Surgical Clearance

[MicroPod]

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I was wondering what everyone does for patients who you feel need to see their primary, cardiologist, etc. for surgical clearance on elective surgery. Do you put it all on the patient telling them they need to get an appointment with their doctor to discuss or do you try to reach out their doctor yourself? I usually try to reach out to their doctor especially if they are in the same facility which makes it easier. When they are not in the same facility/hospital system is where it gets cumbersome and I have thought about just leaving it to the patient in these instances. And just to be clear I do not always get surgical clearance from the patient's PCP when they are generally healthy, but if they see specialist for heart, vascular, kidneys, etc. I do want them to give clearance.

 

[Adam Smasher]

The same person who coordinates scheduling with the OR coordinates preop testing and doctor appts. And if it's you...

 

[Homo sapien]

The same person who coordinates scheduling with the OR coordinates preop testing and doctor appts. And if it's you...

If its me I probably would not operate electively on people that poor healthwise

 

[Weirdy]

Work in same building as their PCP so super easy
Ton of sick patients with cards, neph, endocrine involved
At that point I tell my staff to reach out and give them specific instructions on what the other office needs to send over and what we are requesting

I never trust the patient to reach out unless I cannot find any information on who they are seeing etc.
Have had patients try to say they are cleared for surgery from their cardiologist (confirmed by my front staff) only to pick up phone and find their vascular doc hasn't seen them in 8 months and they need a revasc after getting them in.

 

[Sendin_Toes_2market]

80% of my “limb salvage” are toe procedures. I do a lot under local. I do 5th met head resections while they are awake or MIS osteotomy of lesser mets done under local. Again, for diabetics, their years of Little Debbie’s are my anesthesia and it comes pre dosed. I don’t touch high risk patients. Why we have ortho.

I don’t even stop coags if their numbers aren’t crazy… if it’s rear foot or extensive I will. Other wise it’s basically like doing an overly aggressive PNA.

Any elective bunion, fracture or rear foot I write a letter to each PCP for patients and review their meds and history. I have an office guy who collects all the stuff and I review clearance 2 weeks out. I take medicine for these patients seriously. You have to take a good history and let the system automate. I am very anal with this on surgical planning visit so I don’t have to worry about it.

 

[dtrack22]

Almost everything we do surgically can be done under local/regional if you want. Cards patients need to see their cardiologist. I have Rheum patients on biologics or steroids see whoever is managing (I’m rural so it’s not always rheumatology). Otherwise I risk stratify everyone else. It’s easy and the things we do in the OR are the definition of “low risk” from an anesthesia standpoint in virtually any non-cardiac patient.

Think of your sickest inpatient (where you do zero medical management pre-op) that needed to go to the OR before a hospitalist could “optimize them”…did they wake up from anesthesia? Yes? Then your elective bunions are going to be just fine.

 

[Boba Foot]

Think of your sickest inpatient (where you do zero medical management pre-op) that needed to go to the OR before a hospitalist could “optimize them”…did they wake up from anesthesia? Yes? Then your elective bunions are going to be just fine.

Brah, as long as they wake up after and not during, talking to you while bleeding significantly. That is the worst. It's a crapshoot when they're sick as a dog and the CNRA says "I'm just gonna help sleep for a little bit, is that cool?"

 

[Sendin_Toes_2market]

Almost everything we do surgically can be done under local/regional if you want. Cards patients need to see their cardiologist. I have Rheum patients on biologics or steroids see whoever is managing (I’m rural so it’s not always rheumatology). Otherwise I risk stratify everyone else. It’s easy and the things we do in the OR are the definition of “low risk” from an anesthesia standpoint in virtually any non-cardiac patient.

Think of your sickest inpatient (where you do zero medical management pre-op) that needed to go to the OR before a hospitalist could “optimize them”…did they wake up from anesthesia? Yes? Then your elective bunions are going to be just fine.

If someone’s super sick with documented EGF of 5% and refused dialysis last 3 weeks, they are getting lidocaine and a wooden spoon to bite down on. Unless it’s a TMA where I document they are at high risk of dying due to infection.

 

[air bud]

80% of my “limb salvage” are toe procedures. I do a lot under local. I do 5th met head resections while they are awake or MIS osteotomy of lesser mets done under local. Again, for diabetics, their years of Little Debbie’s are my anesthesia and it comes pre dosed. I don’t touch high risk patients. Why we have ortho.

I don’t even stop coags if their numbers aren’t crazy… if it’s rear foot or extensive I will. Other wise it’s basically like doing an overly aggressive PNA.

Any elective bunion, fracture or rear foot I write a letter to each PCP for patients and review their meds and history. I have an office guy who collects all the stuff and I review clearance 2 weeks out. I take medicine for these patients seriously. You have to take a good history and let the system automate. I am very anal with this on surgical planning visit so I don’t have to worry about it.
View attachment 407577

All of this.

Also another advantage of being rural.... You know who all the PCPs are and have relationships with them.

 

[Feli]

A lot depends the practice environment....

• VA/IHS, you are basically lawsuit proof (tort limits... $$ paid in any settlement is same pool of money that paid for the care/surg). Poor patient care and even very bad outcomes happen fairly often in the system. Therefore, do whatever you want... "clear" patients if you wish (I'd stick to ASA 1 and 2 just to be ethical... ask for help on others). You are largely insulated to bad outcomes in single payer govt setup.
• In (normal, non-govt) hospital employed, there is a bit more risk for malprac or bad press/reviews from bad outcomes, but insurance is paid by facility. Therefore, follow facility rules... do what you find sensible (I'd stick to doing pre-op H&P for ASA 1 and 2 selectively based on peer and other surgeon norms... but that's if facility allows that done by DPMs).
• For private practice, there are serious risks for malpractice rate increase and lost time/income with malpractice or hospital complaints/investigation. Beyond that, it will again be facility rules for podiatry regarding H&P for admit/ pre op /etc at a lot of facilities (JHACO, link below). The rules were likely decided by podiatry state scope, JCAHO risk, or past DPM issues. It'll probably be decided for you. If it's not decided already (allowed at most/all of your surgical facilities), it's still a dumb and unnecessary risk imo. You do not want your PCP refer sources hearing their patient had an elective surgery and their PCP/rheum/cardio/endo/etc had no idea of it until after. In addition to the safety issue, it is a terrible use of your time efficiency, and it looks to the PCP and ansth/hospital like you're being a cowboy.

Personally, it's a non-issue for me (now). We had a couple of DPMs who were "clearing" ASA3 obese and DM and elderly and etc pts for bunions, tendon, even major recon like flatfoot, DM fusion, trauma (and then also taking many hours under anesthesia to do some of the cases). They wanted to push the surgery through asap for numbers or for $ or whatever reason. I don't know if they thought the PCP may have not cleared the pts, that the pts didn't need proper H&P, or maybe just stupidity. Regardless, the bylaws were changed due to many PCPs and anesthesia being concerned... rightly so. I very seldom did H&Ps even before that change (I'd have done it rarely for peds or young healthy adult trauma if they didn't have a PCP and surgery was time-sensitive)... but other DPMs ruined it for everyone. That'll be the case on a lot of things from hospital regs to reimburse to income to public perception of us. Learn to expect it. 🙂

...The way I see it, even if we can do H&P, we should not unless there is little other option (and still only ASA1 or ASA2 ppl, which were are not even really in a training and exp position to recognize). We are not the best for H&P. Some DPMs - usually fresh from residency - seem to think they're well trained on it, but they're comparatively inept when MD/DO are available (maybe not as quick/easy as hoped, but they're there). Think about it: if a patient won't even set up with their PCP group or a new one for H&P, are they going to be compliant with other aspects of surgery? Absolutely any infect/trauma pod case could be admitted if truly needed (ER/hospitalist H&P), and elective that can't get in with their PCP group for H&P pre op can simply delay until they do. It's elective. Who cares if end of the deductible year is coming up or if they want that bunion asap (or if young DPM does want it asap); that is all the patient problem. Simply state safety and facility requirement, and they can make it happen.

At the end of the day, many facilities won't allow pod/dent/OD/etc to do pre op H&Ps for anyone.
They've likely had problems before, or they're following JCAHO and won't risk allowing podiatrist pre op H&Ps.
If you can't do H&P (or don't want to), then just let hospitalist do it for inpts, and PCP do it for outpts.
Either way, not a big loss in my estimation. Best for patient safety that way. When in Rome...

 

[Hybrocure]

PP here..I get PCP clearance for all patients. Some hospitals will let me do H&Ps and others don’t. The irony is the ones who don’t let me do H&Ps also won’t accept a outpatient MD/DO H&P so it becomes a chore since they need to find an MD/DO in preop to work up my patients. These hospitals I don’t operate at unless I really need to because of that bs.



It’s elective surgery, it doesn’t change my or my patients life too greatly if they need to see their PCP before their surgery first. It also can weed out some of the sketchy patients who were a bad idea to cut on if they don’t go to their PCP to get cleared before it happens.

If it’s emergent they can get admitted to the hospital before I operate and get situated there medically.

For the most part though, most of my operative patients are over 40-50 and could benefit from getting cleared by a PCP over me pretending to use a stethoscope.

As far as how they get cleared - my front office does it. I don’t know how to use a fax machine

 

[Boba Foot]

For the most part though, most of my operative patients are over 40-50 and could benefit from getting cleared by a PCP over me pretending to use a stethoscope.

Gotta get some use out of that stethoscope your pod school told you to buy and got no use from, other than headshots and Instagram cred.

 

[heybrother]

What I love/hate is when I send a cardiology clearance request and instead of sending a semi-formal clearance sheet / the most recent progress note - the NP just writes "low risk, proceed with surgery, their initials NP" in the corner of the faxed sheet I send them. I only love it because the look that crosses the anesthesiologist's face when it happens.

 

[DYK343]

What I love/hate is when I send a cardiology clearance request and instead of sending a semi-formal clearance sheet / the most recent progress note - the NP just writes "low risk, proceed with surgery, their initials NP" in the corner of the faxed sheet I send them. I only love it because the look that crosses the anesthesiologist's face when it happens.

This is really annoying. We have to have cardiac and pulomonary exam and clearance be documented in a note to operate at my system.

 

[Boba Foot]

This is really annoying. We have to have cardiac and pulomonary exam and clearance be documented in a note to operate at my system.

Sometimes I feel like the difficulty some facilities give us is intentional.

 

[heybrother]

This is really annoying. We have to have cardiac and pulomonary exam and clearance be documented in a note to operate at my system.

I was going to tell you that some templated text in a cardiologists note is meaningless but interestingly there are components of a physical exam that theoretically demonstrate increased cardiac risk

Revised Cardiac Risk Index for Pre-Operative Risk

The Revised Cardiac Risk Index for Pre-Operative Risk Estimates risk of cardiac complications after surgery.

www.mdcalc.com

 

[Hybrocure]

Sometimes I feel like the difficulty some facilities give us is intentional.

Just work from home admin trying to think of rules to make their job stay relevant

 

[MicroPod]

Don’t even get me started on NP/PA. Some of them have no clue what’s going on but pretend they do or won’t ask for help. I have little confidence when patient is seen by NP/PA unless there is strong physician oversight (rare). They should have to do at least do a 1 year residency type training under physicians before practicing on their own.

Makes me cringe when I have to ask the NP to prescribe the DM shoes/inserts or get “clearance” from them.

I stay in my lane and I ask for help when I am out of my depth.

 

[air bud]

Don’t even get me started on NP/PA. Some of them have no clue what’s going on but pretend they do or won’t ask for help. I have little confidence when patient is seen by NP/PA unless there is strong physician oversight (rare). They should have to do at least do a 1 year residency type training under physicians before practicing on their own.

Makes me cringe when I have to ask the NP to prescribe the DM shoes/inserts or get “clearance” from them.

I stay in my lane and I ask for help when I am out of my depth.

Whatever bro...just spread the risk around. NP/Pa can clear

 

[Feli]

Don’t even get me started on NP/PA. Some of them have no clue what’s going on but pretend they do or won’t ask for help. I have little confidence when patient is seen by NP/PA unless there is strong physician oversight (rare). They should have to do at least do a 1 year residency type training under physicians before practicing on their own.

Makes me cringe when I have to ask the NP to prescribe the DM shoes/inserts or get “clearance” from them.

I stay in my lane and I ask for help when I am out of my depth.

It's the new normal.

The American public will get whatever they will settle for.
If they will accept "primary care" midlevels, "dermatology" midlevels, "gastroenterology" midlevels... then that's what we'll have.
If they want the best, then you'll have residency/fellowship trained physicians (but I can guarantee you most hospital and MSG admins want the cheapest, not the best). It is an easy bait-and-switch to most patients: do you want to see a midlevel next week or a doctor in 3-6 months?

....The midlevels that should truly infuriate you are the ones in ER calling you for ingrown nail, tinea cellulitis, closed fractures, etc that "look pretty bad, would like if you could come in and have a look." 🙂

 

[Boba Foot]

The midlevels that should truly infuriate you are the ones in ER calling you for ingrown nail, tinea cellulitis, closed fractures, etc that "look pretty bad, would like if you could come in and have a look." 🙂

Thank god for tech so you can tell them to send you a pic, look at their chart on the Epic app, and tell them you’ll see it tomorrow if they’re admitted or in office discharge.

They can take a look at deez nuts. If I don’t get paid for call, I’ll see it when I see it. The occurrence of true emergency in podiatry is rare.

 

[air bud]

Thank god for tech so you can tell them to send you a pic, look at their chart on the Epic app, and tell them you’ll see it tomorrow if they’re admitted or in office discharge.

They can take a look at deez nuts. If I don’t get paid for call, I’ll see it when I see it. The occurrence of true emergency in podiatry is rare.

Obviously you don't have a great appreciation for tinea ungium. And a displaced proximal phalanx of the 5th digit. You are bumping 95% of c-sections for that.

 

[Homo sapien]

Thank god for tech so you can tell them to send you a pic, look at their chart on the Epic app, and tell them you’ll see it tomorrow if they’re admitted or in office discharge.

They can take a look at deez nuts. If I don’t get paid for call, I’ll see it when I see it. The occurrence of true emergency in podiatry is rare.

Hell yeah

 

[Homo sapien]

Obviously you don't have a great appreciation for tinea ungium. And a displaced proximal phalanx of the 5th digit. You are bumping 95% of c-sections for that.

Relocate that **** in office lol.

 

[Weirdy]

Thank god for tech so you can tell them to send you a pic, look at their chart on the Epic app, and tell them you’ll see it tomorrow if they’re admitted or in office discharge.

They can take a look at deez nuts. If I don’t get paid for call, I’ll see it when I see it. The occurrence of true emergency in podiatry is rare.

Same.
Heck if whatever ED resident on day shift wants to just curbside me via text, easier to triage than wasting time in the hospital for call I am not getting paid for with a hospital that doesn't want or respect our services (they havn't even set up my EMR access...its been a year.).

 

[diabeticfootdr]

I was wondering what everyone does for patients who you feel need to see their primary, cardiologist, etc. for surgical clearance on elective surgery. Do you put it all on the patient telling them they need to get an appointment with their doctor to discuss or do you try to reach out their doctor yourself? I usually try to reach out to their doctor especially if they are in the same facility which makes it easier. When they are not in the same facility/hospital system is where it gets cumbersome and I have thought about just leaving it to the patient in these instances. And just to be clear I do not always get surgical clearance from the patient's PCP when they are generally healthy, but if they see specialist for heart, vascular, kidneys, etc. I do want them to give clearance.

This is probably individualized based on your medical staff bylaws, your delineation of privileges, and facility policies and procedures.

I know you probably used the term clearance like everyone else does, but it's not really being cleared for surgery. It's having a pre-operative risk assessment and medical optimization. And the timing of that depends on who's doing it. CMS and TJC standards require that within 30 days of surgery they patient will need a complete H&P (which isn't necessarily the same thing as clearance). So the patient could have been "cleared" by cardiology 6 weeks earlier and as long as there are not changes, don't need a repeat cardiology visit. Just the H&P done, which is more of a paperwork issue for compliance with CMS/TJC. If you have privileges to perform a pre-operative H&P, then it's appropriate for you to do it and also document that there are no changes since the cardiac work-up.

But we do frequently get involved in facilitating these pre-op visits since patient's have difficulty communicating the urgency of the visit if trying to make the appointment themselves. Of course, it is helpful if you're in the same system and can send DMs via the EHR.