Preoperative Evaluation: Who Should Do It?

From the 2009 Annual Meeting of the Texas Society of Anesthesiologists, September 10-13, 2009, San Antonio, TX

Educational Objectives

The purpose of this program is to improve preoperative evaluations. After hearing and assimilating this program, the clinician will be better able to:

1.   Summarize the revised Joint Commission standards about preoperative evaluations.

2.   State the goals of the preoperative evaluation.

3.   List the pros and cons of having internists or anesthesiologists perform the preoperative evaluation.

4.   Recognize opportunities for internists to be further familiarized with issues unique to surgery and anesthesiol­ogy.

5.   Explain how current trends and advances in health care influence the requirements for preoperative evalua­tions.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.

Acknowledgements

This program was recorded at 2009 Annual Meeting of the Texas Society of Anesthesiologists, held September 10-13, 2009, in San Antonio, TX, and sponsored by the Texas Society of Anesthesiologists. The Audio-Digest Foundation thanks the speakers and the Texas Society of Anesthesiologists  for their cooperation in the production of this program.

Preoperative Evaluation Must be Performed by Anesthesiologists

Tim M. Bittenbinder, MD, Assistant Professor and Chair, Department of Anesthesiology, Texas A&M Univer­sity Health Science Center, College of Medicine, Scott & White Memorial Hospital, Temple, TX

Joint Commission standards for preoperative evaluation: revised March 2009; state that preanesthesia evaluation must be completed and documented by individual qualified to administer anesthesia; in speaker’s opinion, few in­ternists, hospitalists, pulmonologists, or cardiologists qualified to administer anesthesia

Medicare requirements for medical direction of anesthesia services: prescribe treatment plan; participate in most crucial portions of anesthesia care (ie, induction and emergence); check on patient frequently; remain physically available; provide recommendations for postoperative care; perform preanesthetic evaluation; anesthesiologists also helped by practice advisories, guidelines, and standards

American Society of Anesthesiologists (ASA) 2005 review of basic standards for preanesthesia care: requires anesthesia provider to document any variation from standards; despite documentation, anesthesia provider may still be considered guilty of deviating from standard of care; states that anesthesiologist must be responsible for deter­mining patient’s medical status and developing plan for anesthesia care; lists specific duties of anesthesiologist

Goals of preoperative evaluation: enhance awareness of patient’s medical condition  —  no randomized controlled trials prove preoperative evaluation improves outcomes; data over past 40 yr do show outcomes improving as an­esthesiologists modified practice based on findings of preoperative evaluation (eg, patients who undergo anesthe­sia and surgery 0-3 mo after myocardial infarction have high risk for reinfarction); waiting >6 mo associated with significant risk reduction; later research showed administration of b-blockers to patients identified as high-risk during preoperative evaluation shortens delay of surgery); facilitate plan for intraoperative and postoperative care  —  including identification of postoperative monitoring needs and need for overnight admission; optimize patient for planned surgical procedure  —  dependent upon scope of surgical plan; clinical judgment about sever­ity of physiologic trespass inherent in procedure important; educate patient about perioperative period  —  anesthesiologists witness entire continuum of care and best understand patients’ perioperative experiences; de­velop rapport with patient  —  preoperative evaluation provides opportunity to meet patient; reduce patient’s anxiety  —may provide as much anxiolysis as diazepam (Valium); obtain informed consent  —  anesthesia provider best person to discuss risks of anesthesia and perioperative period

Why internists should not perform evaluation: no training or experience in physiologic changes that occur during surgery; no training in regional anesthesia; medical optimization for daily life not necessarily similar to surgical optimization; no risk stratification method better than ASA physical status system

Documented benefits of preoperative evaluation: fewer day-of-surgery cancellations; reduction in preoperative consultations; preoperative laboratory testing; lower costs; in study of >7000 patients at Stanford University, rate of same-day cancellations dropped 88% after initiation of anesthesiologist-led preoperative evaluation clinic; also as­sociated with significantly fewer consultations and increase in surgeons’ level of trust; directed laboratory tests re­sulted in fewer tests overall; changes associated with significantly reduced costs; airway considerations  —  anesthesiologists better trained than internists to recognize airway challenges

Preoperative Evaluation Could be Performed by Internists

Lori Ann Dangler, MD, Assistant Professor, Anesthesiology and Perioperative Medicine, University of Texas M.D. Anderson Cancer Center, Houston

Preoperative evaluation: service (at point of visit) and product (records and billing information given to downstream providers); traditionally includes medical history, review of systems, examination, testing, informed consent, teaching, and instructions; recently, more emphasis placed on outside record data collection, risk assessment, and coordination of care

Purpose: achieving acceptable outcome (ie, minimizing morbidity and mortality) highest priority; >1 million pa­tients sustain postsurgical medical complications (1 in 50 surgeries); complications include myocardial infarc­tion, heart failure, stroke, pneumonia, respiratory failure, deep venous thrombosis, pulmonary embolism, delirium, and renal failure; postoperative death more often attributable to underlying comorbidities (eg, cardiac disease, diabetes, thrombotic events) than to complications of surgery or anesthesia; emphasizes importance of perioperative medical care in overall case management

Diabetes: management increasingly complicated, due in part to wider use of insulin pumps; patient may experi­ence crisis or infection before surgery

Hypercoagulable states: must be managed weeks in advance

Stakeholders in preoperative evaluation: anesthesiologists, internists, patient and family, surgeon, and hospital; evaluation should optimize outcomes and avoid delays and cancellations

Trends affecting preoperative evaluation

Location: >80% of evaluations performed on outpatient basis; convenience important to ensure patient compliance

Timing: patients often not seen by anesthesiologist until day of surgery; may result in more last-minute cancella­tions or inadequate patient preparation; in one informal survey, <15% of patients seen >7 days before surgery

Patient population: aging rapidly; more complex medically; volume of surgery increasing, with fewer physicians available; raises issues of risk adjustment, escalating costs, and competition for services

Other changes: growth of outpatient procedures fueling demand for in-office perioperative interventions (preopera­tive assessment, intraoperative management, and postoperative care plans)

Physician shortages: predicted in near future; accommodation will require complex changes, including preopera­tive evaluations

Risk factors and risk adjustment: risk factors effective predictors of cost; increasingly used by payors and regula­tory agencies to calculate and adjust risks, costs, and outcomes (eg, National Surgical Quality Improvement Pro­gram)

Competition: growing among hospitals; operating room (OR) efficiency major determinant of hospital costs; streamlining important

Preoperative evaluations for complex patients: in speaker’s opinion, complex patients “require specialized, non-discontinuous care at the physician level”; no randomized controlled trials of relationship between health status, outcomes, and costs; however, evidence shows preoperative education improves recovery and decreases morbid­ity; internists well-qualified for consultation, preparation, and perioperative management of surgical patients

Reasons to consider internists: have well-established offices with support; can provide before- and-aftercare within established patient and collegial relationships; proficient at followthrough, office management, and risk assess­ment; can coordinate care; medical and surgical groups codependent; in greater supply than anesthesiologists; already conducting evaluations

Followthrough and comanagement: management of eg, b-blockade, should begin earlier than just before day of surgery; surgeons need help getting patients through complex perioperative experience; consult with internists for evaluation and management; according to Mayo Clinic study, patients randomized to hospitalists had shorter hospitals stays and fewer complications after orthopedic surgery than patients receiving traditional care

Arguments against using anesthesiologists: anesthesiologists needed in OR to manage it with maximum efficiency; primary relationships typically with other OR personnel; historically, have relied on ASA scoring system for risk assessment; in shorter supply than internists; not as effective at billing for consultations and typically de­fault to basic preoperative assessments; traditional mission intraoperative rather than preoperative evaluation or extended perioperative management; demand for anesthesiologists increasing with increased volumes of sur­gery and relative shortage of anesthesiologist extenders (eg, certified registered nurse anesthetists); dividing time diminishes productivity; full documentation and support for consultative billing rarely available; bottom line  —  preoperative evaluation burdensome for anesthesiologists; logistically inconvenient; expensive, with relatively little reimbursement or subsidy; burdens compounded by shortages of anesthesia providers

Why anesthesiologists performed evaluations in past: are end-users of preoperative evaluation (know what infor­mation necessary); trained in OR and know complexities of surgery; many have background in critical care; can address needs for pain control and regional anesthesia better than internist

Current constraints: limitations of staff and space (preoperative evaluations conducted in holding areas or by tele­phone; anesthesiologists relying increasingly on information from extenders); expense of clinics; some anes­thesiologists lack in-depth critical care training

Rebuttal to arguments against using internists: lack of surgical focus  —  invite internists into OR; show them what anesthesiologists need; provide interdisciplinary rounds or joint conferences; field newer to internists  —  can learn from anesthesiologists’ experiences; ample anesthesiology and internal medicine literature available; al­ready filling gaps with own services and leading some efforts; younger internists now view perioperative medi­cine and preoperative evaluation as expanding field

“Filling in gaps”: internists have established clinics for patient follow-up; evidence shows improvement of hospital-wide care; literature also supports perioperative care protocols (eg, b-blocker prophylaxis, standardization of an­ticoagulation for outpatients); results obtained through outpatient preoperative medical clinics as well as inpa­tient perioperative followthrough; hospitalists now developing protocols and standards

Benefits of internists performing preoperative evaluations: shift from inpatient to outpatient setting and travel logis­tics make it important to improve access; sample reports structured to highlight important information for sur­geon and anesthesiologist; management of complex medical issues; can improve coordination of care and bridge performance gaps; cost-effectiveness; greater supply

Combining resources: anesthesia providers and internists should view roles as complementary; advances in health care delivery over past 5 to 10 yr (eg, telemedicine, medical tourism, home-centered care, minimally invasive surgery) result in anesthesia provider spending less time in traditional OR setting and more in off-site anesthesia areas

Conclusions: perioperative evaluation and management increasingly complex; reasons include high medical acuity, surgical complexity, diverse roles of clinicians, and more subspecialization; providers’ roles often unclear; how­ever, with standards and guiding principles of patient safety in place, internists can take lead in some evaluations

Moderator and Audience Comments

ASA physical status assessment: not intended as risk assessment tool, but correlates with perioperative morbidity and mortality; important information often missing from preoperative evaluation reports; anesthesiologist should use screening information from multiple sources

Preoperative evaluation: when performed by anesthesiologist, includes discussion of anesthesia plan; with increased use of regional anesthesia, still may have “logjam” in holding area on day of surgery; sending patient to internist for evaluation may add to costs

Survey of internal medicine residents at University of Texas Southwestern Medical Center: many internal med­icine residents not being educated about perioperative pathophysiology and unable to answer simple questions on topic; highly complex patients now being seen at ambulatory surgery centers

Patient contact: preoperative assessment presents opportunity for explanation of anesthesia provider’s role to pa­tient; keeping anesthesia providers in OR isolates them from colleagues as well as patients

Suggested Reading

Adesanya AO, Joshi GP: Hospitalists and anesthesiologists as perioperative physicians: Are their roles complementary? Proc (Bayl Univ Med Cent) 20:140, 2007; Correll DJ et al: Value of preoperative clinic visits in identifying issues with potential impat on oper­ating room efficiency. Anesthesiology 105:1254, 2006; Davenport DL et al: National Surgical Quality Improvement Program (NSQIP) risk factors can be used to validate American Society of Anesthesiologists Physical Status Classification (ASA PS) levels. Ann Surg 243:636, 2006; Fischer SP: Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology 85:196, 1996; Flowerdew RM: Preanesthetic evaluation in private practice. Anesthesiol Clin North America 22:141, 2004; Hariharan S, Zbar A: Risk scoring in perioperative and surgical intensive care patients: a review. Curr Surg 63:226, 2006; Katz RI et al : Preoperative medical consultations: impact on perioperative management and surgical outcome. Can J Anaesth 52:697, 2005; Lam E et al: Effect of anesthesia consultation on patients’ perioperative concerns. Can J Anaesth 54:852, 2007; MacPherson DS, Lofgran RP: Outpatient internal medicine preoperative evaluations: a randomized clinical trial. Med Care 32:498, 1994; Merli GJ: The hospitalist joins the surgical team. Ann Intern Med 141:67, 2004; Parker BM et al: Redefining the preoperative evaluation process and the role of the anesthesiologist. J Clin Anesth 12:350, 2000; Saidman LJ: The 33rd Rovenstine Lecture. What I have learned from 9 years and 9,000 papers. Anesthesiology 83:191, 1995.