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* From the Department of Anesthesia, Stanford University School of Medicine, and the Preoperative Evaluation Program, Stanford University Hospital, Stanford, CA.
Correspondence to: Stephen P. Fischer, MD, Preoperative Evaluation Program, Stanford University Hospital, Stanford, CA 94305; e-mail: fischer_s{at}hosp.stanford.edu
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Abstract |
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 TOP Abstract IntroductionThe Preoperative Evaluation...Changes and the Necessity...Preoperative Laboratory Testing...References |
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Introduction |
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TOPAbstractIntroductionThe Preoperative Evaluation...Changes and the Necessity...Preoperative Laboratory Testing...References |
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In preoperative patient preparation, physicians are directly responsible for providing and ordering virtually all of the patient evaluation, preoperative diagnostic testing, and referrals to specialists. It is often difficult for the individual physician or group to change the manner or routine of clinical practice patterns. Cost-effective preoperative evaluation is within the ability of each health-care provider and can be approached from a variety of methods, education, and the use of data to modify clinical practice. The first step toward positive redirection in today’s practice of medicine must begin with the awareness of physicians and the willingness to change their approach to patient care. Keys to promoting cost-effective preoperative preparation include the following: (1) physician education and modification of physician practice (for example, learn the cost of each diagnostic test ordered preoperatively); (2) review and adapt practice guidelines; (3) utilization of clinical pathways (requires interdepartmental teamwork); (4) information sharing (in areas of evaluative protocols and avoiding duplication of services); (5) economic analysis (cost identification, effectiveness, and cost-benefit studies); (6) medical resource management (in efficiency and effectiveness); and (7) outcomes measurement.
This article will focus on proposed organizational and clinical changes in the process of preoperative evaluation, the cost-effective outcomes, and the relative merits these changes provide the physician, operating room nurses, and center administrators.
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The Preoperative Evaluation Clinic |
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A centralized PEC is a positive investment and value in hospital management and hospital quality enhancement.4 5 6 7 8 9 10 11 12 13 14 The PEC can become a recognized center for establishing a standard of efficient clinical services, decreased costs, and for increased patient/surgeon satisfaction.
The operational goals adopted for Stanford University Hospital’s PEC are summarized below: (1) to improve the client’s perception of the preoperative evaluation experience by increasing personalized patient care, comfort, and convenience; (2) to provide a centralized site for preoperative evaluation; (3) to institute an anesthesia scheduling system for timely patient access and flow; (4) to ensure the presence of an anesthesiologist on-site when patients are present; (5) to appoint a medical director of the PEC to coordinate all activities; (6) to ensure the availability of medical records and surgical notes at the time of the preoperative evaluation; (7) to decrease logistical shuffling of patients to multiple hospital service areas; (8) to integrate and coordinate services by means of on-site admitting/registration, insurance authorization, and on-site laboratory and EKG facilities; (9) to improve education of patients and families about the elements of their surgical procedure and the proposed anesthesia, including postoperative pain control options; (10) to ensure and coordinate cost-effective ordering of preoperative laboratory and diagnostic studies; (11) to provide a medical consultation service for evaluation of medically complex inpatients and outpatients; (12) to decrease cancellations and delays of operative procedures on the "day-of-surgery"; (13) to enlist the skills of a registered nurse practitioner to assist in preoperative evaluations and patient/family education; (14) to develop protocols, policies, and clinical pathways; (15) to perform quality assurance reviews; (16) to maximize efficiency in operating room function and turnover time by coordinating all preoperative information into one location (the PEC); and (17) to enhance patient and surgeon satisfaction.
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Changes and the Necessity of Teamwork |
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TOPAbstractIntroductionThe Preoperative Evaluation...Changes and the Necessity...Preoperative Laboratory Testing...References |
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Preoperative Laboratory Testing and Diagnostic Studies |
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TOPAbstractIntroductionThe Preoperative Evaluation...Changes and the Necessity...Preoperative Laboratory Testing...References |
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Unnecessary testing is inefficient, expensive, and requires additional technical resources. Inappropriate studies may lead to evaluation of "borderline" or false-positive laboratory abnormalities. This may result in unnecessary OR delays, cancellations, and potential patient risk through additional testing and follow-up.
The surgical patient requires preoperative laboratory and diagnostic studies that should be consistent with his or her medical history, the proposed operative procedure, and the potential for blood loss. Preoperative laboratory and diagnostic testing should be ordered for specific clinical indications, rather than simply because the patient is about to undergo a surgical procedure.
Preoperative diagnostic guidelines provide basic recommendations. They are not intended as absolute or standard requirements. Practice guidelines should be modified based on clinical needs and individual practice to ensure the highest quality of anesthesia and surgical patient care.
Chest Radiograph
Overview: A preoperative chest radiograph should be
utilized to assess presence of acute, progressive, or chronic changes
of cardiac/pulmonary disease. The decision to obtain a preoperative
chest radiograph should be individualized and based on clinical
indications. Chest radiographs should not be a routine preoperative
protocol.
Clinical Indication: These include the following: pneumonia; pulmonary edema; atelectasis; aortic aneurysm; mediastinal or pulmonary masses; trachea deviation; pulmonary hypertension; cardiomegaly; advanced obstructive lung disease and blebs; dextrocardia; and pulmonary embolism.
Electrocardiogram
Overview: ECG evaluates cardiac rhythm/conduction
disturbances, ischemia, myocardial infarction, metabolic and
electrolyte disorders, and hypertrophy. Suspected or known history of
coronary artery disease, patient age > 50 years, cardiovascular risk
factors, and type of surgery are important factors.
Clinical Indication: These include the following: hypertension; chest pain; congestive heart failure; diabetes; cerebral vascular and peripheral vascular disease; syncope or presyncope; dizziness; shortness of breath; dyspnea on exertion; paroxysmal nocturnal dyspnea; palpitations; leg/ankle edema; and abnormal valvular murmurs.
Liver Function Tests
Overview: Included are aspartate transaminase, alanine
transaminase, 
-glutamyl transferase, alkaline phosphatase, serum
albumin, and bilirubin. Liver function tests establish the absence or
presence of hepatic injury and the degree of hepatic reserve in disease
states.
Clinical Indication: These include the following: hepatitis (infection [viral], inflammation [alcohol, drugs], infiltration [tumor, immunologic]); cirrhosis; portal hypertension; gallbladder or biliary tract disease; jaundice; and intravascular hemolysis.
Renal Function Testing
Overview: Basic includes creatinine and BUN; extended
includes electrolytes, serum/urine osmolarity, and creatinine
clearance. Renal function testing determines the extent of renal
tubular function and glomerular filtration in patients with known or
suspected renal dysfunction.
Clinical Indication: These include the following: hypertension, increased fluid overload (congestive heart failure/peripheral edema/ascites) associated with cardiac, hepatic, or renal impairment; dehydration; diabetes; nausea, emesis, or anorexia; polyuria; nocturia; oliguria; anuria; high-risk surgery in patients with low cardiac output syndrome; hematuria; CVA pain; renal transplant history; renal disease; and dialysis.
Hemoglobin, Hematocrit, CBC
Overview: WBC abnormalities, anemia, or polycythemia
history requires preoperative baseline determination in patients with
known or suspected hematologic disorders. The decision to obtain a
preoperative hemoglobin, hematocrit, or CBC count should be
individualized and based on clinical indications, medical history, and
the proposed surgical procedure. Hemoglobin/hematocrit or CBC count
should not be a routine preoperative protocol.
Clinical Indication: These include the following: hematologic disorder; bleeding/coagulopathy history; malignancy; chemotherapy; radiation therapy (CBC); renal disease; anticoagulant and steroid therapy; surgical procedures with high blood loss (> 1,500 mL); highly invasive or trauma surgery; malabsorption/poor nutrition status; and CNS disease.
Pregnancy Testing
Overview: This test is to diagnose pregnancy. Several
assays are available (serum human chorionic gonadotropin [HCG], urine
HCG); ß-HCG is detectable in maternal urine and blood 8 to 9 days
postconception. The decision to obtain a preoperative pregnancy test
should be individualized and based on clinical history and examination.
Clinical Indication: These include the following: sexually active status; time of last menstrual period; presence or absence of birth control method; and patient intuition.
Coagulation Testing
Overview: Testing includes prothrombin time, partial
prothrombin time, international normalized ratio, and platelet count.
Coagulation testing or clotting function studies should not be routine
but obtained in patients with known, suspected, or potential
coagulopathies secondary to medical history and drug therapies.
Clinical Indication: These include the following: bleeding disorder history; anticoagulants or other drugs affecting coagulation; critical risk surgical procedures with significant blood loss expected; hepatic disease; and malabsorption/poor nutrition.
Urine Analysis
Overview: Included are the following: assessment of
renal function, inflammation, and infection; intravascular volume
status; and metabolic disorders. There are no routine anesthesia
preoperative requirements for a urine analysis.
Figure 3 summarizes the suggested preoperative laboratory testing for selected medical conditions and diseases.
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References |
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TOPAbstractIntroductionThe Preoperative Evaluation...Changes and the Necessity...Preoperative Laboratory Testing...References |
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This article has been cited by other articles:
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  A. Ferrando, C. Ivaldi, A. Buttiglieri, E. Pagano, C. Bonetto, R. Arione, L. Scaglione, E. Gelormino, F. Merletti, and G. Ciccone Guidelines for preoperative assessment: impact on clinical practice and costs Int. J. Qual. Health Care, August 1, 2005; 17(4): 323 - 329. [Abstract] [Full Text] [PDF]
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 S. Dzankic, D. Pastor, C. Gonzalez, and J. M. Leung The Prevalence and Predictive Value of Abnormal Preoperative Laboratory Tests in Elderly Surgical Patients Anesth. Analg., August 1, 2001; 93(2): 301 - 308. [Abstract] [Full Text] [PDF]
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