. With passage of Public Law 92-603, preadmission evaluation for certain groups of patients became mandatory. Insurance carriers, especially the Centers for Medicare and Medicaid Services (CMS), asked for justification of in-hospital days and often denied them. Anesthetic agents became safer, return to the preoperative state became quicker, and a more comprehensive understanding of pain management and control of nausea and vomiting allowed for earlier discharge. Surgical techniques became less invasive. The idea of “medical clearance” was questioned, as was the need for general application of so-called routine tests. Patients appreciated that hospitals carried risks of their own, including infection. In a down economy, absence from work was costly.

With so many radical changes, it is not surprising that some entities, including patients, healthcare practitioners, and hospital administrators, are confused and still cling to the older and accepted practices. Some are anxious to adopt and adapt to new guidelines, especially as evidence-based medicine has become the mantra of today's practice. For others, financial considerations may be a motivating factor. As a result, meaningful communication has declined. Re-evaluation and integration of perioperative information from all sources is necessary to improve patient care in these changed times. Appreciated also must be the appropriate focus for assembly and interpretation of perioperative information, whether it be by computer file or in a preanesthetic assessment clinic, the surgeon's office, or the holding area prior to surgery.

Reevaluation and integration of perioperative information from all sources is necessary to improve patient care in these changed times.

PATIENTS

  1. Top of page
  2. Abstract
  3. PATIENTS
  4. FAMILIES
  5. PRIMARY CARE PROVIDERS
  6. SPECIALISTS
  7. ASSEMBLY AND INTERPRETATION OF INFORMATION
  8. CONCLUSION
  9. DISCLOSURES
  10. References

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.

Preoperative Testing

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.

FAMILIES

  1. Top of page
  2. Abstract
  3. PATIENTS
  4. FAMILIES
  5. PRIMARY CARE PROVIDERS
  6. SPECIALISTS
  7. ASSEMBLY AND INTERPRETATION OF INFORMATION
  8. CONCLUSION
  9. DISCLOSURES
  10. References

Family members can be an enormous source of information, especially when the patient has cognitive dysfunction or is in other ways handicapped. Medication lists, an accounting of activities of daily living, and past medical and surgical histories may all be revealed. For many patients it is not only comforting, but also essential, to have family members around for practical reasons, such as transportation during outpatient procedures. A family member is also often the one to whom postsurgical information is imparted and the one entrusted to fill prescriptions for immediate care.

However, the Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires that patients be advised that they have the right to exclude family members from discussions with healthcare providers. Although few choose to do so, their rights must be disclosed. Problems arise when a language barrier exists and an older patient is accompanied by a younger family member who wishes (or even insists) to act as interpreter. It is appropriate to contact an impartial service to provide interpretation and to verify, when the patient is alone, that he or she does not object to the family member's presence. A recent report describes experience with a computerized system to communicate in other languages.15 A software application categorically grouped phrases, spoken by a native to that language, and allowed caregivers to select a phrase and play the associated sound file to the patient. The program is deployed on a touchscreen-enabled anesthesia information management system workstation.

Parents are often understandably anxious about their children and may feel pressured or indeed entitled to accompany them into the operating room. Contrary to popular belief, in most cases parental presence does not alleviate parents' or children's anxiety.16 In rare instances when concern is diminished, premedicating children with oral midazolam or distracting them with video games has been shown to be a viable alternative.

PRIMARY CARE PROVIDERS

  1. Top of page
  2. Abstract
  3. PATIENTS
  4. FAMILIES
  5. PRIMARY CARE PROVIDERS
  6. SPECIALISTS
  7. ASSEMBLY AND INTERPRETATION OF INFORMATION
  8. CONCLUSION
  9. DISCLOSURES
  10. References

The patient's internist or primary care physician is in the best position to offer pertinent information that will impact perioperative care. The ASA Practice Advisory for Preanesthesia Evaluation states: “It is an obligation of the healthcare system to, at a minimum, provide pertinent information to the anesthesiologist for the appropriate assessment of the severity of the medical condition of the patient.”17 Therefore, the onus of information-gathering should not be incurred by anesthesiologist, but by the patient's internist or surgeon. However, in practice this ideal is often not realized because of lack of computer link-up, poor record-keeping, change of office venues, and lack of fundamental medical care, among other reasons. In the absence of a direct computer link to the surgeon's office or the preanesthetic clinic, medical information should be sent by other means to both areas and, even more importantly, copies of all medical records should be given to the patient with instructions to present them to attending surgeons and the anesthetic care team. It is also the obligation of the primary care provider to ensure that the patient and often also family members are aware of the patient's condition and the reason for any prescribed medications and tests. Results of laboratory findings should be made available to the patient, again with the instruction to make them known to other healthcare providers. Thus, the need to repeat tests is decreased, as most laboratory studies are valid for at least 6 months. In years to come, computer chips may be implanted in everyone, making it unnecessary to carry paper records or amass various computer files.

The patient's internist or primary care physician is in the best position to offer pertinent information that will impact perioperative care.

SPECIALISTS

  1. Top of page
  2. Abstract
  3. PATIENTS
  4. FAMILIES
  5. PRIMARY CARE PROVIDERS
  6. SPECIALISTS
  7. ASSEMBLY AND INTERPRETATION OF INFORMATION
  8. CONCLUSION
  9. DISCLOSURES
  10. References

Prior to surgery, consultation is frequently sought from several sources.

Surgeons

The surgeon is usually the specialist with the most information, generated from his or her own consultation, referral information from the primary care physician or other specialists, and preexisting laboratory studies. This information is often maintained in paper records, but in some offices computerized files allow dissemination within an area determined by the compatibility of the software systems. In this regard, there is yet much to be done to achieve better and wider communication and at the same time ensure the privacy of individuals. Despite the possession of much patient information, surgeons frequently defer to the judgment of other specialists prior to surgery, especially in older patients. Such referrals may be made based on fear of litigation, at the request of the patient, for completeness of the record, because of uncertainty about the patient's health status or a belief that it is institutional policy, or as a routine. Regarding medicolegal consequences, additional testing may have adverse consequences. Not only may insurance carriers refuse to pay for tests based on age alone—putting the financial responsibility on the patient—but also some studies may actually be dangerous. For example, should a stress test in a patient with coronary artery disease trigger ventricular fibrillation and death, the family could sue successfully if this possible outcome had not been discussed.

The surgeon is usually the specialist with the most information, generated from his or her own consultation, referral information from the primary care physician or other specialists, and preexisting laboratory studies.

Particular attention has been paid to cataract surgery, as it is generally carried out in older patients with other comorbidities. To address the generally accepted doctrine of routine testing for all older patients, a North American national survey of randomly selected ophthalmologists, anesthesiologists, and internists was conducted.18 Responses were obtained from 538 (82%) of 655 eligible ophthalmologists, 109 (76%) of 143 anesthesiologists, and 54 (44%) of 122 internists. Fifty percent of ophthalmologists, 40% of internists, and 33% of anesthesiologists frequently or always obtained chest x-rays, whereas 20% of ophthalmologists, 27% of internists, and 37% of anesthesiologists never obtained chest x-rays unless dictated by another medical condition (P < 0.01 for differences between ophthalmologists and other specialists). Similarly, 90% of ophthalmologists, 79% of internists, and 41% of anesthesiologists frequently or always obtained a CBC, electrolyte panel, and EKG. On the other hand, 11% of ophthalmologists, 17% of internists, and 28% of anesthesiologists never obtained these tests. The majority of responders (32%–80%) believed that the tests were unnecessary but cited many reasons for doing them (eg, medicolegal considerations, institutional policy, general screening for the elderly). Such preoperative evaluation was also viewed as a good opportunity to check patients who were liable to have disease processes, while acknowledging that life-threatening conditions such as prostatic cancer screening and mammography were not addressed. Also, each specialist thought that the other 2 physicians required the tests and that the hospital had regulations mandating them preoperatively. This latter view is also widely held by nurses who are responsible for checking that all requirements have been fulfilled before the patient enters the operating room. Another study of 19,557 patients showed that routine testing is of no value or importance in this geriatric, cataract-removal patient population.19 Patients were randomly assigned to 2 groups: one group underwent a complete battery of tests (EKG, CBC, serum electrolytes, BUN, Cr, and glucose), and in group 2 no tests were done. A complete history and physical examination was undertaken in all patients. Adverse medical events and interventions on the day of surgery and during the 7 days after surgery were recorded. The most frequent medical events in both groups were treatment for hypertension and bradycardia. The overall perioperative complication rate between the 2 groups was the same, at 31.3 events per 1000 operations. There were no differences in the incidence of intraoperative events (19.2 and 19.7 events, respectively, per 1000 surgeries) or postoperative problems (12.6 and 12.1 per 1000 surgeries). Analyses stratified to age, sex, ASA classification, and medical history revealed no benefit to the tests performed. In other words, routine medical testing before cataract surgery does not measurably increase the safety of surgery. In fact, in many cases, test results, which had been sealed and taped to the hospital chart, were still unopened at the time of discharge. Liability is considerably increased if tests have been ordered for a specific reason and the results not read and/or acted upon by the practitioner.

Cardiologists

Prior to more invasive surgery and in older patients, cardiology consultation is often sought. For consultation, key questions should be identified to ensure that all of the perioperative caregivers are considered when providing a response.20 Several studies suggest that such an approach is not always taken. A multiple-choice survey regarding the purposes and utility of cardiology consultations was sent to randomly selected New York metropolitan-area anesthesiologists, surgeons, and cardiologists.21 There was disagreement on the importance and purposes of a cardiology consultation on general topics such as what might constitute intraoperative monitoring, “clearing the patient for surgery,” and advising as to the safest type of anesthesia and avoidance of hypoxia and hypotension. This advice was regarded as important by most cardiologists and surgeons but as unimportant by the majority of anesthesiologists. Thus, consultation reports may be disregarded by segments of the healthcare team and even viewed as insulting. Also, the charts of 55 consecutive patients aged >50 years who received preoperative cardiology consultations were examined to determine the stated purpose of the consultation, recommendations made, and concordance by surgeons and anesthesiologists with the recommendations. Of the cardiology consultations, 40% contained no recommendations other than “proceed with case,” “cleared for surgery,” or “continue current medications.” A review of 146 medical consultations suggested that the majority of such consultations give little advice that impacted either perioperative management or outcome of surgery.22 In only 5 consultations (3.4%) did the consultant identify a new finding; 62 consultations (42.5%) contained no recommendations. Recently, several leading cardiologists have noted that “cardiac clearance” must be further defined. For example, in high-risk situations such as the pregnant patient with escalating pulmonary hypertension, cardiology consultation immediately prior to termination or delivery is certainly indicated, and even essential. In such circumstances, the consult request is better worded specifically: that is, “the surgery with anesthesia is indicated (or essential); can this patient's cardiac condition be improved?” Therefore, careful history-taking and physical evaluation by the anesthesiologist and surgical team preoperatively are essential, as not only can situations change over a few weeks, but factors that are critical in perioperative management may appear of less significance to the cardiologist. Recent developments, based on the revised Lee cardiac risk index, note that routine stress testing is not indicated prior to vascular surgery and should be reserved for patients with ≥3 risk factors (high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin-dependent diabetes, renal failure, hypertension, and age >75 years) if the surgery can be delayed.23

A special situation arises in patients with drug-eluting coronary stents. Clopidogrel and aspirin are usually administered to prevent clotting. Clearly, such a situation might not be compatible with major surgery, and medication should be modified, days in advance. Also, a prior history of placement of a pacemaker or implantable cardioverter-defibrillator should be investigated and the type of device identified so that compatibility with cautery can be assured. This information must be clearly available to the perioperative team.

Current recommendations regarding continuing drug therapies are24:

  • 1.
    If the patient is medicated with statins and/or beta-blockers, these medications should be continued.
  • 2.
    Beta-blocking therapy should not be started de novo.
  • 3.
    Some clinicians advise discontinuing angiotensin-converting enzyme inhibitors on the day before surgery.
  • 4.
    Patients with a bare-metal stent should not have surgery for a month, and patients with a drug-eluting stent should continue clopidogrel for a year, and perhaps even longer.

Pulmonologists

The presence of either obstructive or restrictive pulmonary disease places the patient at increased risk of developing perioperative respiratory complications, compounded by long surgery and obstructive sleep apnea. Hypoxemia, hypercapnia, acidosis, and increased work of breathing can all lead to further deterioration of an already-compromised cardiopulmonary system. If significant pulmonary disease is suspected, documentation of response to bronchodilators and/or evaluation for the presence of carbon dioxide retention through arterial blood gas analysis may be justified. If there is evidence of infection, appropriate antibiotic therapy is critical. Steroids and bronchodilators may be indicated, although the risk of producing dysrhythmias or myocardial ischemia by beta-agonists and hyperglycemia must be considered. Complete abstinence from tobacco intake for several weeks prior to surgery would be ideal to allow regeneration of lung function, but is rarely possible. A carboxyhemoglobin level of 15% can reduce the availability of oxygen by up to 25%, and although this level may not be significant in asymptomatic patients, it may present a considerable risk for patients with coronary artery disease, in whom a favorable myocardial balance is critical. These patients should be advised to refrain from smoking for at least 24 hours prior to surgery. Though pulmonary function tests are not usually helpful in predicting postoperative pulmonary events or the need for mechanical ventilation (except perhaps in morbidly obese patients presenting for bariatric surgery), a low preoperative oxygen room air saturation may identify patients at higher risk. Other important factors in determining postoperative pulmonary complications include the site and duration of the surgical procedure and the amount of blood lost. Preoperative pulmonary therapy might be useful, if only to acquaint the patient with the several tools that may be used in the postoperative period to maintain oxygenation. Patients with a history of asthma but who are not actively wheezing usually do not present any additional risk for anesthesia. However, bronchospasm may develop in response to intubation or oral manipulation. Pneumothorax is a common complication after lung biopsy, occurring in about 40% of cases.25 Patient factors include greater age, male sex, history of ipsilateral lung surgery, and grade of emphysema. Procedure factors include lower locations, needle type, greater number of pleural punctures, pleural angle, longer length of needle in aerated lung, and greater number of harvesting attempts. Ultrasound imaging and reduction of aspirated volume reduce the risk.26 Lung resection increases the risk of contralateral pneumothorax, especially in patients with emphysema and continued smoking history.27 Accurate and early diagnosis by increased awareness of the complication, auscultation, and chest x-ray are essential.

Anesthesiologists

As has been reported in many studies cited above, the role of the anesthesiologist in ordering tests and integrating information prior to surgical intervention is key. It stands to reason that the only individual qualified and legally able to “clear” a patient for anesthesia is the anesthesiologist. Preanesthetic assessment is a critical part of the anesthetic process and must be customized to each patient. In a preoperative assessment clinic, a member of the anesthetic team, whether it be an attending anesthesiologist, a resident, or a certified registered nurse anesthetist, is able to spend time with patients to determine what if any further tests, evaluations, or consultations are indicated. Moreover, the ability to be able to explain the anesthetic process in a quiet setting can immeasurably enhance a patient's understanding and peace of mind.

The only individual qualified and legally able to “clear” a patient for anesthesia is the anesthesiologist.

Endocrinologists

The importance of glycemic control has been emphasized, as perioperative morbidity and mortality increase with hyperglycemia.28,29 Patients inadequately controlled by current medication should be referred to an endocrinologist to better manage glycemic levels, especially prior to carotid endarterectomy.

Pain Management Specialists

Preoperative assessment must include a plan for postoperative pain management. Most patients anticipate pain after surgery, and the ideal of pain-free surgery is far from realized. Patients often request pain consultation preoperatively, and there is much to offer. Pain departments may be part of anesthesia departments or freestanding within the hospital. Plans for patient-controlled intravenous or epidural analgesia, regional techniques, or implanted pumps should be made and available for review by the operating team to allow adjustments in anesthetic or surgical technique. A significant limit to the ability to perform surgery on an outpatient basis has been the need for pain management. A recent study has incorporated thoracic paravertebral block with gabapentin and celecoxib to successfully allow discharge on the same day following mastectomy.30

Preoperative assessment must include a plan for postoperative pain management.

ASSEMBLY AND INTERPRETATION OF INFORMATION

  1. Top of page
  2. Abstract
  3. PATIENTS
  4. FAMILIES
  5. PRIMARY CARE PROVIDERS
  6. SPECIALISTS
  7. ASSEMBLY AND INTERPRETATION OF INFORMATION
  8. CONCLUSION
  9. DISCLOSURES
  10. References

The question as to where and how perioperative information can best be collected has been debated. Given the diversity of practice and needs of patients, one site does not fit all. Information can be gathered in surgeons' offices, in preanesthetic clinics at an interview prior to or on the day of surgery, by telephone consultation, or by computer-generated health assessment questionnaire. One company, Epic Systems, established in 1976 in Madison, WI, provides healthcare-management software that attempts to integrate financial and clinical information across inpatient, ambulatory, and payer technology systems. Products include scheduling and registration tools, billing and managed care administration applications, inpatient and outpatient core clinical systems, electronic medical records applications, and software for managing hospital pharmacy, emergency, surgery, radiology, laboratory, and intensive care departments. Within a hospital system, much information can be generated and shared. However, many patients have primary care physicians and other healthcare providers outside the hospital. The cost of incorporating the program in a 2- to 3-doctor practice might well be financially prohibitive (exceeding $60,000), and thus delayed.

The question as to where and how perioperative information can best be collected has been debated. Given the diversity of practice and needs of patients, one site does not fit all.

A greater need for interprofessional collaboration (IPC) has been identified.31 However, these authors conclude that although practice-based IPC interventions can improve healthcare and outcomes, limitations in terms of small numbers of studies, sample sizes, problems with conceptualizing and measuring elements of IPC, and heterogenicity of interventions and settings make it difficult to generalize inferences about effectiveness. Other studies have emphasized the need for knowledge translation.32 A common core data set for preoperative evaluation has been suggested to solve the problem of data exchangeability, given that at present there is wide variation in the amount and types of information collected.33 Virtual outreach in the United Kingdom through videoconferencing has been shown to improve healthcare.34 Patients underwent joint teleconferencing where they and their primary care physician consulted with the specialists via videolink between the hospital and the practice.

CONCLUSION

  1. Top of page
  2. Abstract
  3. PATIENTS
  4. FAMILIES
  5. PRIMARY CARE PROVIDERS
  6. SPECIALISTS
  7. ASSEMBLY AND INTERPRETATION OF INFORMATION
  8. CONCLUSION
  9. DISCLOSURES
  10. References

The groundwork for the integration of perioperative information from divergent sources is available, but its incorporation into practice is far from complete. More education is needed for all the players. Patients must be made more aware of a responsibility to themselves to be aware of their medical condition. Healthcare workers know that patients have the right to their medical records and freely provide these documents. Anesthesiologists, surgeons, and consultants should be knowledgeable about large randomized trials that indicate preoperative testing can be minimized or even omitted in many situations, thus substantially decreasing the size of the patient record. Standardization of common core data collection, either by paper records or by communicating and user-friendly computers, must be developed. Interspecialty collaboration can be improved through joint conferencing, allowing an understanding of specific needs. As healthcare costs spiral out of control, more can be done to curb these costs in the perioperative setting by integrating, rather than duplicating, services.

References

  1. Top of page
  2. Abstract
  3. PATIENTS
  4. FAMILIES
  5. PRIMARY CARE PROVIDERS
  6. SPECIALISTS
  7. ASSEMBLY AND INTERPRETATION OF INFORMATION
  8. CONCLUSION
  9. DISCLOSURES
  10. References
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