Transforming the preoperative patient consultation: from “clearance” to “evaluation and optimization”

A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.

Put yourself in the anesthesiologist’s shoes. It’s 7:00 a.m., and you’ve just finished setting up the operating room (OR). You make your way to the preoperative unit to evaluate your patient and find a prescription pad note that says, “Patient cleared for surgery at acceptable risk.” As you review the chart and speak to the patient, it becomes apparent the patient has multiple serious cardiac and pulmonary comorbidities, so you quickly seek additional information. It’s now 7:30 a.m., and you still can’t find documentation regarding the patient’s coronary artery disease, recent echocardiography, or chronic obstructive pulmonary disease (COPD). You’re under pressure from the surgeon, nurse administrator, and anesthesia practice director to have the patient in the room on time, so what do you do? Where was the breakdown that led to the patient’s chart being so scantily populated?

The top priority of the anesthesiologist is the safety of the patient and to ensure the patient’s clinical status has been optimized preoperatively. Although maximizing OR use, avoiding case cancellations, and minimizing length of stays are priorities in health care, this is often dependent upon safe and effective perioperative care by anesthesiologists. This includes not only the care received by patients in the OR and the post-anesthesia care unit (PACU) but also the preoperative consultation prior to surgery.

The final “clearance” for a patient to receive anesthesia comes from the anesthesiologist. It is the anesthesiologist who assesses the patient’s current clinical condition and decides whether it is safe to deliver anesthesia, taking into account whether the procedure is emergent. Nonetheless, it has become commonplace to hear statements such as: “This patient needs clearance,” “This patient has a clearance note,” or “We can’t go to the OR without clearance” on a near daily basis. These statements, while well-intentioned, actually hold very little weight and tell us next to nothing about what the patient needs or what workup they have already received.

The more appropriate terms we should use instead of “clearance” are “evaluation and optimization.” These terms much more clearly define what documentation anesthesiologists are seeking from physician specialist colleagues, such as cardiologists, pulmonologist, and hematologists. When we send patients to cardiologists, for example, a note saying “patient cleared from cardiology perspective for moderate risk” or recommending “cardiac anesthesia” has a greater chance of causing frustration, than assisting in the management of a patient.

A thorough evaluation of a patient’s current clinical condition is a critical step in the preoperative consultation. For example:

  • If the patient is hypertensive, is it well controlled, and is the patient compliant with their medication? Does the patient have any sequelae associated with the hypertension or signs of end-organ damage? Does the patient have associated comorbidities that may be causing the hypertension?
  • If the patient has coronary artery disease, are they currently stable, or are there changes in the patient’s activity level or symptom profile since their last echocardiogram or stress test? Is there further testing needed?
  • If the patient has COPD, do they require oxygen? Have they recently been hospitalized? What medications do they use? Has there been a recent change in activity level?

The importance of a thorough evaluation cannot be overstated. As anesthesiologists, we are trained to take care of the sickest patients. Having knowledge of the patient’s most current clinical condition allows us to navigate even the most treacherous of patient conditions successfully. Understanding a patient’s current condition helps us to prepare an anesthetic plan, discuss the risks and benefits of anesthesia accurately with patients and their families, anticipate potential complications, and prepare for potential perioperative emergencies.

Optimization goes hand in hand with the evaluation. The key question anesthesiologists need answered by physician specialists is: “Have the patient’s chronic conditions been optimized to the best of our ability prior to surgery?” Particularly for elective surgery, we are asking whether we can further minimize perioperative risk. For example:

  • If the patient is hypertensive and it is poorly controlled, is there another medication we can add to improve the patient’s perioperative blood pressure? Does the patient need workup for conditions that may be contributing to severe hypertension?
  • If the patient has new symptoms related to their coronary artery disease, do they now need a stress test or a cardiac catheterization? Does the patient require evaluation by a cardiothoracic surgeon for a valve replacement for a new valvular lesion? What takes priority – a new coronary stent for exertional symptoms or the patient’s surgery?
  • If the patient’s COPD is severe, are they on all the medications that can possibly assist with this disease? Or does the patient now need pulmonary function testing to evaluate for new medications to assist with their breathing?

A poor preoperative consultation (or poor documentation) can negatively affect perioperative patient care. Although anesthesiologists delay or cancel cases as a last resort, they may have to when provided a poor preoperative consultation. Not surprisingly, patient satisfaction can be significantly affected by a surgical delay or cancellation. Surgeons are also negatively affected by delays and cancellations, costing them valuable time and clinical revenue, as well as the opportunity to help another patient. Additionally, perioperative efficiency is affected by lost or delayed surgical time, with a negative drain on physical space resources, nurse and technician labor, as well as lost revenue from an OR that remains open and unused.

Anesthesiologists play a critical role in ensuring patient safety while maximizing OR efficiency, avoiding case cancellations, and minimizing length of stays for patients in the perioperative period. Many studies have shown that anesthesiologists reduce unnecessary testing, same-day cancellations, perioperative emergencies, surgical complications, and the risk of hospitalization after outpatient surgery. Anesthesiologists can do this more efficiently when physician specialists provide “evaluation and optimization” of patients during the preoperative consultation. In fact, anesthesiologists can actually reduce unnecessary consults when involved earlier in the preoperative evaluation process.

To improve this process, changes may be required in several areas, including systems, workflows, and education. Systems or workflow changes may include clarification regarding which personnel ordered a specialist “consultation” prior to anesthesia care. Is the referral ordered by anesthesia personnel in a pre-anesthesia clinic or by a surgeon in their office? Is the consultation ordered by medical professionals or by clerical staff? Is a formal request written on paper, or is the consultation requested by phone or electronic order? Does this institution provide a form for the specialist to fill out or provide documentation regarding the patient’s condition that needs evaluation and optimization? It is important to remember that specificity helps everyone on the patient’s care team. If a clinician is requesting evaluation of a patient’s coronary artery disease, one must not rely on the cardiologist reading their minds; instead, they can write a note or a formal order asking for assessment and risk stratification of that disease state. Also important is evaluation by an anesthesiologist prior to referral for a consultation. Even in cases where a pre-anesthesia clinic is run by resident physicians or other health care professionals, the need for consultations should be assessed by a supervising anesthesiologist to ensure the information obtained by the consult truly facilitates the successful completion of that patient’s surgery in a timely and efficient manner.

Educational interventions are also critical if we hope to improve the “clearance” process and move successfully to “evaluation and optimization.” It is important to convey to all relevant health care stakeholders the purpose of the referral for consultation, the process required, and potential side effects of a poor clearance to ensure accountability. Relevant stakeholders who need to be involved in this process include the health care and clerical staff of surgeons’ offices and pre-anesthesia clinics, as well as all perioperative staff at hospitals or ambulatory surgical centers. Understanding the purpose of the consultation ensures that everyone who reviews the chart will be on the same page regarding what information is needed to safely proceed with anesthesia care.

While anesthesiologists’ top priority is ensuring the safety of the patient, we also strive to complete the surgical procedure in a safe, efficient, and timely manner. Help us shift the conversation from “clearance” to “evaluation and optimization” to ensure that preoperative consultations achieve the goal of ensuring safe and timely surgery for patients.

George Tewfik, Monica Harbell, Emily Methangkool, and Stephen Rivoli are anesthesologists.

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