Chapter 2 Practical Aspects of Preoperative Patient Management
2.1 Role of the Preanesthesia Assessment Clinic in Patient Blood Management
2.1.1 Function of the Preanesthesia Clinic
The preanesthesia clinic is an integral part of modern anesthesia departments and hospitals. Its role is to provide information and to take charge of the medical optimization and risk stratification of patients undergoing a surgical procedure under anesthesia. This also explains its pivotal role in the perioperative sequence of events. Although reports on the first preanesthesia clinics date back considerably (Howland and Wang 1956), it was only in the 1990s that this approach was used on a broader scale (Fischer 1996). The perioperative medical optimization of patients in particular would be inconceivable without a well-functioning preanesthesia clinic. Only the preanesthesia clinic can guarantee the timely enrollment of patients in a PBM program, i.e., enrollment with a sufficient time reserve. This calls for close cooperation between diverse specialist disciplines, which is possible only when there is widespread acceptance of the preanesthesia clinic as an institution in its own right. The aims are to reduce the transfusion rates and to improve the general perioperative course of disease and the scheduling of operations.
2.1.2 Organization of a Preanesthesia Clinic
Patient Flow and Appointment Scheduling
Patient flow in the preanesthesia clinic is determined by several factors. These include the clinic times and the organizational procedures used by the referring departments on the one hand, and various circadian factors on the other. It is beneficial to assure a regular patient flow throughout the entire day. Patient satisfaction is closely linked to the amount of time—including waiting times—patients spend in the clinic. Therefore, the patient flow should be regulated such that waiting times are kept to the minimum, and that the ratio of contact time (consultation/treatment time) to waiting time is high (Edward et al 2008, Harnett et al 2010).
In principle, there are three models of appointment scheduling from which a preanesthesia clinic can choose:
Appointments arranged in advance.
No appointments, as in the case of a walk-in clinic.
Combination of advance appointments and a system where a defined proportion of patients can present without an appointment.
▶ Clinic with scheduled appointments. In a clinic with scheduled appointments, patients are seen only if they have been given an appointment in advance. This helps to better allocate personnel resources and integrate services into the clinical pathways (e.g., management of admissions or diagnostic pathways for certain indications), and to reduce waiting times. However, it requires effective operational time management. Often, such a system will not have the flexibility to receive patients at short notice. Moreover, smooth functioning of a clinic with scheduled appointments depends on the contact time of the patients. The more variable these times are, the more difficult it will be to adhere to the scheduled appointments.
▶ Walk-in clinic. Compared with a clinic with scheduled appointments, a walk-in preanesthesia clinic that does not arrange appointments in advance faces certain drawbacks such as operational peaks and idle times when there is no patient contact, making it impossible to manage resources in a well-targeted and rational manner. Typically, peaks occur in the late mornings, when the highest patient throughput from referring clinics is expected. Naturally, these operational peaks mean increased patient waiting times and decreased patient satisfaction. The advantage conferred by a system that does not operate on the basis of fixed appointments is that it enables a certain amount of flexibility in scheduling appointments. This benefits patients who have to be integrated into the surgical schedule at short notice or because of an emergency.
▶ Combination. An appointment scheduling system that combines the two forms described above can offer the advantages inherent in both systems while minimizing the disadvantages. In particular, a certain amount of flexibility in arranging appointments increases acceptance among the referring parties. The proportion of clinic visits available without appointment should be tailored to the total proportion of acute operations in the operating room schedule.
Generally, organizational interventions can have a positive influence on waiting times and contact times in the preanesthesia clinic (Edward et al 2010).
Appointment scheduling is aimed at achieving patient satisfaction and optimizing resource utilization. Preference should be given to a combined system with a high proportion of fixed appointments and a certain number of freely available time slots.
Documentation and Administration
For administrative purposes, a preanesthesia clinic must be fully integrated into the hospital information technology system (HITS). This is essential because medical information, for example laboratory values and their progression over time, medical reports, and other medical history data, is required for the preoperative treatment of patients. Details of treatments received in, or suggested by, the preanesthesia clinic should be clearly documented in the HITS. Many of the current systems have facilities for the electronic allocation of appointments. This can greatly reduce the administrative effort.
A medical record must be maintained for each patient seen in the preanesthesia clinic. This should contain all the information needed for further preoperative measures, including any preoperative PBM optimization measures. The medical record should give a transparent overview of appointments, laboratory values, and treatment regimens ( Table 2.1 ).
Abbreviation: ASA, American Society of Anesthesiologists.
Human Resources Planning
▶ Length of stay of patients. Planning of human resources for a preanesthesia clinic should be tailored to the patient flow, patient group(s) (comorbidities, age) seen in the clinic, and services rendered. This plan should strike a balance between patient throughput, medical care, and personnel workload. For mixed patient groups, an effective length of stay of 20–30 minutes per patient can be assumed. This does not include the waiting time. The physician contact time should be estimated at 15 to 20 minutes. The given time frames must be viewed as a guide only, and can be shortened or prolonged if justified. Parameters that help to predict the length of stay in the preanesthesia clinic include the number of long-term medications, the patient’s physical status according to the American Society of Anesthesiologists classification, and the patient’s age (Dexter et al 2012).
▶ Nursing personnel. Assuming that 25 patients per physician can be seen per day, this amounts to a throughput of approximately 6,000 patients per year. To achieve these figures, it is imperative that administrative tasks and medical diagnostic procedures be delegated to secretaries and nurses, respectively. There are marked differences in the range of professional activities entrusted to nursing personnel in various countries. For example, nurses in Austria and Germany are not authorized to engage in independent professional practice, whereas graduate nurses in the United Kingdom, the Netherlands, France, and Switzerland have much greater competencies. Therefore, it is not possible to give general recommendations for preanesthesia clinics. It should, however, be possible to achieve an optimum division of the workload in accordance with the legal regulations.
▶ Medical specialist personnel. The qualifications required by the medical specialists who work in preanesthesia clinics are a matter of much debate in clinical practice. However, there is unanimous agreement that at least one anesthesiologist is required (ÖGARI 2012a). Important decisions such as the therapeutic measures to be taken for PBM should be left to the anesthesiologist. Besides, having an anesthesiologist on site has financial implications because the number of preoperative tests ordered depends on the medical specialty and qualification of the requesting physician (Vogt and Henson 1997, Katz et al 2011). The preanesthesia clinic is the ideal place for providing the patient with information in accordance with the guidelines. The financial benefits can be clearly calculated and documented (Flamm et al 2011). In-depth knowledge of the processes of PBM and preoperative evaluation can be imparted on a routine basis in a preanesthesia clinic.
The documentation of activities in the preanesthesia clinic is intended as a means of assuring the highest possible standard of information provision and communication. The electronic documentation systems available in the hospital should be used.
2.1.3 Therapeutic Measures in the Preanesthesia Clinic
The preoperative optimization of patients scheduled to undergo a surgical procedure can dramatically influence the outcome. Medical interventions aimed at improving the physical state of pre-operative patients are best undertaken at a site where medical information and competence are concentrated. Hence, a well-managed preanesthesia clinic is eminently suited to this task. The chief determinant of a successful outcome is the timely implementation of such optimization measures. If undertaken too close to the date of surgery, medical interventions may even present a danger to patients, or at best be ineffective. Often, a number of weeks are needed for the patient to respond to preoperative optimization. Another benefit of the timely implementation of interventions is that they offer the chance to monitor and, if necessary, adjust or modify treatments. Cooperation with other specialist disciplines is advantageous in the case of PBM, especially if preoperative anemia is multifactorial or if the patient has a complex comorbidity. In this regard, hematology and nephrology play a key role.
▶ Structural prerequisites. As already mentioned, certain structural preconditions for therapeutic measures must be met:
Swift and easily accessible diagnostic testing and contact with other specialist disciplines such as cardiology, hematology, nephrology, and neurology.
A sufficient number of suitably equipped treatment rooms.
Reimbursement guarantee for the therapeutic agents and their administration.
Medical competence is an indispensable prerequisite because of the complex nature of the problems associated with PBM. Training and provision of information to the entire medical personnel of a preanesthesia clinic underpins the quality of pre-operative optimization strategies.
The preanesthesia clinic is the ideal place to plan and implement measures aimed at optimizing the postoperative outcome.
2.1.4 Patient Blood Management in the Preanesthesia Clinic
Each preoperative optimization strategy must be organized in a stringent and reproducible manner. This includes allowing for a sufficiently long interval between therapeutic measures, such as preoperative iron therapy, and the operation date. It is unacceptable in the case of PBM that patients do not attend the preanesthesia clinic until the day before the scheduled operation. The ideal time for a preoperative patient consultation in the preanesthesia clinic is 4 to 6 weeks prior to the date set for surgery. In practice, PBM comprises a complex network of collaborations, and this should be made clear from the outset. The following disciplines are involved: surgical disciplines, anesthesia, hematology, and transfusion medicine.
Organization of PBM
It is generally advisable to draw up a plan for the introduction of PBM. The project management should be left to the management board of the preanesthesia clinic because of the integrative and multidisciplinary functions of the clinic. It is recommended that the details regarding planning, implementation, and audit of the PBM project are set out in writing in the form of a project plan.
Planning, Information, and Implementation
First of all, the potential medical partners in the hospital should be identified. Ideally, certain surgical disciplines and procedure types should be defined as suitable candidates for PBM on the basis of their associated transfusion rates. Once suitable patient groups and surgical disciplines have been identified, contact must be established and stringent agreement on the order of events must be reached. In a pilot phase, it must be determined which, and how many, patients are suitable candidates for PBM, and how they will benefit from PBM. Likewise, it must be established in advance whether, and to what extent, PBM patients will represent an additional burden to the preanesthesia clinic in terms of time and personnel resources.
The following organizational steps are advisable at the time of introducing a PBM project.
▶ Planning phase. Right at the start of the project, suitable patient groups should be identified and initial contact should be established with the respective surgical disciplines. Next, evaluation of patient throughput is recommended. The preoperative process will need to be modified if patients only present to the preanesthesia clinic on the day before surgery. It is important that certain parties are appointed to take responsibility on behalf of the clinic and of the surgical partners. This communication channel is essential throughout the entire project. Presentation of the financial aspects of the project is advisable because the need for any additional resources should be justified. One way to ensure financial evaluation of the project would be to establish contact with the hospital’s accounting department and to request supervision of the project.
▶ Information and training of all participants. After the planning phase, it is important to pass on information to all participants in a well-regulated, selective, comprehensive, and easily accessible manner:
Information seminars: The aim of information seminars is to reach all participants, not forgetting any professional group, since hospital processes are often codetermined by administrative and nursing personnel.
Process description in the form of a manual or other information materials: This manual should list all patient routes and the responsible personnel. It is also advisable to define algorithms and dosage regimens for preoperative treatment regimens such as iron and erythropoietin therapies.
▶ Pilot phase. In the pilot phase, a limited number of patients should be enrolled in the PBM project for a defined period of time (ideally only for a few months). The entire pilot phase should be evaluated in medical and financial terms.
▶ Implementation phase. Any weak links in the organization and implementation can be identified during the pilot phase. These should be documented during the implementation phase and appropriate remedial measures should be taken. It is recommended that the medical and financial performance of the project is evaluated at regular intervals. Often, the communication and information channels need to be improved. Naturally, PBM can only be effective if as many patients with preoperative anemia as possible are identified and appropriately treated.
Preoperative Examination and Clinical Aspects Specific to PBM
The preoperative evaluation should be based on the current guidelines and recommendations (Geldner et al 2010, De Hert et al 2011, ÖGARI 2012b). These guidelines are designed to help identify patients who can potentially be included in the PBM project. The criteria to consider when deciding whether PBM strategies are indicated are the type of surgery, the comorbidities associated with anemia, and the patient’s age, sex, and body mass index.
Severity Classification of Surgical Procedures
During the preoperative evaluation, the type and invasiveness of a surgical procedure must be determined. The guidelines available use somewhat different classification systems.
▶ American College of Cardiology/American Heart Association and European Society of Cardiology. The tripartite classification employed in the guidelines of the American College of Cardiology/American Heart Association and the European Society of Cardiology is used on a broad scale ( Table 2.2 ) (Fleisher et al 2009, Poldermans et al 2009). This categorization of surgical procedures determines the cardiac risk of a given operation. For patients undergoing a procedure belonging to the moderate- or high-risk category, it is necessary to identify any existing anemia and to enroll patients for PBM if required.
▶ Austrian Society for Anesthesiology, Resuscitation and Intensive Care (ÖGARI). Another method of classifying procedures is that proposed by the Austrian Society for Anesthesiology, Resuscitation and Intensive Care (ÖGARI 2012b). Here operations are classified according to three criteria: duration of the operation, potential blood loss, and anatomical region ( Table 2.3 ). All patients with a predicted intraoperative blood loss of more than 500 mL should be assigned to the PBM program. The volume of 500 mL is independent of the patient’s weight or height and serves only as a guide value that was deliberately kept small. What is important is that no patient who might need a transfusion or is at risk of significant anemia is missed during preoperative diagnostic testing. The basic threshold for the need for transfusion is a blood loss of 10–15 % of the calculated blood volume. The guideline algorithm stipulates the requirement for a blood count during the initial series of tests.
Each preoperative evaluation should start with a medical history. Further tests will only be performed in combination with clinical examination. The aim of taking the history is to obtain a comprehensive overview of the patient’s entire state of health prior to surgery. Special attention must be paid to certain organ systems, such as the cardiovascular system, kidneys, liver, hematopoietic system, and coagulation system, in relation to PBM. It should be borne in mind that diseases of these organ systems are often associated with anemia and with unexpected intraoperative bleeding complications. Cancer patients who are scheduled to undergo neoadjuvant chemo- or radiation therapy need special attention.
It is recommended to use standardized medical history forms, focusing in particular on the cardiac history, the cardiac stress test results, and the coagulation history. In addition to the type of procedure, any abnormal findings in the medical history constitute risk factors for perioperative complications (Fritsch et al 2012).
▶ Coagulation history. Taking a detailed coagulation history is imperative to detect any existing coagulation disorders. This is of greater diagnostic relevance than conventional laboratory parameters such as prothrombin time, partial thromboplastin time, and platelet count (Pfanner et al 2007). Any measures designed to reduce blood transfusions must be viewed in the context of the functioning of the coagulation system. If coagulation abnormalities are suspected, further laboratory tests, such as prothrombin time, partial thromboplastin time, platelet count, and fibrinogen testing, are indicated. Special attention should be paid to platelet function.
▶ Transfusion trigger. A transfusion threshold must be defined for each patient in the preanesthesia clinic, based on a thorough understanding of the patient’s underlying conditions and demographic characteristics. The guiding principle is that transfusion in the clinical setting should be tailored to the clinical symptoms. For example, typical lead symptoms are chest pain, orthostatic intolerance, and fluid-refractory tachycardia.
The preanesthesia clinic is the hub of PBM. Its most important prerequisite is the provision of high-quality administrative and medical services that are based on current guidelines.
2.2 Role of the General Practitioner
2.2.1 Health Care Sectors
The role of the general practitioner (GP) differs remarkably in the health care systems in Western countries. In Germany, for example, approximately 90 % of the population have a GP, who is usually (but not necessarily) the first physician to consult in the ambulatory care sector. For most of their lifetime, patients will be cared for by their GP. Only 5 % of a GP’s patients are treated in a hospital. At the same time, some 50 % of all physicians work in the inpatient sector (BAEK 2011b). The two sectors often come into contact with each other when patients are admitted to hospital, in particular during the preoperative preparation for an elective procedure. Chapter 2.1 describes the challenges faced when defining standards for the preoperative preparation of patients for elective procedures in general practice.
In most countries, the majority of the population is cared for by GPs.
2.2.2 Role of the General Practitioner in Preoperative Assessment
To understand the role of the GP in preoperative assessment, understanding the status of primary care is of major importance. For example, in Germany current legislation makes a clear distinction between the inpatient and outpatient sectors. Office-based GPs are reimbursed through the National Association of Statutory Health Insurance Physicians (KBV) if they are involved in the preoperative assessment before procedures performed in the outpatient or GP-ward setting.
▶ Prerequisites for outpatient operations. Patients must meet certain medical and social prerequisites to be considered as suitable candidates for outpatient surgical procedures. In particular, such patients have no underlying general disease (“otherwise healthy patients”) or, at most, only a mild form of a general disease. Based on the classification of the American Society of Anesthesiologists (ASA), these are patients belonging to ASA groups I and II. The social prerequisites include having someone available to care for the patient during the first 24 postoperative hours. The procedures that best lend themselves to the outpatient setting are operations involving a minimal risk of secondary bleeding or postoperative complications, and procedures that do not require any special postoperative care (DGAI 1999).
▶ Responsibilities of the general practitioner. For these types of procedures and patients, intensive preoperative diagnostic testing is only needed in exceptional cases. The GP’s main task will be to ensure that only those patients undergo outpatient surgery who belong to ASA groups I and II and who also meet the other criteria mentioned above, rather than determining which additional diagnostic tests should be performed. As such, the treating GP plays a pivotal role in assuring the safety of an outpatient procedure. In addition to verifying the patient’s suitability, the GP gives advice and discusses the pros and cons of outpatient surgery.
In Germany, preoperative assessment is reimbursed at €60 for patients aged 60 years or more. We mention this figure to clarify the scope of the preoperative workup expected from the GP. It includes medical history taking, a complete physical examination, and the preparation of a medical report that sets out all the information that is relevant for the anesthesiologist and the surgeon. The report should include a complete list of current medications, an overview of all relevant diagnoses, and warnings of allergies or intolerances. As an optional service, the GP may assess the patient’s suitability for surgery, and perform a resting electrocardiogram or laboratory tests if this is warranted by findings from the medical history or physical examination. The results should not be older than 6 weeks.
2.2.3 Collaboration between Health Care Sectors
In line with the increasing population age in other developed countries, one-third of the German population will be aged 65 years or more by 2060. It is expected that population aging will be accompanied by rises in the number of chronic diseases and, accordingly, in the number of medications taken. In 2010, patients aged 65 years or more received an average of 3.6 daily doses of medication. Some 42 % of this age group received five or more active ingredients, thus meeting the definition of polypharmacy (Thürmann et al 2012). In terms of patient safety, this opens up a number of prospects for cross-sector collaboration. In particular, the GP’s knowledge about patients, their medical history, and their medication should not be lost at the interface between ambulatory and hospital care.
▶ Information for the hospital clinician. When being admitted to hospital, patients should receive a list of their current medications, including overthe-counter drugs. This applies even to patients who are not scheduled for surgery. Information about complications that occurred during previous procedures, and about intolerances or previous allergic reactions, can provide valuable insights to hospital clinicians. Measures to optimize the blood sugar metabolism should be taken prior to admission.
▶ Information for the general practitioner. In an age of increasingly shorter hospital stays and, accordingly, of discharge earlier during the postoperative period, hospital clinicians should ensure that the GP will receive any important information in a timely fashion to effect a smooth transition from the inpatient setting to ambulatory care. For example, the information provided by the discharging physician is essential for the organization of care at home or at a nursing home. Medication prescriptions at discharge should ideally reflect the main medications used in the outpatient sector (KBV 2011).
In the interest of patient safety, both hospital clinicians and GPs should be provided with comprehensive information at an early stage.