Pre-Anesthesia Screening Algorithm

[callmeanesthesia]

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I'm an anesthesia-trained pain doc working at an ortho group. The surgeons keep getting cases canceled due to the anesthesiologist or CRNA wanting more cardiac workup. Long story short, I'm trying to develop a preop workflow using a web form and an MA, that can appropriately risk-stratify most patients according to established guidelines into needing cardiology clearance or not. Some background: Some of the anesthesia providers are apparently quite conservative - a surgeon complained to me that a patient with a BMI about 35 and hypertension, no other comorbidities, got canceled because the CRNA thought he should have a cardiology clearance. On the flip side, the surgeons are taking a surgical history, so a lot of serious comorbidities only come to light when the ASC or hospital does their pre-op eval a week before surgery, resulting in unfilled OR slots because someone had a cardiac history that wasn't caught. The director of anesthesia for the ASC is a semi-retired guy who is also pretty conservative. I tried to talk to him about this project and when I talked about the ACC/AHA preop testing guidelines he seemed unfamiliar. The ASC also won't take anyone with even a family history of MH.

I've spent hours reviewing the ACC/AHA guidelines, various preop risk calculators (RCRI, NSQIP, Gupta, ARISCAT, DASI), ASA and SAMBA preop protocols and guidelines. I can build a form that will do a nice job of collecting an anesthesia history including anesthetic complications, cardiac history, other medical history, and functional status. I'll incorporate that with some vitals and labs from the MA. What I'm struggling with is how to put that together into a meaningful algorithm. I can follow the ACC/AHA algorithm by using the presence of risk modifiers in the history plus the RCRI (or Gupta periop risk score, if I let the surgeons pick an ASA status), then use the DASI to determine if <4 mets, then have the MA place an order for a cardiac clearance/stress test if indicated. However, the risk scores use so few criteria and our anesthesia providers are so conservative that I'm worried this will still result in a lot of cancellations. Someone with NIDDM, HLD, OSA, and a 2 pack a day smoking habit still scores zero on the RCRI as long as they haven't their MI or stroke yet.

I can either just have the form output a letter saying "Per ACC/AHA Perioperative Cardiovascular guidelines, this patient has RCRI of 0 (or elevated RCRI but >4 METS functional capacity) therefore no further testing is indicated" (suck it up Mr CRNA and do your job) or I can maybe try to use the Framingham calculators to capture more of the comorbidities like NIDDM, HTN, HLD, and smoking, and maybe say, anyone with a 20% 10 year CHD risk needs cardiac clearance. Problem with that is that it isn't really evidence-based and I'm just sort of making up my own periop testing guidelines.

What do you all think? Is this a hopeless project? Yes, I realize ideally this would be done by a pre-anesthesia clinic. We're a private practice ortho group, we don't have an affiliated anesthesia group that could do this for us, and our business office is wasting massive amounts of time chasing down unnecessary clearances because the surgeons are trying to cover against getting stuff canceled.

Anyone with a coding/development background want to collaborate with me on this? We could build an app and sell it to surgical private practices all over the country. We could even make the risk tolerance tunable to the local environment.

 

[callmeanesthesia]

Do you have an anesthesia medical director? Because this is their job. Nurses (or MAs I guess) can ask screening questions in a preop call, but if anything pops up yes it goes to the anesthesia director to figure out. If they feel additional testing is needed you should have plenty of time to do it or at least enough heads up to schedule someone else in their slot. If it seems like too much testing, that's a discussion to have. Maybe they're overtesting. But at least it's done before day of surgery.

Day of surgery anesthesia may always have different thoughts and still cancel a case occasionally but that should be very rare.

The BMI > 35 thing is weird but if your anesthesia is uncomfortable it may be best for everyone to just not do those cases with that anesthesia.

I am a coder and have built these sorts of apps but are you sure it's necessary?

Problem is there are 4 different facilities. Each one has a different anesthesia provider/group and in general they’re doing their preop assessment (the ASC for example has patients fill out a form through One Medical Passport) 1-2 weeks ahead of surgery. Then it’s getting reviewed by the anesthesia director maybe a week before surgery. If he decides they need cardiac clearance it’s impossible to get it that fast, and almost impossible to fill the hole in the schedule.

My ideal state here is:
1. Surgeon sees patient in clinic and they decide on surgery.
2. Patient is directed to “Pre-surgery” desk on the way out (staffed by MAs of whichever surgeon is in the OR that day).
3. MA finds out where patient has had labs and testing done and works on retrieving them digitally (Quest portal, HIE, etc). Meanwhile patient fills out history form on tablet.
4. Results go to MA, who inputs relevant labs (Cr, A1C, Hgb), vitals, and details of surgery (low/moderate risk, anesthesia type requested).
5. Output is a word or PDF document with risk stratification outcome, red flags or contraindications for ASC (e.g. BMI threshold), names of patient’s current specialists, and a nice summary of their history of anesthesia and their pertinent medical history.
6. Patient gets EKG if needed, lab slip if needed. Orders are placed for clearance referrals if needed, for surgeon to co-sign.
7. If patient is low risk and no pre-auth required, patient is scheduled for surgery before leaving.

If this seems like overkill, our current process is worse and wastes so much time. We have several surgeons who gets PCP clearances on in total joints. I looked through one’s queue and it took our business office staff 3 months and over a dozen phone calls to make that happen. Several where they got cardiac and PCP clearance, insurance auth, only to find ther A1C was too high.

(Also I’m going to use this for my QI project for MOCA…)

 

[CopaceticOne]

Or… the surgeons can be real doctors and actually get a full medical history from the patients. They, or at least their MLP staff, should know what is needed to proceed to surgery. Shocking concept, I know!

A web form and an MA isn’t going to solve the apparent lack of clinical decision making on preop eval. Obviously whatever process flowchart or “algorithm” being used sucks is cases are frequently cancelled on the day of surgery.

Addendum: Your proposal is trying to fix things on the back end. Unfortunately, the real sustainable fix will be on the front end.

 

[PpfSuxTube]

Yeah dont employ idiots. Problem solved

 

[callmeanesthesia]

These are orthopedic surgeons. They’re good guys, and generally efficient, but I don’t think it’s reasonable to expect them to take a full anesthesia H&P in addition to the surgical evaluation. Doesn’t help that our EMR isn’t great so our intake forms are on paper. We could put the questions on our intake but that will only help if it’s a new patient. We have a lot of long-established patients and internal referrals, and patients tend to not fill out the paperwork fully when they’ve done it before. “See chart” etc.also our local payout mix sucks, so they all pretty much have to be 90th percentile plus productivity to make even a halfway decent income, even with ASC shares.

I’m not trying to eliminate clinical decision making, just reduce the burden of it. I’ll sort patients into low, moderate, and high risk. Low goes to scheduling. High goes to clearances. Moderate goes back to the surgeon for review and decision on clearances. I’m just hoping to make that moderate category as small as possible.

I’ve already started building this out - we have a FormSite subscription (HIPAA-Compliant tier). It’s just that Formsite’s built in ability to score things and do logic is clunky. It can take custom code so I can paste in Javacript to do things like calculate a score and store it to another field. However, the biggest problem there is that I don’t know how to write code. I’ve done the best I can by having ChatGPT write it for me, and I’ve even managed to make several components work, but it’s like a blind man who has only felt an elephant trying to tell a sighted man who’s never even seen a picture of one how to paint it.

Low risk surgeries are another tricky point I’ve been trying to figure out - the ACC/AHA flow chart doesn’t directly deal with them. I think a high risk patient (chest pain with activity, AICD, hx of stroke, etc) should still require clearance, but a moderate risk one probably shouldn’t.

Anyway, for those of you who staff pre-anesthesia clinics, what algorithms do you follow? When I was in residency, we ran far more tests than guidelines would recommend, all because some of the staff upstairs were more conservative.

 

[callmeanesthesia]

Looks like someone did this already and its performance was... not great. But looking at their algorithm it doesn't take very many factors into account. https://www.bjanaesthesia.org/article/S0007-0912(24)00335-0/fulltext

I'm going to incorporate a Framingham score of >20% 10 year risk of CVD as a secondary risk factor, algorithmically a little like an additional RCRI point I guess. So moderate risk surgery plus Framingham >20% buys you a cardiology consult even with RCRI 0. Framingham 20% plus RCRI 1, and we'll request a stress test.

The more I think about this, the more I think it could really be standardized and put into practice.

No one really likes running the PAC anyway - let's automate it as much as possible.

 

[CopaceticOne]

These are orthopedic surgeons. They’re good guys, and generally efficient, but I don’t think it’s reasonable to expect them to take a full anesthesia H&P in addition to the surgical evaluation

Literally it is having patients filling out the PMHx info before being seen.

“Oh, you take metformin and glipizide. We better know what your last A1c was.”

“Why do you take plavix and aspirin?”

This isn’t rocket science. Good guys can slide into laziness too.

 

[CopaceticOne]

Anyway, for those of you who staff pre-anesthesia clinics, what algorithms do you follow? When I was in residency, we ran far more tests than guidelines would recommend, all because some of the staff upstairs were more conservative.

I work in a high-risk preop clinic where at least 20% of the patients I see are ASA 4s. In the setting of all the various recommendations, guidelines, and risk scores… I use my brain and clinical judgement.

 

[NPJR]

Just have every patient undergoing surgery get a medical clearance from their family doctor/ Internist. Let them decide whether patient needs a cardiologist. That will take the mystery out of it. And if CRNA/ Anesthesiologist wants to turn away patients by going against their internist- there needs to be a pretty good reason.

 

[callmeanesthesia]

Just have every patient undergoing surgery get a medical clearance from their family doctor/ Internist. Let them decide whether patient needs a cardiologist. That will take the mystery out of it. And if CRNA/ Anesthesiologist wants to turn away patients by going against their internist- there needs to be a pretty good reason.

Wish we could. People are lucky to have a PCP at all and it’s usually an NP who’s going to just check the “cleared for surgery” box and send it back having no idea what risk stratification means. Even the cardiologists are iffy. One of my partners said they got a cardiology clearance, and the cardiologist’s note said “cleared for surgery, but should return after surgery for cardiac cath.”

 

[CopaceticOne]

Wish we could. People are lucky to have a PCP at all and it’s usually an NP who’s going to just check the “cleared for surgery” box and send it back having no idea what risk stratification means. Even the cardiologists are iffy. One of my partners said they got a cardiology clearance, and the cardiologist’s note said “cleared for surgery, but should return after surgery for cardiac cath.”

Come on now, they obviously should have know no reasonable anesthesiologist / CRNA would take that person to the OR.

Sounds like it is worth it for the ortho docs to step up and be more of a doctor so that their patients get appropriate care prior to surgery (aka they can make their joint replacement money by filling all their OR time without cancellations).

To do this they, or a person in their office, will need to do a real PMHx, full ROS, and physical exam since apparently the alternative of PCP is too slow or too crappy.

 

[ucladoc2b]

Just have every patient undergoing surgery get a medical clearance from their family doctor/ Internist. Let them decide whether patient needs a cardiologist. That will take the mystery out of it. And if CRNA/ Anesthesiologist wants to turn away patients by going against their internist- there needs to be a pretty good reason.

So you are asserting that the internist is the expert in surgery and anesthesia? That’s loaded.

These exams are so often just rubber stamped that they essentially pass the responsibility to the surgeon/anesthesiologist to figure out.

There is value in an internist or other clinical person reviewing/meeting with patients prior to surgery. Too often, even with nursing review, significant comorbidities are missed in pre op.

 

[callmeanesthesia]

Literally it is having patients filling out the PMHx info before being seen.

“Oh, you take metformin and glipizide. We better know what your last A1c was.”

“Why do you take plavix and aspirin?”

This isn’t rocket science. Good guys can slide into laziness too.

Like I said above (I know my posts are probably a bit “tl;dr”) our intake forms are paper and we have lots of returning patients and internal referrals who get pissy about re-filling out medical history.
Similar idea though - I’m just trying to automate the process a bit. Yes, sure, the surgeons need to be real doctors and getting them to take responsibility is part of this process. However, these guys are seeing patients in 10-20 minute slots. Have to in order to be even marginally profitable in our area. It’s a terrible use of their time to have them going through the whole med list, digging the intake form out of the chart, and having to listen to the patient go into a Grandpa Simpson style story just because they got asked if they’ve had a heart attack.
Why do a whole process manually when you can automate and delegate 80% of it, and have it done better because it’s standardized?

 

[callmeanesthesia]

So you are asserting that the internist is the expert in surgery and anesthesia? That’s loaded.

These exams are so often just rubber stamped that they essentially pass the responsibility to the surgeon/anesthesiologist to figure out.

There is value in an internist or other clinical person reviewing/meeting with patients prior to surgery. Too often, even with nursing review, significant comorbidities are missed in pre op.

Stuff gets missed for sure and there’s no way to truly idiot-proof the process. “Oh, I forgot I had a defibrillator.” 🤦‍♂️
But a standardized computerized intake that is done by the patient, while the MA is pulling their labs and records is going to be much more thorough than what the surgeon can accomplish in the exam room. Anything weird goes back to the surgeon for review and decision, and marginal cases go for anesthesia review at the center prior to scheduling, but it will be a more informed decision with a complete medical history and lab work, and any specialist notes we can obtain, rather than just relying on the patient’s memory.

 

[CopaceticOne]

Like I said above (I know my posts are probably a bit “tl;dr”) our intake forms are paper and we have lots of returning patients and internal referrals who get pissy about re-filling out medical history.
Similar idea though - I’m just trying to automate the process a bit. Yes, sure, the surgeons need to be real doctors and getting them to take responsibility is part of this process. However, these guys are seeing patients in 10-20 minute slots. Have to in order to be even marginally profitable in our area. It’s a terrible use of their time to have them going through the whole med list, digging the intake form out of the chart, and having to listen to the patient go into a Grandpa Simpson style story just because they got asked if they’ve had a heart attack.
Why do a whole process manually when you can automate and delegate 80% of it, and have it done better because it’s standardized?

I’m curious why you are so invested in making sure their patients are getting through to the OR.

If it is a group practice, hire a RN/PA/NP to do this work for all the patients. Using MAs will not get you the level of quality you want; unless they were a physician in another country.

 

[kidthor]

OP - you really need full buy-in from your department leadership and the ASC leadership, otherwise you're trying to solve their problem from the ground up and they won't care or align with you...

Another thing - are there certain anesthesiologists/CRNAs who are cancelling needlessly (you mentioned the one CRNA, but are there more)?

 

[callmeanesthesia]

I’m curious why you are so invested in making sure their patients are getting through to the OR.

If it is a group practice, hire a RN/PA/NP to do this work for all the patients. Using MAs will not get you the level of quality you want; unless they were a physician in another country.

It’s a 10 doc group and I’m one of the partners. Them being more profitable also equals me making more. Them being more efficient means me paying less overhead. Things are, tbh, kind of headed down hill because we haven’t been able to recruit so we need to save money where we can. For me, family makes it hard to just up and leave. I’m also making plenty of money thanks to the global fees for in-office procedures. If I can get the process up and running I’ll hire an RN to oversee it and up the quality of the clinical evals.

Also I kind of want to do it because… I can? I see a broken dysfunctional process and know I can make it better.

@kidthor, buy in from the anesthesiologist at the ASC is tricky because he’s not guidelines-driven at all, but I can deliver better risk stratification and less work for him, which he will respect. Department leadership: we’re a pretty flat organization. If I want to make a change, I just do it. I’ve found that rather than asking our CEO for permission, I just tell him what to do. Not that he’s a pushover or not savvy - he just has learned to respect my ideas. I got buy in from the surgeons with “hey, I think I can reduce your cancellation rate by a lot. I just need to borrow your MA for one day a week while you’re in the OR.”

 

[gunnershow]

How can a CRNA cancel a case? Assuming they are opt-out, isn't the surgeon "supervising" them?

 

[amyl]

I second the notion that medicine clearance is worthless. I had a medicine dr write in their preop clearance note that patient had a “harsh systolic murmur… new onset b/l pitting edema…. Cleared for surgery”. 8-9h of spine surgery…. The platelets were 48k. Which the medicine Dr either didn’t notice or at least didn’t comment on. Patient had no idea about any thrombocytopenia…. I cancelled the case. Surgeon said “but I got medicine to clear him” -
The answer is to have anesthesia review charts ahead of time - put a little folder together for them with labs, ekg, echo if available, past medical history and a reconciled med list. Make the patients fill out the medical history, surgical history and current meds list - sure patients will mess it up but you’ll catch some. Hand the anesthesiologist the charts for the next week amd ask them to clear them.
My current group does exactly this - we review all charts for the asc to make sure they’re appropriate. We have PAT for the hospital patients but the nurses at the asc put packets together for us

 

[CopaceticOne]

It’s a 10 doc group and I’m one of the partners. Them being more profitable also equals me making more. Them being more efficient means me paying less overhead. Things are, tbh, kind of headed down hill because we haven’t been able to recruit so we need to save money where we can. For me, family makes it hard to just up and leave. I’m also making plenty of money thanks to the global fees for in-office procedures. If I can get the process up and running I’ll hire an RN to oversee it and up the quality of the clinical evals.

Also I kind of want to do it because… I can? I see a broken dysfunctional process and know I can make it better.

@kidthor, buy in from the anesthesiologist at the ASC is tricky because he’s not guidelines-driven at all, but I can deliver better risk stratification and less work for him, which he will respect. Department leadership: we’re a pretty flat organization. If I want to make a change, I just do it. I’ve found that rather than asking our CEO for permission, I just tell him what to do. Not that he’s a pushover or not savvy - he just has learned to respect my ideas. I got buy in from the surgeons with “hey, I think I can reduce your cancellation rate by a lot. I just need to borrow your MA for one day a week while you’re in the OR.”

In that case, first look at the past 3 years worth of case cancellations and the reasons. This will tell you where to focus your initial energy.

Unexplained DOE/SOB? HF exacerbations? COPD flair? Poor DM control?

The anesthesia people can say “needs cardiac clearance” but why are they saying that? The why is the important part.

Trying to solve an issue without knowing what the underlying causes are will result in lack of success. Even if you think & believe you know the root causes, get the data first. I’ve seen waaaaaay to many “improvement” projects that end up failing miserably because the didn’t actually address the true issues.

 

[callmeanesthesia]

In that case, first look at the past 3 years worth of case cancellations and the reasons. This will tell you where to focus your initial energy.

Unexplained DOE/SOB? HF exacerbations? COPD flair? Poor DM control?

The anesthesia people can say “needs cardiac clearance” but why are they saying that? The why is the important part.

Trying to solve an issue without knowing what the underlying causes are will result in lack of success. Even if you think & believe you know the root causes, get the data first. I’ve seen waaaaaay to many “improvement” projects that end up failing miserably because the didn’t actually address the true issues.

I went through the surgeons’ scheduling queues and looked at reasons for delays, talked to the surgeons, anesthesiologists, and surgery schedulers about reasons they see cancellations. I’ve also asked our business office to start a spreadsheet tracking cancellations. Our EMR makes it hard to do retroactive chart review of cancellations because it doesn’t track them in a consistent way. There are many different reasons but the most common are that it takes too long to get clearances, or inadequate workup was done resulting in discovery of risk factors either a week before surgery when the center RNs do intake or the day of surgery. I’ve put way more thought than I should have into this already.

 

[Meyer-Overton]

Seems like something AI could help with if it were integrated into EMR

 

[callmeanesthesia]

Seems like something AI could help with if it were integrated into EMR

In a big health system where the patient’s labs, PCP notes, and cath report are already in the system, absolutely.

We’re in a rural and medically underserved area. I’ve heard our EMR described as a cash register with a word processor strapped to it. I’m lucky if the PCP’s name is even in the chart, never mind their notes.

 

[NPJR]

So you are asserting that the internist is the expert in surgery and anesthesia? That’s loaded.

I'm asserting they are medical experts. They should know (more than me) if the disease processes at hand are optimized or not. List the disease processes that patient may have and the interventions and mention whether or not they are optimized.

The main problem is: It's work and often they get 50-90 dollars to do that work when they should be reimbursed 300-600 dollars to do that job. SO people dont do it or they do it but not well. You get what you pay for.

 

[Hoya11]

In a big health system where the patient’s labs, PCP notes, and cath report are already in the system, absolutely.

We’re in a rural and medically underserved area. I’ve heard our EMR described as a cash register with a word processor strapped to it. I’m lucky if the PCP’s name is even in the chart, never mind their notes.

I dont think you should bother with a risk calculator and then flag everyone above a certain calculated risk.. too complex for the audience

What I have done in a similar situation for some difficult surgeons/offices (for low risk surgery) is use certain key words to trigger further investigation

cardiac stent, afib, esrd, chf, pacemaker, stroke, wc bound - pretty much anything that makes someone an ASA 3 is a trigger word

i ask for the last cardiac note and/or last pcp note for anyone with a trigger word..

they dont have to go to another pcp/cardiac visit , just get the note

this has cut down a lot on cancellations just by providing basic info about the person, did they have a cabg? is the ef ok? when were they last seen by another doctor?

 

[Shimmy8]

Pretty easy. If it’s really an issue…Either pay someone or don’t and suffer the consequences.

Technology can’t replace this just yet without a solid wide-encompassing EMR, patients don’t even know their own damn history or meds half the time.

 

[caligas]

At our surgery center the nurses do a phone history and if the patient is questionable they come talk to one of us to ask if more work up is needed etc.

The algorithms have too much leeway for interpretation and judgment to use as a predictor of whether a random anesthesiologist will be ok with a particular patient and case