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Outpatient Surgery Services, VA Palo Alto Health Care System, Palo Alto, California
To the Editor:
Dr. van Klei and his colleagues should be commended for the quality and the scope of their work to measure the impact of outpatient preoperative evaluation (1). In this large study, they documented that outpatient evaluation is associated with more selective preoperative testing, fewer late operating room cancellations, and shorter lengths of stay. However, the authors found that the magnitude of these effects was less than expected. It appears that the way the clinic was structured diminished these benefits. In particular, these benefits would have been greater if future inpatients had been evaluated only if the plan was to admit them on the actual day of surgery. We took this approach with our preoperative evaluation clinic and documented greater benefits (2) and found that our surgeons quickly gained confidence in the anesthesia outpatient assessments and were willing to forgo admitting patients one or more days before surgery to get access to the resources available in our outpatient preoperative evaluation clinic.
Failure to limit who will be seen in the outpatient preoperative evaluation clinic can result in a number of problems. When the outpatient preoperative evaluation is completed for a patient who will be admitted before surgery, there is typically significant duplication of effort. Laboratory tests are often repeated (even if they were initially normal), consultations and functional tests not deemed necessary during the outpatient assessment may be arbitrarily added, and a second anesthesiologist’s preoperative evaluation may be nearly completed before the initial outpatient assessment is located.
These problems can create an atmosphere in which anesthesiologists working in the outpatient clinic quickly learn that their assessments have relatively little impact on the patient’s preoperative care. This atmosphere can have an adverse effect on the morale of the clinic staff. A recent survey documented that a lack of decision-making authority was associated with discontent among anesthesiologists working in preoperative evaluation clinics (3). If an anesthesiologist completes an outpatient preoperative evaluation and determines that the patient does not need any further testing prior to surgery, then it is understandably frustrating to learn that the patient was subsequently admitted and received a battery of unnecessary tests or consults before surgery.
Rather than waiting for the hospital to establish a new incentive system or hoping for the surgeons to develop and follow appropriate clinical pathways, it makes sense to limit the patients who will be seen in the outpatient clinic to exclude those who are planned for admission one or more days before surgery. Without setting reasonable criteria like this, the preoperative evaluation clinic can be misconstrued as a place where anesthesia gets comfortable with the status of the patient, but where the "real" work-up is completed by the surgeons after admission. In reality, experience has shown that the preoperative evaluation clinic is typically the ideal setting in which to complete these assessments. The benefits of outpatient preoperative evaluation are obvious enough and enticing enough to motivate the surgeons to change from their outdated routines. The trust of the surgeons in the anesthesiologist’s assessments manifests as a willingness to discontinue unnecessary admissions. This is a significant change in behavior that attests to how much the surgeons value the services that are provided in anesthesiologist-directed outpatient preoperative evaluation clinics.
References
UMC Utrecht, Dept. Perioperative care and Emergency Medicine, Utrecht, Netherlands
In Response:
We thank Dr. Pollard for his positive comments on our study on the impact of Outpatient Preoperative Evaluation (OPE) for potential inpatients (1).
We do agree that experience has shown that the OPE clinic is the ideal setting in which preoperative assessments are completed. The benefits of OPE are indeed obvious enough to motivate the surgeons to change from their outdated routines (i.e., to discontinue unnecessary admissions as a manifestation of the surgeon’s trust in the anesthesiologist’s assessments).
Dr. Pollard states that the beneficial effects of OPE would have been higher when we had agreed to evaluate future inpatients only if the plan was to admit them on the actual day of surgery. However, we did not make such agreements, because in our opinion, in principle, each potential inpatient can be admitted on the day of surgery. Only a small percentage of patients should be admitted one or more days before surgery, typically based on the patients’ health condition (e.g., severe chronic obstructive pulmonary disease that requires IV medication for optimization). This decision to admit patients before the day of surgery should be made by the anesthesiologist at the OPE clinic, after completion of the preoperative health assessment. Furthermore, in the Dutch setting, the anesthesiologist does not have the authority to compel surgeons to admit patients at the day of surgery. Anesthesiology departments can only strongly recommend the authorities (whether these are surgeons, hospital boards, or insurance companies) to admit patients at the day of surgery to achieve the optimal benefits of OPE, both from a medical and a financial perspective. Finally, if we would evaluate only those patients at the OPE clinic, who are admitted by the surgeon on the actual day of surgery, the patients who might benefit most from OPE (those who the surgeon considered admitting before the day of surgery) would not be evaluated at the OPE clinic. These patients then have to be assessed the afternoon before surgery, a policy that has been demonstrated to be less cost-effective, resulting again in late operating room cancellations and inappropriate additional testing by surgical residents "to satisfy the anesthesiologist."
In conclusion, in our opinion each potential surgical inpatient is a candidate for admission on the day of surgery and should therefore be evaluated at the OPE clinic some weeks before surgery. The specialist in perioperative care (i.e. the anesthesiologist) should agree with the surgical specialist to admit patients before the day of surgery only for reasons of optimization of concurrent diseases.
Reference
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