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From the Departments of *Anesthesiology and Neurosurgery, Yale University School of Medicine; Department of Biostatistics, General Clinical Research Center, Yale University School of Medicine, New Haven, Connecticut; Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and ||ASA Committee on Electronic Media and Information Technology, American Society of Anesthesiologists, Park Ridge, Illinois.
Address correspondence and reprint requests to Natalie F. Holt, MD, MPH, Department of Anesthesiology, Yale University School of Medicine, 333 Cedar St., TMP 3, New Haven, CT. Address e-mail to natalie.holt{at}post.harvard.edu.
Abstract
BACKGROUND: One purpose of preanesthesia evaluation clinics (PECs) is to decrease the incidence of day-of-surgery delays and cancellations by ensuring that patients are medically ready for surgery. In several single-center studies, PECs have been shown to have a positive impact. However, limited information is available regarding their overall use and perceived effectiveness.
METHODS: A survey was distributed to attendees of the 2005 Annual Meeting of the American Society of Anesthesiologists. The survey addressed the national prevalence of PECs and the most common methods for referral to them. Respondents were also asked to address the impact of PEC visits on perceived prevalence of day-of-surgery delays caused by missing patient information.
RESULTS: One thousand eight hundred fifty-seven surveys were returned. Sixty- nine percent of respondents worked at institutions with a PEC. Fifty-seven percent of respondents indicated that delays occur in at least 1 in 10 patients not seen for preanesthesia evaluation prior to the day of surgery. For patients who had a PEC visit prior to surgery, the same frequency of delays was reported by 23% of respondents.
CONCLUSIONS: Day-of-surgery delays caused by missing information remain relatively common despite preanesthesia evaluation. Possible causes for these delays include failures of information transfer, lack of consensus on criteria for surgical readiness, or other institutional factors.
The development of an anesthesia outpatient clinic was recommended more than 50 years ago in response to the "pressure of work in the surgical outpatient clinic." The purpose of such a clinic was to optimize the condition of persons "not in the best possible state for operation" (1). The recent increase in outpatient and same-day surgical admissions has increased the potential for patients not to be assessed by an anesthesiologist until the day of surgery. Preanesthesia evaluation clinics (PECs) and other forms of preanesthesia evaluation have been shown to allay patient anxiety and enhance patient satisfaction (2–6); improve patient preparation for surgery (7); diminish unnecessary preoperative consultations, laboratory tests, and diagnostic studies (8–11); reduce hospital costs and duration of hospital stay (10,12–14), and reduce day-of-surgery cancellations and delays (10,15,16).
Most studies demonstrating the benefits of PECs have been conducted at single centers and have been based on data collected over brief time periods. The present survey was conducted to develop a more global perspective on the prevalence of PECs and their relationship to day-of-surgery delays caused by missing information.
METHODS
Members of the American Society of Anesthesiologists (ASA) Committee on Electronic Media and Information Technology developed a list of five questions designed to elicit the frequency of day-of-surgery delays caused by missing information and the perceived impact of PEC visits on reducing their occurrence (Table 1). The anonymous survey was included as part of the registration materials given to attendees of the 2005 ASA annual meeting that took place in Atlanta, GA in October 2005. Completed surveys could be returned via drop boxes located in the registration area or handed to meeting personnel at the time of conference check-in.
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The Wilcoxon’s ranked sum test was used to compare the responses of participants who worked at an institution with a PEC to those who did not. Within-respondent comparisons of the estimated proportions of subjects having surgical delays were made using the Wilcoxon’s signed rank test. Median values of the categorized percent ranges (i.e., 5%, 18%, 37%, 63%, 87%) were used in this comparison.
RESULTS
An estimated 5796 ASA members and 2336 nonmembers attended the ASA’s 2005 annual meeting. Of these, 1857 attendees completed and returned surveys (response rate 23%). Sixty-nine percent of respondents reported working at institutions that used an anesthesia-staffed PEC (Question 1). Of these institutions, the most common mechanisms for referral to PEC were departmental/ hospital policy (38%), surgeon discretion (29%), planned postoperative admission (25%), and patient request (8%) (Question 2).
For patients who had been evaluated in a PEC, 23% of respondents reported incidences of delays on the day of surgery occurred in more than 10% of patients. This increased to 57% for patients first seen by an anesthesiologist on the day of surgery (Table 2, P < 0.001). Sixteen percent of respondents indicated that an anesthesiologist evaluated patients prior to the day of surgery despite reporting the absence of a PEC. Of these, 22% reported more than a 10% incidence of delays on the morning of surgery. This was similar to the 23% of respondents in institutions with a PEC who reported more than a 10% incidence of delay in the start of surgery (P = 0.352).
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Perceived prevalance of day-of-surgery delays was higher among respondents from institutions with a PEC than in those without a PEC; 63% and 42% of respondents, respectively, reported more than a 10% incidence of delays among patients first seen on the day of surgery (Table 3, P < 0.001). When asked to estimate the percentage of cases in which missing information retrieved prior to the start of anesthesia actually changed management, 54% of all respondents indicated that this occurred more than 10% of the time (Table 4). Again, the impact of day-of-surgery information was judged to be higher at institutions with a PEC than institutions without a PEC (60% vs 41%, respectively; P < 0.001).
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DISCUSSION
The results of this survey indicate that many anesthesiologists do not have information about patients’ preoperative conditions by the day of surgery. The data also indicate that assessment by an anesthesiologist prior to the day of surgery reduces, but does not eliminate, delays. Additionally, they suggest that preoperative assessment does not always require an established PEC. The findings are consistent with data from single-center studies. Ferschl et al. (16) recently reported that, in outpatients, an anesthesiologist-directed preoperative interview reduced day-of-surgery cancellations and delays; however, among same-day surgical admissions, preoperative evaluation only reduced cancellations. Neither the present survey nor the Ferschl et al. study was designed to investigate the reason for such a discrepancy.
In the present study, 16% of respondents indicated that preanesthesia evaluation was available despite the absence of an established PEC. This finding is particularly relevant to the care of patients for whom a separate PEC visit is not practical due to geographic or other constraints. Research on the effectiveness of alternative methods of preanesthesia screening at improving day-of-surgery logistics is limited. In the pediatric population, Patel and Hannallah (17) found that preoperative telephone screening decreased day-of-surgery cancellations. Other investigators have demonstrated the utility of automated questionnaires for the collection of a patient’s medical history. In this research, however, these aides were used as an adjunct to, rather than substitution for, face-to-face patient evaluation (18,19).
The difference in responses observed between anesthesiologists working in institutions with and without a PEC may be affected by the likelihood that anesthesiologists working at institutions with a PEC typically care for patients with higher disease acuity, or those undergoing more complicated surgeries. This may partially explain why missing information was considered more significant among respondents with a PEC compared to respondents without a PEC.
Preanesthesia evaluation may not be as effective as anticipated at reducing day-of-surgery delays because the anesthesiologist taking care of the patient may not always agree with the criteria used in the preoperative testing clinic to determine patient readiness for surgery. Additionally, issues identified during the preanesthesia evaluation may be left unfinished by the time of surgery due to failed follow-up, or simply lack of time. Delays also may be the result of nonanesthesia related issues, including late arrival of the surgeon or patient which would affect activities such as surgical site marking or administration of preoperative antibiotics.
The utility of PECs also may be limited by ineffective recording and/or transmission of patient information. Most anesthesia departments communicate via paper records, which may be difficult to decipher and are vulnerable to loss and misfiling. Establishing an electronic database for the collection and retrieval of patient information provides immediate access to a complete record of patient information and might, therefore, maximize the benefit of preoperative evaluation. Understanding the relationship between PECs, automated information management systems, and operating room efficiency would seem to be a useful goal for future research.
This study has several limitations. First, the survey instrument was distributed at a professional meeting and electively completed by attendees. Second, the response rate of the survey was low (23%). However, although more than 8000 individuals attended the meeting, approximately 32% were not physicians in active practice, so that the 1857 respondents likely represent more than 30% of anesthesiologists attending a professional meeting. Second, because demographic information was limited, respondents may not have reflected a characteristic population sample. This study also measured perceived delays; the extent to which perceptions mirror reality is a matter of debate. Finally, this survey was not designed to identify the specific circumstances surrounding delays that occur on the day of surgery. Therefore, it is difficult to establish whether a PEC visit could have prevented their occurrence.
The data indicate that assessment of patients prior to the day of surgery reduces the likelihood of delays on the day of surgery. The present study did not identify the subset of patients that would benefit most from such assessment. ASA Guidelines for Preoperative Assessment recommend that patients with complex medical conditions and/or those undergoing complex surgery should be seen by an anesthesiologist prior to the day of surgery (20). Preliminary research suggests that evaluation of ASA PS III and IV patients in a PEC is associated with the largest net benefit in terms of reductions in day-of-surgery delays and cancellations (21).
In summary, the present survey indicates that PECs are prevalent in medical institutions. Although they appear to reduce day-of-surgery delays caused by missing information, they by no means eliminate the problem. Further research is necessary to elucidate strategies that can reduce this costly problem and to increase the benefit of preanesthesia evaluation.
Footnotes
Accepted for publication November 9, 2006.
This work is based on a survey performed by the ASA Committee on Electronic Media and Information Technology at the 2005 Annual Meeting of the ASA.
REFERENCES
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