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Anesth Analg 2004;99:1058-1069 © 2004 International Anesthesia Research Society doi: 10.1213/01.ANE.0000133910.55244.0E
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Abstract |
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 Top Abstract IntroductionCommitting to the ConceptStaffingThe Evaluation ProcessLogistic Concerns of the...The Preoperative VisitThe Complex Ambulatory PatientSummaryReferences |
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Fewer and fewer patients spend time in the hospital in advance of a surgical or interventional procedure requiring anesthesia care. As a result, there is increasing reliance on a thorough preoperative evaluation directed toward identifying anesthetic risks. For this to occur, each medical institution must have a clear and comprehensive system that processes patients during the preoperative period. There are specific and unique personnel and system requirements for the accumulation of multidisciplinary information in the pediatric patient population. The justification for the cost of this type of program is the savings realized by the decrease in wasted operating room time due to inadequate or incomplete patient preparation. The following is a description of a successful perioperative evaluation and preparation process that has been in place for 7 yr in a major pediatric academic institution.
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Introduction |
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TopAbstractIntroductionCommitting to the ConceptStaffingThe Evaluation ProcessLogistic Concerns of the...The Preoperative VisitThe Complex Ambulatory PatientSummaryReferences |
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As the concept of perioperative medical care expands, it is becoming increasingly evident that anesthesiologists are the logical "perioperative physicians" (1). In an era when medical care has become so subspecialized and fragmented, the presence of a "captain of the ship" who evaluates the patient as a whole is frequently missing. Patients with complex disease processes and medical comorbidity require a comprehensive multidisciplinary approach to preanesthetic evaluation. With the advent of ambulatory surgery and same-day-admission status, most patients with complex conditions are not admitted to the hospital in advance of surgical or interventional procedures, thus requiring that the evaluation take place on an outpatient basis. This advance preparation facilitates the perioperative planning and management of elective surgical cases and maximizes the quality and efficiency of the surgical or interventional process (2). The evaluation and preparation of infants and children, as compared with adults, is further complicated by the fact that the compilation of medical information must be obtained not only from the patient directly, but also from many other sources, including parents, other caregivers, pediatricians, and neonatologists.
The guidelines for the medical practice of anesthesiology, as determined by the American Society of Anesthesiologists (ASA), state that the responsibilities of the anesthesiologist include preanesthetic evaluation of a patient and prescription of the anesthetic plan. The ASA ethical guidelines add that "Anesthesiologists should provide preoperative evaluation and care and should facilitate the process of informed decision-making, especially regarding the choice of anesthetic technique.... Anesthesiologists should provide for appropriate postanesthetic care for their patients" (3,4). The ASA directive regarding ethical responsibilities also refers to communication with other medical colleagues and suggests that "Anesthesiologists should provide timely medical consultation when requested and should seek consultation when appropriate." It then follows that the responsibilities of the anesthesiologist are a continuum from the preoperative encounter to the postanesthetic recovery phase (5). There have been prior reports of preanesthetic evaluation programs in an academic institution; however, these were not based on physician-directed evaluation, nor were they specific to the pediatric population (6,7).
The following is an operational model of a physician-based preanesthetic evaluation process in a large pediatric academic institution. The following process and staffing have been applied to an institution that performs 22,000 surgical procedures with a volume of 7,200 preoperative clinic visits and 800 anesthesia consultations on ambulatory patients each year.
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Committing to the Concept |
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TopAbstractIntroductionCommitting to the ConceptStaffingThe Evaluation ProcessLogistic Concerns of the...The Preoperative VisitThe Complex Ambulatory PatientSummaryReferences |
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In a time of diminishing revenue and financial resources, hospitals may be reluctant to allocate funds to the staffing of a preoperative evaluation clinic. There may be, however, substantial overall institutional financial gain when improved throughput in the operating room (OR) results in an increase in reimbursable surgical volume (8). Maximum OR use can be achieved only if turnover between cases is rapid and efficient and last-minute cancellations are minimized. For this to occur, a thorough comprehensive medical assessment must be completed before patient arrival in the OR. This eliminates delays due to lack of information or examinations that were incomplete or not performed.
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Staffing |
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TopAbstractIntroductionCommitting to the ConceptStaffingThe Evaluation ProcessLogistic Concerns of the...The Preoperative VisitThe Complex Ambulatory PatientSummaryReferences |
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Adequate and appropriate staff must be allocated to the clinic for it to be successful. Staffing a preoperative evaluation center is a joint project between the departments of anesthesia and nursing in which each division has a coordinator. The medical director should be a fellowship-trained pediatric anesthesiologist and, when possible, hold dual board certification in pediatrics and anesthesia so that, when they arise, general pediatric medical issues may be easily resolved without using resources out of the preoperative clinic environment. The medical director is assisted by a consistent subgroup of pediatric anesthesiologists who rotate through the clinic when assigned to the OR. One anesthesia faculty member is assigned to the clinic each day and is assisted by one pediatric anesthesia fellow. Because patient evaluation is an essential part of the anesthesiologist’s role, exposure to the preoperative clinic should be an integral part of pediatric anesthesia fellowship training (9). A nurse manager who oversees the daily process and participates in clinical care with staff nurses and nurse practitioners is essential. Experienced nurse practitioners under the supervision of an anesthesiologist can screen patients for potential anesthetic problems with 86% accuracy (10). In an institution that processes 7200 preoperative patients, a staff of 8 nurses is appropriate. This ratio would be sufficient to have one nurse assigned to chart review, five nurses evaluating and processing patients, and one nurse unassigned each day. If an institution has funding for a full-time child-life specialist, this is a valuable resource and complement to the preoperative education available to patients and families.
One administrative assistant position is dedicated to scheduling preoperative appointments. In addition, the preoperative clinic scheduler is responsible for posting charges for hospital facility and physician professional fees generated from the preoperative visit. An additional administrative assistant handles all other operational details, such as chart preparation, filing, and phone calls, and two front-desk personnel keep track of patient location and progress through the preoperative process on the day of the visit. Another important function of the support staff is to review the OR schedule for the next day each afternoon to verify that every nonambulatory patient has completed a preoperative appointment. If a patient is identified who has not been properly screened, the surgical office is contacted, and appropriate arrangements are made. Alternate arrangements include a same-day preoperative evaluation (if feasible) or rescheduling of the procedure.
The cost of staffing a program such as this is significant. The estimated cost of nursing and administrative personnel is $950,000, inclusive of all salary and benefits. The annual cost of supplies for the support of the clinic is an additional $50,000. The cost of professional staffing is based on 1.5 full-time equivalent salaries at the average departmental rate for both faculty and fellows. The average hospital charges generated by the activity in the clinic are between three and four times the operational cost, excluding the time saved on patient throughput in the OR and the prevention of unused OR time because of unexpected cancellations. The professional anesthesia fees are bundled into the total anesthesia reimbursement, in which a preoperative evaluation, procedural anesthetic, and postoperative evaluation are included.
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The Evaluation Process |
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TopAbstractIntroductionCommitting to the ConceptStaffingThe Evaluation ProcessLogistic Concerns of the...The Preoperative VisitThe Complex Ambulatory PatientSummaryReferences |
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The goal of an efficient preoperative evaluation facility is to provide a comprehensive heath history and assessment to the caregivers involved in the care of the patient on the day of the procedure. Frequently, medical information is fragmented and may come from multiple areas, and one of the challenges of the preoperative clinic is to compile and assess all of the various parts of the health history into a single coherent report (11). Because information may be available from multiple sources—such as parents, primary care physicians, surgeons, and subspecialists, to name only a few—different tools must be available to capture and standardize this information.
The process begins in the surgeon’s office far in advance of the preoperative clinic appointment. A Preoperative Patient Flow Sheet (see Fig. 1) is distributed to all surgical booking offices. A description of this form and its required use is sent out on a regular and periodic basis as a reminder to staff who may be new or may have forgotten the process over time. This is a comprehensive visual representation of the steps that must be taken to ensure that sufficient information is available to care for the patient during the perioperative period, and it outlines the responsibilities of the booking office for providing that information (Appendix 1). The difference in preparation required for local compared with out-of-state patients is presented. In addition, the requirements for subspecialty evaluation by in-hospital consultants and out-of-hospital consultants are described, and referral to this flow diagram is a constant reminder for surgical office support staff.
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The surgical booking office also provides a Provider Order Sheet for each patient; this is a comprehensive form filled out by the surgeon at the time of surgical booking (Appendix 2). Included in it are special needs, laboratory orders, radiograph orders, blood bank orders, preferred inpatient unit (if known), additional physician or service appointments related to the procedure, special equipment needed in the OR, a reservation for an intensive care unit bed, and other miscellaneous information of interest to varied caretakers during the hospital admission. This information is simultaneously sent to the coordinator of patient placement so that an appropriate inpatient bed assignment may be made and to the preoperative clinic so that specific needs are documented in the medical record.
Given the intensity of the production pressure in physician offices, it is impossible for every surgeon to know all the details of each patient. Acknowledging this, an assumption may be made that the parents and caretakers of young children or older patients themselves have accurate documentation of past illness and procedures, as well as other physicians involved in their medical care. A General Medical Health Form (Appendix 3) is a comprehensive health evaluation that is filled out by the patient or parents and is required for surgical booking to take place. This document is completed at the surgical office visit and is faxed or delivered to the preoperative clinic in advance of the visit. Information regarding past hospital admissions, surgical procedures, other medical subspecialists who care for the patient, and contact information is reviewed by a nurse practitioner and recorded. Complete drug and allergy information is also noted. This is just one way to elucidate medical comorbidity that may not have previously been noted by referring physicians.
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Logistic Concerns of the Perioperative Evaluation Process |
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TopAbstractIntroductionCommitting to the ConceptStaffingThe Evaluation ProcessLogistic Concerns of the...The Preoperative VisitThe Complex Ambulatory PatientSummaryReferences |
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The scheduling process begins when the surgeon’s or practitioner’s office schedules a procedure on an electronic Web-based OR-booking program. The booking information is automatically and simultaneously sent from the surgeon’s office to the OR-booking office and the preoperative clinic. Receipt of this booking notification triggers the placement of the patient on the preoperative daily nursing log. The patient’s medical record is ordered and thoroughly reviewed by a member of the nurse practitioner staff in the preoperative clinic. This review consists of reading pertinent sections of the paper medical record and accessing all available electronic medical records. All prior surgical procedures or other procedures under anesthesia are reviewed, and complications are documented on the Preanesthetic Evaluation Form, which is a cumulative document that will accompany the patient to the OR or anesthetizing site on the day of the procedure (Appendix 4).
A telephone call is made to the patient or parent to review and verify information obtained from the medical record. Patients are instructed to bring all current medications with them on the day of the preoperative visit so that doses can be verified and documented. There is potential for error amplification when an incorrect medication dose is recorded during the preoperative visit and then copied during the inpatient stay; therefore, no medication doses are written on the patient record unless they are verified first.
If a patient expresses difficulty in being able to come to the preoperative visit, a nurse practitioner can determine whether a patient is appropriate for a same-day workup to eliminate the need for a separate visit. Similarly, the nurse-practitioner can determine whether a patient who comes to the hospital repeatedly can be evaluated on the same day as the procedure in the future.
In this way, the process is streamlined on the day of the visit. The review and documentation of medical history has been completed, so only review and verification (in addition to the physician examination) are required during the face-to-face interview. Families are reassured by the fact that they have had contact with a member of the perioperative team in advance of their visit and feel as though they are already known upon their arrival.
When children have multiple physicians involved in their medical care, coordination of the preoperative evaluation process becomes more complex. Children who receive care for medical issues that are not related to the current surgical or interventional procedure must be identified so that there can be coordination of caregivers. The subspecialty consultants (cardiology, pulmonary medicine, endocrinology, and so on) should be identified before the preoperative visit so that a current evaluation can be obtained and reviewed. The adequacy of the evaluation is determined by an anesthesia faculty member, and if the patient requires updated evaluation by a subspecialist, the surgeon is informed and the appointment is made by the parent or is facilitated by the preoperative clinic nursing staff or the surgeon’s office.
Occasionally a patient may have a medical issue that has not been adequately evaluated. This is determined after a thorough chart review, review of the electronic medical information available, and phone conversation have been completed. When this situation occurs, the surgeon’s office is notified and asked to arrange the appropriate consultation. Frequently, scheduling these appointments is facilitated by the preoperative clinic staff as a courtesy only, because it is not the primary responsibility of that staff. The preoperative clinic staff does, however, keep a record of the appointment, and the report of the evaluation is reviewed by the preoperative clinic physician and nursing staff. All consultant information is included in the OR chart that accompanies the patient on the day of the procedure.
Preoperative clinic faculty and staff consult with medical subspecialists on a regular basis (12). Because the perioperative time course of surgical patients frequently requires "attending first" evaluation and recommendations, the more traditional resident-fellow-attending sequence is not timely enough for the preoperative period. Usually if multiple junior physicians or students must present a case to the faculty member before a plan is created, patients and families are forced to extend the preoperative visit to what is frequently an unacceptable length of time. It is advisable to determine a streamlined process within each subspecialty. For instance, select services might suggest that a specific faculty member be called for perioperative issues. Another service might provide a rotating beeper or faculty roster so that a specific person is designated to be the perioperative consult faculty member. Finally, a specific medical service might designate that the consult fellow be called with the caveat that a faculty member will render an opinion and care plan within an appropriate period of time (13).
Another solution is to create institution-specific care plans or clinical practice guidelines (CPG) for the perioperative period. These are very useful in the multidisciplinary care of patients with associated medical comorbidities. Some examples might be a CPG for the perioperative management of insulin in the child with diabetes mellitus, the management of vasopressin or desmopressin in the child with diabetes insipidus, or the management of the child with hemophilia or sickle cell disease (14). Laboratory examinations may be protocolized for specific surgical procedures, and this also helps to streamline the process. Predetermination of these types of care plans helps to eliminate differences of opinion among practitioners within a subspecialty, as well as differences among individual anesthesiologists, so that all the members of the care team for each patient have the same expectations. Also included in the CPG are plans for postoperative disposition (inpatient unit, home, intensive care unit, and so on) and medical subspecialist follow-up. Figure 1 helps to summarize the flow of information within the perioperative environment when medical subspecialists are involved in a patient’s care.
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The Preoperative Visit |
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TopAbstractIntroductionCommitting to the ConceptStaffingThe Evaluation ProcessLogistic Concerns of the...The Preoperative VisitThe Complex Ambulatory PatientSummaryReferences |
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The preoperative evaluation appointment is made within 30 days of the procedure (15). At the time of patient arrival to the preoperative clinic, the medical record should have been reviewed, relevant subspecialist consultants should have been contacted, and their care plan should have been documented. In addition, a phone call to the family or adult patient should have been made, the medical history reviewed, and medications documented on the preoperative assessment form. On arrival to the preoperative clinic, medical insurance is verified, and, if applicable, a copayment is collected. If there are outstanding financial issues, the family is referred to an on-site financial representative. The patient is seen first by the nurse practitioner, who reviews the previously documented medical history from the Preoperative Evaluation Form and adds any additional information, including medications and doses. A physical examination and measurement of vital signs are performed and recorded. The nurse practitioner provides any information that is still outstanding on the Preanesthetic Evaluation Form and concludes with some preoperative teaching regarding the process on the day of the procedure. Information on eating and drinking on the day of the procedure is reviewed as well. The hospital preoperative Web site address is given to the family so that they can review any of the preoperative instructions at their leisure if they desire.
If the nursing staff determines that a child is especially anxious or if there are special considerations for a specific family, a referral to the child-life specialist is made. An on-site child-life specialist confers with the nurse and proceeds with his or her visit and recommendations.
The child and family meet with the anesthesiologist, who reviews all of the information that has previously been gathered. The physical examination is completed, and the anesthetic plan is reviewed. All questions are answered, and consultant reports are reviewed. The anesthesia consent is obtained, questions are answered, and anesthetic options are discussed. At this time, the faculty anesthesiologist confers with any involved subspecialty faculty member to reiterate a specific care plan and determine whether involvement into the postoperative period should be arranged. For example, should the endocrinology service write the postoperative insulin orders, or can the surgeon do it? Similarly, does a patient with cardiac issues require a postoperative cardiac unit-monitored bed, or is a regular inpatient surgical bed acceptable? If specific anesthesia expertise is required or if the family has a staffing request, these are communicated to the OR scheduling office at this time. The surgical service representative may also choose to perform the specialty-specific history and physical examination in the preoperative clinic during this visit if this has not been previously done.
After all interviews and visits are completed, laboratory examinations that have been ordered are obtained (16). The nurse-practitioner who evaluated the patient is responsible for checking laboratory results. Any abnormality is reviewed with the faculty anesthesiologist who is staffing the clinic that day and is reported to the appropriate surgical service. Follow-up is arranged by the faculty members.
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The Complex Ambulatory Patient |
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TopAbstractIntroductionCommitting to the ConceptStaffingThe Evaluation ProcessLogistic Concerns of the...The Preoperative VisitThe Complex Ambulatory PatientSummaryReferences |
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The other important service that a comprehensive preoperative clinic should provide is consultative support to the ambulatory surgery program. Day surgery patients are expected to be healthy and have a medical history that is uncomplicated so that the preoperative assessment may be performed on the same day as the procedure. Approximately 15% of patients scheduled for ambulatory surgery on the main campus of the institution required preoperative anesthesia consultation. This service is provided by the anesthesia fellow and faculty member assigned to the preoperative clinic. Anesthesia consultations should be arranged in advance of elective surgery whenever there is a concern that a preoperative medical condition may present perioperative problems. Anesthesia consultations may be scheduled up to 4 weeks in advance of the scheduled surgery. The requesting physician should state the specific problem that initiated the consultation and clearly define the question being asked of the consultant. This is essential in distinguishing an anesthesia consultation, which evaluates anesthesia risk and planning, from the preoperative visit. Preoperative anesthesia consultations are indicated in patients who have one or more of the following:
- Patients who are actively followed by multiple consult services, where the input from those services is important for proper anesthetic planning.
- There are questions regarding the appropriateness of the surgical location as it relates to the needs, complexity, and safety of the patient (main OR, ambulatory surgery center, procedure room, and so on).
- Any single self-limited or acute minor problem that may affect the safe administration of general anesthesia.
- Two or more self-limited problems.
- One or more stable chronic illnesses.
- Any stable chronic illnesses with an acute exacerbation or progression or with side effects of treatment.
- A new problem with uncertain prognosis requiring risk assessment for general anesthesia.
- Acute simple illness with systemic symptoms.
- Acute complicated injury or a condition in which the risk of general anesthesia is uncertain.
- An difference in the patient’s current state of health as compared with the usual state of health.
Once the consultation has been completed, a written report is placed in the patient’s record, and a copy is sent to the referring physician to complete the loop of communication. If a change in patient status or designation (i.e., ambulatory to observation) is warranted, an attending-to-attending conversation is required. If additional investigations or examinations are required before general anesthesia, these are arranged by the referring physician and reviewed by the anesthesiologist when they are completed. This process is very useful in maintaining the ambulatory status of patients who require more in-depth evaluation and review of their medical history.
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Summary |
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TopAbstractIntroductionCommitting to the ConceptStaffingThe Evaluation ProcessLogistic Concerns of the...The Preoperative VisitThe Complex Ambulatory PatientSummaryReferences |
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As ORs become busier and the production pressure increases, accurate and comprehensive preoperative preparation and perioperative planning are essential to the success of the facility. An improved medical and financial outcome will emerge, as will a system that defines the quality of perioperative care for each patient (17). The evolving role of the anesthesiologist as perioperative physician suggests that anesthesiologists have the best background for overseeing these systems. A well organized preoperative clinic appropriately and sufficiently staffed with nurse practitioners and anesthesiologists will ensure that the throughput in the ORs and outfield anesthetizing locations is maintained. The finances and time invested in this type of program are easily recovered by the institution as a result of decreased cancellations and OR delays, thus allowing for enhanced use of OR time.
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References |
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TopAbstractIntroductionCommitting to the ConceptStaffingThe Evaluation ProcessLogistic Concerns of the...The Preoperative VisitThe Complex Ambulatory PatientSummaryReferences |
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- Prough D. Perioperative medicine: a natural for anesthesiologists. ASA Newslett 1999; 63: 6–12.
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[Abstract/Free Full Text] - American Society of Anesthesiologists. Guidelines for the ethical practice of anesthesiology. ParkRidge, IL: ASA, 2001.
- Klopfenstein C, Forster A, Gessel EV. Anesthetic assessment in an outpatient consultation clinic reduces preoperative anxiety. Can J Anaesth 2000; 47: 511–5.[Web of Science][Medline]
- Hepner D. The anesthesiologist as perioperative physician: the PCP of the perioperative period. ASA Newslett 2002; 66: 5–14.
- Fisher S. Development and effectiveness of an anesthetic preoperative evaluation clinic in a teaching hospital. Anesthesiology 1996; 85: 195–206.
- Kenridge R, Lee A, Latchford E, et al. The perioperative system: a new approach to managing elective surgery. Anaesth Intensive Care 1995; 23: 591–6.[Medline]
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- Vaghadia H, Fowler C. Can nurses screen all outpatients? Performance of a nurse based model. Can J Anaesth 1999; 46: 1117–21.[Web of Science][Medline]
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- Burke GR, Corman LC. The general medicine consult service in a university teaching hospital. Med Clin North Am 1979; 63: 1353–7.[Web of Science][Medline]
- Tsen L, Segal S, Pothier M, et al. The effect of alterations in a preoperative assessment clinic on reducing the number and improving the yield of cardiology consultations. Anesth Analg 2002; 95: 1563–8.
[Abstract/Free Full Text] - Wise-Faberowski L, Soriano S, Ferrari L, et al. Hyponatremic seizures and excessive intake of hypotonic fluids in young children. J Neurosurg Anesthesiol 2004; 16: 14–9.[Medline]
- Pollard JB, Olson L. Early outpatient preoperative anesthesia assessment: does it help to reduce operating room cancellations? Anesth Analg 1999; 89: 502–5.
[Abstract/Free Full Text] - Kain Z, Wang S, Caramico L, et al. Parental desire for perioperative information and informed consent: a two-phase study. Anesth Analg 1997; 84: 299–306.[Abstract]
- Deutschman C, Traber K. Evolution of anesthesiology. Anesthesiology 1996; 85: 1–3.[Web of Science][Medline]
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