19.1 Staffing for Preoperative Assessment
Ronald P. Olson
There are many staffing models for preoperative assessments. Each institution will need to develop a process to serve patients with a balance of proportion and depth of preoperative assessment for its unique needs.
One end of the spectrum is from a perhaps mythical age when every patient had a primary care physician (PCP
) who could quickly summarize the patient’s current medical, psychological, and social status, as well as expeditiously and knowledgably discuss the risks and benefits of contemplated interventions with the surgeon, anesthesiologist, and patient. Consultations required for optimization would have already been arranged as part of routine care. There may be some communities which are close to this Nirvana, in which case perioperative assessment and optimization can be deferred to the PCP
, and the hospital needs only to gather information. In this case a nurse screening call or perhaps just a clerical collation of the information will be satisfactory, as long as the information gets to the operating room on time.
The other end of the spectrum is where patients arrive the morning of surgery with no knowledge or documentation of previous health status, and little idea of what is about to occur. Admittedly, if the patient had to climb a flight of stairs to get to the operating suite, and the procedure does not involve significant physiologic stress, all will probably go well, thanks to the large margin of safety that current anesthesia and surgery provide.
Increasingly, however, patients present with multiple comorbidities which may or may not have been recently optimized or even assessed. Anesthesiologists may be pressured to accept small risks in the name of patient convenience. But these may be preventable. Even if surgery can proceed with little change in medical care, the perioperative period presents an opening to improve long-term health, which may not happen otherwise. It is an opportunity to clearly demonstrate the institution’s interest in the patient’s overall health, which has ethical and public relations justification.
Comprehensive preoperative assessment and optimization (1
) involves the following: (1
) information gathering; (2
) reviewing and evaluating the adequacy of that information; (3
) determination of need for further assessment, investigations, and treatments to optimize perioperative health; and (4
) actually doing the optimization. All of these should be documented in a concise, structured, and available format.
If patients have had good comprehensive health care, and documentation of that care is available, there is little need for further preoperative assessment (3
). If most patients in a healthcare system are in this category, have a PCP
who knows them well, or can easily be seen by a consultant preoperatively, information gathering can be done by clerical staff. The few questionable cases can be deferred to an advanced practice provider (APP
) or preoperative physician. As the proportion of cases with uncertain medical care increases, it will become necessary for a clinician with a higher level of training and certification to be the primary information gatherer.
DETERMINATION OF ADEQUACY OF INFORMATION
As health care has become more fragmented, collating accurate medical records has become more difficult. Electronic health records (EHRs) are making it easier to share records across institutions, but extricating useful information from auto-populating templates becomes challenging. It is not fair to expect clerical staff to discern if the content of the information is adequate. Nursing staff are likely better able to make this assessment. If there is a large proportion of complex, suboptimally managed patients, an APP
may be needed to make medical decisions about the adequacy of patient information.
Some patients can be assessed remotely (e.g., telephone, EHR
, telemedicine) without an in-person visit (4
). The problem is determining which patients can be assessed from afar. In some communities, surgeons are familiar enough with their patients, to triage appropriately. When many patients are referred from afar with inconsistent information, other triage methods will be needed. One option is for all patients to receive an initial remote (typically by phone) assessment, which can determine who needs a clinic assessment. This requires enough lead time for the phone call. If further care is needed, the next question is how will this be accomplished and by whom.
DETERMINATION OF NEED FOR FURTHER ASSESSMENT
The simplest approach may be to refer patients to their local provider. Another option is to refer to an internal medicine service. This may be inconvenient for the patient, especially if it represents a duplication of care. If services are included in a global surgical fee, it may be advantageous to utilize an anesthesiology-directed preoperative clinic. This will likely minimize overinvestigation, as preoperative care directed by anesthesiology limits unnecessary testing (5
). While experienced nurses often make these determinations, there is a concern that they do not exceed their scope of practice. APPs, with training and support of anesthesiologists, may represent the best balance of skills.
Asking consultants to “clear” the patient for surgery is inappropriate (7
). The goal is to provide information to assist the anesthesia team to care for the patient. If the determination is that the patient is not fully optimized, the next question is, “Who will do this?”
It may be necessary to refer the patient to the appropriate consultant when there is a complex medical issue. But many medical issues can be easily managed by preoperative specialists. Examples include prescribing medications to optimize asthma or hypertension, treating infections, or instructing on perioperative anticoagulants and chronic medications. Similar to preoperative investigations, medical optimization may increasingly be considered part of a global fee, and referring the patient to a consultant adds inconvenience and cost, as well as reducing income.
While some certified registered nurse anesthetists (CRNAs) may have the training and interest to do perioperative optimization, many institutions find it is not the most efficient use of their skills. PCPs are well suited if they have guidance from anesthesiology. Consultants and anesthesiologists certainly can do it. However, as described previously, APPs working with anesthesiologists may be the ideal balance of skills and availability. If only a very few patients require additional evaluation and intervention, it may be more efficient to use nurse screening with involvement of a part-time anesthesiologist or consultant for those few cases.
ROLE OF THE SURGEON
An obvious omission from the potential staff for perioperative assessment and optimization is the surgeon. There are some surgeons who know their patients well, have maintained some knowledge of medical conditions, and continue to make time to attend to medical preparation. It is commended and encouraged when possible. However, it is increasingly an unrealistic approach. Surgeons have their own increasing demands on time and expertise, and preoperative medical evaluation and care may not have high priority.
EHRs can provide the benefit of a standard document that increases the likelihood that relevant information is gathered and recorded, regardless of who gathers it. EHRs can also provide a surplus of unneeded trivia and information that is not useful for preoperative care. Institutions must keep system-wide programs relevant to the perioperative period. The preoperative clinician must be empowered to produce a selective synopsis, not an unfiltered anthology.
1. Cohn SL. Preoperative evaluation for noncardiac surgery. Ann Intern Med. 2016;165(11): ITC81-ITC96.
2. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. J Am Coll Cardiol. 2014;64:e77-e137.
3. Keay L, Lindsley K, Tielsch J, et al. Routine preoperative medical testing for cataract surgery. Cochrane Database Syst Rev. 201214;(3):CD007293.
4. Olson RP, Dhakal IB. Day of surgery cancellation rate after preoperative telephone nurse screening or comprehensive optimization visit. Perioper Med (Lond). 2015;4:12.
5. Finegan BA, Rashiq S, McAlister FA, et al. Selective ordering of preoperative investigations by anesthesiologists reduces the number and cost of tests. Can J Anaesth. 2005;52(6): 575-580.
6. Fischer SP. Development and effectiveness of an Anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology. 1996;85:196-206.
7. Goldman L. Cardiac risks and complications of noncardiac surgery. Ann Intern Med. 1983;98(4):504-513.
8. Wijeysundera DN, Austin PC, Beattie WS, et al. Outcomes and processes of care related to preoperative medical consultation. Arch Intern Med. 2010;170(15):1365-1374.