"Pre-op Clinic Visit Is Associated with Decreased Risk of In-hospital Post-op Mortality"

[Carbocation1]

So it this really the future of the specialty of Anesthesiology? Do real world anesthesiologists see value in leading "perioperative teams"? As a medical student, I want to know what I will be buying into.

August 2016
Preoperative Evaluation Clinic Visit Is Associated with Decreased Risk of In-hospital Postoperative Mortality
Jeanna D. Blitz, M.D.; Samir M. Kendale, M.D.; Sudheer K. Jain, M.D.;Germaine E. Cuff, Ph.D.; Jung T. Kim, M.D.; Andrew D. Rosenberg, M.D.

From the Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, New York.

Anesthesiology 8 2016, Vol.125, 280-294.

Abstract
Background: As specialists in perioperative medicine, anesthesiologists are well equipped to design and oversee the preoperative patient preparation process; however, the impact of an anesthesiologist-led preoperative evaluation clinic (PEC) on clinical outcomes has yet to be fully elucidated. The authors compared the incidence of in-hospital postoperative mortality in patients who had been evaluated in their institution’s PEC before elective surgery to the incidence in patients who had elective surgery without being seen in the PEC.

Methods: A retrospective review of an administrative database was performed. There were 46 deaths from 64,418 patients (0.07%): 22 from 35,535 patients (0.06%) seen in PEC and 24 from 28,883 patients (0.08%) not seen in PEC. After propensity score matching, there were 13,964 patients within each matched set; there were 34 deaths (0.1%). There were 11 deaths from 13,964 (0.08%) patients seen in PEC and 23 deaths from 13,964 (0.16%) patients not seen in PEC. A subanalysis to assess the effect of a PEC visit on deaths as a result of failure to rescue (FTR) was also performed.

Results: A visit to PEC was associated with a reduction in mortality (odds ratio, 0.48; 95% CI, 0.22 to 0.96, P = 0.04) by comparison of the matched cohorts. The FTR subanalysis suggested that the proportion of deaths attributable to an unanticipated surgical complication was not significantly different between the two groups (P = 0.141).

Conclusions: An in-person assessment at the PEC was associated with a reduction in in-hospital mortality. It was difficult to draw conclusions about whether a difference exists in the proportion of FTR deaths between the two cohorts due to small sample size.

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[Consigliere]

We have a pre-op clinic and it's worth it.

 

[Noyac]

It's a great alternative use for that pain in the arse crna that is just down right dangerous in the OR.
Actually, it's genius.
Who knew the ASA could have such foresight.

By putting this midlevel in a non acute setting you save lives.

 

[Robotic Wis-Hipple]

So I haven't read the full article yet but it at least appears as though they separated by "encounter type" (inpatient vs outpatient), ASA, comorbidities, and surgery type. I'd be interested to see how the analysis was performed, how they accounted for the acuity of illness/condition, and if inpatient vs inpatient was a subgroup analysis. Curious how they excluded 11 of the PEC deaths but only one of the non-PEC deaths with the propensity matching when initially there was only a total difference of 2 deaths between the groups including 64k patients.

This could be another one of the "This just in, sicker patients do worse!" type of studies.

 

[Planktonmd]

It's a great alternative use for that pain in the arse crna that is just down right dangerous in the OR.
Actually, it's genius.
Who knew the ASA could have such foresight.

By putting this midlevel in a non acute setting you save lives.

 

[urge]

So it this really the future of the specialty of Anesthesiology? Do real world anesthesiologists see value in leading "perioperative teams"? As a medical student, I want to know what I will be buying into.

August 2016
Preoperative Evaluation Clinic Visit Is Associated with Decreased Risk of In-hospital Postoperative Mortality
Jeanna D. Blitz, M.D.; Samir M. Kendale, M.D.; Sudheer K. Jain, M.D.;Germaine E. Cuff, Ph.D.; Jung T. Kim, M.D.; Andrew D. Rosenberg, M.D.

From the Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, New York.

Anesthesiology 8 2016, Vol.125, 280-294.

Abstract
Background: As specialists in perioperative medicine, anesthesiologists are well equipped to design and oversee the preoperative patient preparation process; however, the impact of an anesthesiologist-led preoperative evaluation clinic (PEC) on clinical outcomes has yet to be fully elucidated. The authors compared the incidence of in-hospital postoperative mortality in patients who had been evaluated in their institution’s PEC before elective surgery to the incidence in patients who had elective surgery without being seen in the PEC.

Methods: A retrospective review of an administrative database was performed. There were 46 deaths from 64,418 patients (0.07%): 22 from 35,535 patients (0.06%) seen in PEC and 24 from 28,883 patients (0.08%) not seen in PEC. After propensity score matching, there were 13,964 patients within each matched set; there were 34 deaths (0.1%). There were 11 deaths from 13,964 (0.08%) patients seen in PEC and 23 deaths from 13,964 (0.16%) patients not seen in PEC. A subanalysis to assess the effect of a PEC visit on deaths as a result of failure to rescue (FTR) was also performed.

Results: A visit to PEC was associated with a reduction in mortality (odds ratio, 0.48; 95% CI, 0.22 to 0.96, P = 0.04) by comparison of the matched cohorts. The FTR subanalysis suggested that the proportion of deaths attributable to an unanticipated surgical complication was not significantly different between the two groups (P = 0.141).

Conclusions: An in-person assessment at the PEC was associated with a reduction in in-hospital mortality. It was difficult to draw conclusions about whether a difference exists in the proportion of FTR deaths between the two cohorts due to small sample size.

There is no way on earth I can believe this.

Every time I see a study propensity score matching I classify it as garbage.

 

[criticalelement]

It's a great alternative use for that pain in the arse crna that is just down right dangerous in the OR.
Actually, it's genius.
Who knew the ASA could have such foresight.

By putting this midlevel in a non acute setting you save lives.

Until that crna starts ordering every test known to mankind and calling every specialist in the hospital for their opinion for a patient going in for a cataract or carpal tunnel. That is equally dangerous and makes your whole group look like Horses- asses. The best way to deal with a dangerous CRNA is to man-up and fire their asses. In my opinion, the best person to deal with medical issues preoperatively is the medical internist.

 

[Ronin2258]

In my opinion, the best person to deal with medical issues preoperatively is the medical internist.

I would agree. However, when they start dictating anesthesia techniques, I get a little...testy. "Patient is suitable for spinal." with a critical aortic stenosis, for example.

We just started a pre-op clinic a couple of months ago. Surgeons are starting to pick up the idea of sending people to it. Our slowest adopters were our vascular service, but with some gentle convincing and one of their patients having chest pain/EKG changes on-check in for his elective AAA repair with the barest of workups, they came around.

The measuring metrics include delay/cancellation of cases, missing data, etc. I will hold judgment until the 6-month results.

 

[VA Hopeful Dr]

As a family doctor who is often asked to give "pre-op clearance" on patients, I would be hard pressed to think that a pre-op anesthesia-led clinic would not do a better job. I don't know jack about the anesthetic agents y'all use or what goes on physiologically during surgery (between the procedure itself and whatever y'all do on your end). I

 

[pjl]

As a family doctor who is often asked to give "pre-op clearance" on patients, I would be hard pressed to think that a pre-op anesthesia-led clinic would not do a better job. I don't know jack about the anesthetic agents y'all use or what goes on physiologically during surgery (between the procedure itself and whatever y'all do on your end). I

You are not consulted to clear them, you are consulted to optimize them. That is what is lost on most people.

No way can I optimize someone for surgery when I see them an hour before the case, nor do I have experience changing the majority of pill form medications to improve chronic disease.

We can take excessively sick people to the OR basically no matter what, but their risk of a bad outcome is high enough to make the trip ill advised. Sometimes that trip and risk is worth it, but clearly getting control of chronic illness when possible decreases that risk. That is the whole point of a preop clinic.

Step 1: Evaluate and properly quantify patient illness/risk factors
Step 2: Manage illness/risk factors to decrease risk
Step 3: Proceed with surgery if benefits outweigh risk.

Maybe it is just where I am practicing, but I almost never see Step 2 occur at a preop visit. Our guys are pretty good at Step 1, and our surgeons are definitely good with the proceeding to surgery part.

Step 2 is what the whole concept of a PSH is about.

 

[urge]

You are not consulted to clear them, you are consulted to optimize them. That is what is lost on most people.

It takes 3 to 6 moths to optimize somebody.

There is not way they can get BP, ischemic heart disease, DM, COPD, thyroid, etc., optimized in one visit. We all know that.

People just want a note saying they are optimized to avoid Monday Morning Quarterbacks later on if something happens.

 

[deleted171991]

It takes 3 to 6 moths to optimize somebody.

There is not way they can get BP, ischemic heart disease, DM, COPD, thyroid, etc., optimized in one visit. We all know that.

People just want a note saying they are optimized to avoid Monday Morning Quarterbacks later on if something happens.

No. People want optimized patients. They just can't refuse most of the unoptimized ones because of greedy employers. Many of us have to defend every cancellation as if we are burning thousands of dollars.

 

[urge]

I don't know jack about the anesthetic agents y'all use or what goes on physiologically during surgery (between the procedure itself and whatever y'all do on your end).

It is irrelevant. Our job is to maintain normal physiology despite the side effects of all the anesthetics.

What you should focus on is whether their BP is well treated, DM under control, Asthma/COPD well managed, and assessing the potential for cardiac ischemia during high risk surgery.

I'm sure you are more used to treating all those chronic conditions as an out patient than we are.

 

[urge]

No. People want optimized patients. They just can't refuse most of the unoptimized ones because of greedy employers. Many of us have to defend every cancellation as if we are burning thousands of dollars.

Between an optimized patient and a non optimized patient I'm sure everyone will prefer the former.

But I'm sure you have seen many optimized patients (BP under control, diabetes well treated, good exercise tolerance) being sent to their Primary MD to get a letter saying they are optimized even though everybody can tell they are optimized because a lot of doctors (surgeons and anesthesiologists) want a note in the chart saying they are.

 

[urge]

You are not consulted to clear them, you are consulted to optimize them. That is what is lost on most people.

No way can I optimize someone for surgery when I see them an hour before the case, nor do I have experience changing the majority of pill form medications to improve chronic disease.

We can take excessively sick people to the OR basically no matter what, but their risk of a bad outcome is high enough to make the trip ill advised. Sometimes that trip and risk is worth it, but clearly getting control of chronic illness when possible decreases that risk. That is the whole point of a preop clinic.

Step 1: Evaluate and properly quantify patient illness/risk factors
Step 2: Manage illness/risk factors to decrease risk
Step 3: Proceed with surgery if benefits outweigh risk.

Maybe it is just where I am practicing, but I almost never see Step 2 occur at a preop visit. Our guys are pretty good at Step 1, and our surgeons are definitely good with the proceeding to surgery part.

Step 2 is what the whole concept of a PSH is about.

That's because step 2 takes like 6 month of routine follow up visits to titrate drugs in order to achieve.

There is no anesthesia preop clinic that will do that.

That's why I think the result of the paper that started the whole thread is bogus.

The only thing that an anesthesia preop clinic does is gather prior tests so there are no delays the day of surgery. I don't see how it would improve the outcome ( provided you delay the case instead of rushing in blindly on a patient with 10% EF and inducible ischemia for example).

 

[deleted171991]

Between an optimized patient and a non optimized patient I'm sure everyone will prefer the former.

But I'm sure you have seen many optimized patients (BP under control, diabetes well treated, good exercise tolerance) being sent to their Primary MD to get a letter saying they are optimized even though everybody can tell they are optimized because a lot of doctors (surgeons and anesthesiologists) want a note in the chart saying they are.

I don't do that, unless I have a contradiction somewhere. As in the genius who clears the patient for surgery and, at the same time, books him for a postop stress test.

 

[pgg]

Shouldn't patients be getting "optimized" whether they're having surgery or not? Isn't that the entire point of primary care?

This PSH silliness amounts to taking people who've either been noncompliant with their primary care management, or whose health has been mismanaged or unmanaged for an extended period of time, and using the occasion of surgery to make a half-assed last-minute stab at doing something that should have already been happening.

As an opportunity to motivate people to get healthier, sure, making people see a doctor prior to surgery to talk about all the other stuff that's wrong with them isn't a bad idea. Sometimes surgery is the occasion that gets people to quit smoking. Great. But if I wanted do primary care or run a smoking cessation support group, I would've done that with my life, not become an anesthesiologist.

My brother is an ER physician and he can't understand how anybody could tolerate being an anesthesiologist, staring at monitors and listening to beeps all day, but he's glad people like me want to do it. I can't understand how anybody can tolerate being a 24-hour primary care sniffle clinic, but I'm glad there are people like him who want to do it.

I want nothing to do with the PSH and if that makes me less employable in the ASA's imagined future, so be it. I'm not a primary care doctor and I don't want to be one.

 

[GravelRider]

What is "optimization" anyway? Do we even have data on this? Aside from the previously pretty clear and now more vague cardiac risk stratification guidelines, I'm not aware of any other clear points of optimization. Clearly someone in DKA shouldn't have elective surgery, but are you going to cancel a case for a patient who has a hgb a1c of 10? What about someone who has a blood pressure consistently 160-180? Delay the case for 3-6 months until we have the patient on a good dose of Norvasc? We all know when someone is acutely ill, but beyond that, I don't see a point to this whole optimization thing. This whole thing is just a "cover your a$$ and spread the risk around." It's more docs with their name on a chart and thus more potential lawsuit targets. Most of the time these pre-op clinic dates are scheduled a week before elective surgery. What on earth are you optimizing in that time?

I do like when I get a good primary care note outlining a complicated patient's medical history and the treatment they've been through. None of this is about "clearance" or optimization, but occasionally helps me form an anesthetic plan. However, getting those notes is rare. Notes nowadays are mostly useless EMR checklists that do not in the slightest way create a good narrative of the patient's medical history.

 

[urge]

I do like when I get a good primary care note outlining a complicated patient's medical history and the treatment they've been through. None of this is about "clearance" or optimization, but occasionally helps me form an anesthetic plan. However, getting those notes is rare.

You, like pretty much all of us, like having a good H&P so you don't have to do it yourself. This is not optimization by any means. It's just a way to make your preop assessment easier.

Optimization is having all chronic conditions properly managed and under control.

No preop clinic will ever do that. All they do is gather data (H&P, echo results, cath, PFTs, etc.,) to avoid having delays or cancellatioms the day of surgery.

 

[BobBarker]

Correct, FSBS 210 in preop clinic on a 220lb 50 year old man? Preop clinic isn't going to prescribe that metformin. All preop clinic does is gather information and fills in the preop assessment in the EMR

 

[WholeLottaGame7]

No preop clinic will ever do that. All they do is gather data (H&P, echo results, cath, PFTs, etc.,) to avoid having delays or cancellations the day of surgery.

Bingo. Better to cancel it a week out when you can fill the gap with another surgery than the day of and lose out on the room/block time. Occasionally if the surgery is truly elective it may serve as a gateway for someone who has had no primary care whatsoever to get plugged into the system.

 

[pgg]

Bingo. Better to cancel it a week out when you can fill the gap with another surgery than the day of and lose out on the room/block time.

But how often are cases actually getting cancelled? Somewhere between rarely and never, every place I've ever been, even in the cancel-free-for-all academic world some people believe exists.

If the purpose of the preop clinic is to "reduce day-of-surgery cancellations," it's a cumbersome solution to a non-problem.

Occasionally if the surgery is truly elective it may serve as a gateway for someone who has had no primary care whatsoever to get plugged into the system.

What, are the surgeons who book the surgery too dumb to notice that their patient hasn't seen a doctor in 44 years and has uncontrolled diabetes and hypertension? Can't they plug the patient into the system? Why is it suddenly a good idea for long term medical care to be our job?

 

[deleted171991]

Because the surgeons don't want to do it anymore, and because in the new Obamacare reality we have much less clout with the bean counters. All surgeons want to do is show up, cut and leave. Everything else is for the minions.

Also, in the era of bundled payments, we'll have to work more for the same money or less, PSH being one of the things we can add to our shrinking small share of the big pie. And, as long as all reimbursement will come from the ACO, i.e. the hospital, not the insurance companies, some must hope that it will give us a better negotiating position and a bigger slice. Plus with shifting OR care to CRNAs, suddenly there are too many anesthesiologists in certain markets. Etc.

 

[deleted162650]

Because the surgeons don't want to do it anymore, and because in the new Obamacare reality we have much less clout with the bean counters. All surgeons want to do is show up, cut and leave. Everything else is for the minions.

Also, in the era of bundled payments, we'll have to work more for the same money or less, PSH being one of the things we can add to our shrinking small share of the big pie. And, as long as all reimbursement will come from the ACO, i.e. the hospital, not the insurance companies, some must hope that it will give us a better negotiating position and a bigger slice. Plus with shifting OR care to CRNAs, suddenly there are too many anesthesiologists in certain markets. Etc.

Ugh. Not s world I want to live in. Time to get rolling on my Australian visa.

 

[pgg]

Because the surgeons don't want to do it anymore, and because in the new Obamacare reality we have much less clout with the bean counters. All surgeons want to do is show up, cut and leave. Everything else is for the minions.

Also, in the era of bundled payments, we'll have to work more for the same money or less, PSH being one of the things we can add to our shrinking small share of the big pie. And, as long as all reimbursement will come from the ACO, i.e. the hospital, not the insurance companies, some must hope that it will give us a better negotiating position and a bigger slice. Plus with shifting OR care to CRNAs, suddenly there are too many anesthesiologists in certain markets. Etc.

It was a rhetorical question.

The PSH accomplishes no tasks that can't be done better, and more appropriately, by other doctors in other places. The fact that primary care doctors aren't doing this work routinely for everyone (not just preop patients) is the simplest proof imaginable that there's no system capacity to do it and/or no money to be made doing it. Pulling anesthesiologists out of the OR to do protocol-dicated pseudo- primary care in a clinic is a monstrous nonsensical waste of resources.

I just left a hospital where our department ran a preop clinic that had an anesthesiologist behind a desk seeing ASA 3+ patients from 8 AM until closing time. It was sometimes useful in that the schedulers would get a heads up if something especially complicated was coming our way and the patients would get instructions about their insulin or ACE/ARB or other meds. (This is very protocol-driven ... no mystery to it. Why isn't the surgeon giving those instructions?) But if the PSH doesn't flag a patient as having a difficult airway, it's not like that patient won't be seen DOS anyway and an appropriate airway plan won't be made.

The ASA is desperately scratching at the PSH idea to suck up to hospitals the way an awkward nerdy teenage boy acts obsequiously nice to girls in the hopes it'll make her like him. I just want no part of it. We're not going to suddenly become "that person's doctor" via a preop visit.

We are an ancillary service in the hospital. Pretending differently doesn't make us anything else. There's no shame in our role; we're the offensive linemen of the OR. We should own it and be content with it, not pretend that a preop PSH visit makes us better "owners" of the patient or does anything more than irritate the patient with one more post-surgery-clinic preop stop in the hospital (after the lab, after radiology, after an ECG) where they answer the same questions all over again.


If the ASA really wanted to do something useful, it'd be fighting independent CRNA practice with an aggressive national campaign to demand that an anesthesiologist direct every single anesthetic delivered in the country, because nurses lack the education and training to give optimal safe care to all comers. The rural pass through law would be killed because the only thing that keeps it alive is unopposed AANA lobbying. We'd see posters like the ones all over the walls in radiology that say "Who's reading your xray? Demand a radiologist!" Like this:

Instead we get told we need to work in a clinic to prove our value.

No. I won't.

 

[urge]

The PSH accomplishes no tasks that can't be done better, and more appropriately, by other doctors in other places. The fact that primary care doctors aren't doing this work routinely for everyone (not just preop patients) is the simplest proof imaginable that there's no system capacity to do it and/or no money to be made doing it. Pulling anesthesiologists out of the OR to do protocol-dicated pseudo- primary care in a clinic is a monstrous nonsensical waste of resources.

.

There are some benefits to the preop clinic. 1 It removes the stress of dealing with a grumpy surgeon when data is missing. 2 It speeds ups the preop assessment since you are just reviewing the H&P, not doing it from scratch. 3 It gives you a chance to get the weakest clinicians out of the OR.

The downside is that it is extremely expensive.

 

[pgg]

There are some benefits to the preop clinic. 1 It removes the stress of dealing with a grumpy surgeon when data is missing. 2 It speeds ups the preop assessment since you are just reviewing the H&P, not doing it from scratch. 3 It gives you a chance to get the weakest clinicians out of the OR.

The downside is that it is extremely expensive.

#1 - In the absence of an anesthesia preop clinic, any "missing information" on DOS is 100% the surgeon's fault. If they want to be grumpy because they screwed up, oh well. If there's an anesthesia preop clinic, if there's data missing, the surgeons will be grumpy ... and now they've got actual legit cause to be grumpy at you and your department.

#2 - In the absence of a anesthesia preop clinic, we can review the surgeon's H&P just as easily for background, and then do our own brief focused anesthesia H&P. Which sensible anesthesiologists still do anyway even if there's a note from the anesthesia preop clinic, since the patient is getting anesthetized by you, not the guy who saw him in clinic. (Who might be weak, per your #3.)

#3 - Tongue in cheek, I know, but putting weak people in the preop clinic doesn't save anyone any time. Bad data and bad instructions and bad flags in the schedule are worse than no data, no instructions, and no flags in the schedule.

 

[urge]

#1 - In the absence of an anesthesia preop clinic, any "missing information" on DOS is 100% the surgeon's fault. If they want to be grumpy because they screwed up, oh well. If there's an anesthesia preop clinic, if there's data missing, the surgeons will be grumpy ... and now they've got actual legit cause to be grumpy at you and your department.

#2 - In the absence of a anesthesia preop clinic, we can review the surgeon's H&P just as easily for background, and then do our own brief focused anesthesia H&P. Which sensible anesthesiologists still do anyway even if there's a note from the anesthesia preop clinic, since the patient is getting anesthetized by you, not the guy who saw him in clinic. (Who might be weak, per your #3.)

#3 - Tongue in cheek, I know, but putting weak people in the preop clinic doesn't save anyone any time. Bad data and bad instructions and bad flags in the schedule are worse than no data, no instructions, and no flags in the schedule.

1 Regardless of it being their fault they will be grumpy and there will be delays/cancellations.

2 True. Assuming they are well done and all the data is available.

3 I think this is the real value of a preop clinic. A good anesthesiologist does not need much data, a bad one will not make miracles with all the data in the world.

 

[SeniorWrangler]

Lots of patients have primary care doctors but don't go to them, or don't comply with their instructions. Then they go see an ortho guy for their shoulder or whatnot and get on the OR schedule, regardless of their blood sugar control or heart failure. A good anesthesiologist can manage all these things during surgery, but these patients are still more likely to run into trouble postoperatively.
Preventing postoperative complications is where the real money is and that's why these clinics are getting more popular.

 

[VA Hopeful Dr]

You are not consulted to clear them, you are consulted to optimize them. That is what is lost on most people.

No way can I optimize someone for surgery when I see them an hour before the case, nor do I have experience changing the majority of pill form medications to improve chronic disease.

We can take excessively sick people to the OR basically no matter what, but their risk of a bad outcome is high enough to make the trip ill advised. Sometimes that trip and risk is worth it, but clearly getting control of chronic illness when possible decreases that risk. That is the whole point of a preop clinic.

I, and most PCPs that I know, am aware of this but when I get a form from the surgeon that says (honest to God) "Please insure that the phrase 'Cleared for Surgery' is present in the consult note", what am I to do? I know of PCPs who have refused and worded things properly which just results in a fight between them and the surgeon.

 

[VA Hopeful Dr]

It is irrelevant. Our job is to maintain normal physiology despite the side effects of all the anesthetics.

What you should focus on is whether their BP is well treated, DM under control, Asthma/COPD well managed, and assessing the potential for cardiac ischemia during high risk surgery.

I'm sure you are more used to treating all those chronic conditions as an out patient than we are.

Hadn't thought of it that way - but fair enough

 

[deleted171991]

I, and most PCPs that I know, am aware of this but when I get a form from the surgeon that says (honest to God) "Please insure that the phrase 'Cleared for Surgery' is present in the consult note", what am I to do? I know of PCPs who have refused and worded things properly which just results in a fight between them and the surgeon.

The answer to that is: "I don't clear patients for surgery; the anesthesiologist does that, on the day of surgery. What I do is optimize them for surgery, so what I can write is that this is the patient's problem list and this is how optimized each of them is compared to the patient's possible best."

Because, in the end, that's what an anesthesiologist cares about.

You guys are between a rock and a hard place, and you are not paid enough for this crap.

 

[Robotic Wis-Hipple]

The answer to that is: "I don't clear patients for surgery; the anesthesiologist does that, on the day of surgery. What I do is optimize them for surgery, so what I can write is that this is the patient's problem list and this is how optimized each of them is compared to the patient's possible best."

Because, in the end, that's what an anesthesiologist cares about.

You guys are between a rock and a hard place, and you are not paid enough for this crap.

Nah, I like to see a note that says CLEARED!!!. Oh, and avoid hypotension and hypoxia. Makes me feel better AND reminds me of my intraop goals.

 

[deleted171991]

Nah, I like to see a note that says CLEARED!!!. Oh, and avoid hypotension and hypoxia. Makes me feel better AND reminds me of my intraop goals.

I love when cardiac patients are "cleared" only for spinal anesthesia. Typically with a severe valvular stenosis.

 

[WholeLottaGame7]

But how often are cases actually getting cancelled? Somewhere between rarely and never, every place I've ever been, even in the cancel-free-for-all academic world some people believe exists.

If the purpose of the preop clinic is to "reduce day-of-surgery cancellations," it's a cumbersome solution to a non-problem.

What, are the surgeons who book the surgery too dumb to notice that their patient hasn't seen a doctor in 44 years and has uncontrolled diabetes and hypertension? Can't they plug the patient into the system? Why is it suddenly a good idea for long term medical care to be our job?

Maybe "cancel" is the wrong word, more like postponed. I've seen cases postponed for workup for a carotid bruit, a new BBB on an EKG, better control of an A1C of 16, etc. It's certainly not zero.

I don't know if I just notice it more now, or things are changing, but a pretty significant number of surgeons are embracing the "technician" role. The overwhelming majority of surgeon H&Ps are useless (at least at my academic place). It's just a history of the surgical problem and their assessment and plan for fixing it. No note of comorbidities, consultation with other physicians, no records of cath reports, PFTs, stress tests, etc. You can argue that it's the surgeon's responsibility to get that information, but in the end, it doesn't matter, someone has to get it and you're not going to get all of it on the DOS.

The one thing I learned from our pre-op clinic in residency is that it takes time to run all that crap down. Getting in touch with cardiology and PCP offices, faxing medical release forms, following up on the records, etc, is not a quick undertaking. It's definitely an NP/PA type job, and probably just needs an MD to be available for consultation more than anything else.

I agree it's definitely not our job to be managing all that crap. We don't need to be starting anti-hypertensives and anti-hyperglycemics; that's not our job.

 

[Psai]

Make sure that you tell them they are only cleared for an open appy but not laparoscopic.

 

[seinfeld]

Read the article and table 3. I am not convinced that a face to face in the prep clinic prevents sepsis, respiratory failure or intraoperative hemorrhage when it comes to thoracic, cardiac or vascular surgery (most of theses surgery are not truly elective and are usually more time sensitive than other types of surgery). Its one thing to be seen in a clinic but the article really should have been more focused on whether higher number of preop interventions were conducted and how that impacted the results. Also they should have excluded deaths from such things as intraop hemorrhage and there is no biological plausible way a preop visit could decrease that risk (barring the patient being on anticoagulation but then they should have reported that in the study)

I should add that issues like, uncontrolled DM, which could impact sepsis rates could be controlled for on the day of surgery with either canceling the case or glucose management.

Also in regards to respiratory failure that is more about optimization and if the patient is wheezing and barely breathing preop who would do the case?

 

[Raryn]

http://gomerblog.com/2013/06/398/

Anesthesia Preop Clinic Moved to the 4th Floor

CLEVELAND, OH – With budgets being slashed and insurers looking to save money, theAnesthesia Department at Memorial Hospital made a significant change to its Anesthesia Preop Clinic. The clinic moved to a section of the building that has permanent broken elevators and is on the 4th floor. You might be asking yourself, “Ok, how does that help?”

The anesthesia clinic name is a misnomer. To be frank, there actually isn’t a anesthesia preop clinic at Memorial Hospital anymore. The door at the top of the 4th floor is a door to a janitorial supply closet. On the outside of the door is a sign that reads, “If you can read this sign, please take a copy. You are cleared for surgery. Take care.” Dr. Ruth Vanderrutt was instrumental in starting this groundbreaking new clinic style. “Most people do fine with anesthesia and surgery. If you can walk up a few flights, chances are you will do well.”



Robert Snidell, an upcoming surgical patient, was initially confused. “I dreaded going to my preop appointment. The last time I had to wait 2 hours to see someone, and then I had to get all kinds of blood tests and x-rays. It was an all-day affair.” Snidell describes having this same fear yesterday as he went to get his preop exam done for an upcoming ankle scope. “I went to a different wing of the hospital that I hadn’t seen before and initially I was furious when I saw the broken elevator sign. I stormed up the steps and was getting ready to give someone a piece of my mind at the clinic. When I got to the top and saw the sign, I was elated. “Snidell described feeling ‘on top of the world,’ and ‘thrilled to be at this hospital.'”

Dr. Vanderrutt even had a plan for the people who can’t make it up the stairs. Down on the first floor, there is a small bench at the bottom and next to it reads a second sign with handouts. “If you are sitting here, and you have an upcoming surgery, please go see Internal Medicine and Cardiology prior to your surgery. Thank you.”

Vanderrutt’s program is catching on with other clinics. The Emergency Room now posts signs at the front saying, “If you are not sick, please leave.” The labor deck has posted signs saying, “If you are not in labor than please leave and return when in true labor.” A simple plan for a complex medical system.

And all throughout my IM residency, we were explicitly told both in primary care, inpatient medicine, and multiple cardiology rotations to never, ever "clear" anyone for surgery. Our job was to optimize (as possible) and most importantly risk stratify. We would do an H&P and our "clearance" would be identifying patients as low risk, moderate risk, high risk (with data regarding odds of adverse outcomes whenever possible) or an indeterminate one that required further workup. I am neither a surgeon nor an anesthesiologist and am not clearing anyone for anything.

 

[Carbocation1]

http://www.anesthesiallc.com/publications/blog/entry/the-perioperative-surgical-future
Posted by Rick Bushnell, MD, MBA on Wednesday, 31 August 2016 in Anesthesia

"If they haven’t yet realized the value of your perioperative skill set, then it’s time for you to offer your assistance. You may not personally know it, but your management and vision are in demand outside the operating room. Your new management target is the 20 percent of sickest patients presenting for surgery. In an era where the emphasis is to reduce length-of-stay and readmissions, your anesthesia preoperative surgical involvement is your opportunity for medical, logistical and administrative leadership."

 

[jthedestroyr]

Correct, FSBS 210 in preop clinic on a 220lb 50 year old man? Preop clinic isn't going to prescribe that metformin. All preop clinic does is gather information and fills in the preop assessment in the EMR

This makes me laugh. I feel this is exactly what our preop clinic does. Info gathering for preop. We dont optimize anything.

In fact one of the neuro attendings was griping when one of his cases got cancelled. His view, patient went to our preop, but still got cancelled. Therefore, what exactly is the point of anesthesia preop clinic.

Side note, I actually took someone to surgery that had BP 》220/110, was on 3 different BP meds AND was a physician as well. Of course this was a 100% Elective surgery. Yet, We still did the case and he had already been to our preop clinic.

If anything ive learned as a resident, you learn you're doing the case, you just got to figure out how to keep them alive during the case.

The surgeons dont care about optimization, nor what you do as long as 1) patient doesnt move during the case
2)they dont die during the case
3)no major postop complications at least not directly attributable to us.

 

[Nivens]

Our preop clinic is staffed by NPs who see the patients and present to two anesthesiologists who then direct them on what needs to be done further. Both the pre-op and the surgery H&P are completed by the NP (or our residents) and signed by the anesthesiology attending. Multiple things can be said about this setup, but an effect I've noticed is the young surgeons and residents show up day-of not knowing hardly anything about the patient. I wind up knowing far more about the patient's history than they do. So I agree, it seems as if the next generation of surgeons is embracing more of a technician role. Will be interesting to see how this all plays out.