LETTERS TO THE EDITOR: Letters & Announcements
To the Editor:
Dr. van Klei and his colleagues should be commended for the quality and the scope of their work to measure the impact of outpatient preoperative evaluation (1). In this large study, they documented that outpatient evaluation is associated with more selective preoperative testing, fewer late operating room cancellations, and shorter lengths of stay. However, the authors found that the magnitude of these effects was less than expected. It appears that the way the clinic was structured diminished these benefits. In particular, these benefits would have been greater if future inpatients had been evaluated only if the plan was to admit them on the actual day of surgery. We took this approach with our preoperative evaluation clinic and documented greater benefits (2) and found that our surgeons quickly gained confidence in the anesthesia outpatient assessments and were willing to forgo admitting patients one or more days before surgery to get access to the resources available in our outpatient preoperative evaluation clinic.
Failure to limit who will be seen in the outpatient preoperative evaluation clinic can result in a number of problems. When the outpatient preoperative evaluation is completed for a patient who will be admitted before surgery, there is typically significant duplication of effort. Laboratory tests are often repeated (even if they were initially normal), consultations and functional tests not deemed necessary during the outpatient assessment may be arbitrarily added, and a second anesthesiologist’s preoperative evaluation may be nearly completed before the initial outpatient assessment is located.
These problems can create an atmosphere in which anesthesiologists working in the outpatient clinic quickly learn that their assessments have relatively little impact on the patient’s preoperative care. This atmosphere can have an adverse effect on the morale of the clinic staff. A recent survey documented that a lack of decision-making authority was associated with discontent among anesthesiologists working in preoperative evaluation clinics (3). If an anesthesiologist completes an outpatient preoperative evaluation and determines that the patient does not need any further testing prior to surgery, then it is understandably frustrating to learn that the patient was subsequently admitted and received a battery of unnecessary tests or consults before surgery.
Rather than waiting for the hospital to establish a new incentive system or hoping for the surgeons to develop and follow appropriate clinical pathways, it makes sense to limit the patients who will be seen in the outpatient clinic to exclude those who are planned for admission one or more days before surgery. Without setting reasonable criteria like this, the preoperative evaluation clinic can be misconstrued as a place where anesthesia gets comfortable with the status of the patient, but where the “real” work-up is completed by the surgeons after admission. In reality, experience has shown that the preoperative evaluation clinic is typically the ideal setting in which to complete these assessments. The benefits of outpatient preoperative evaluation are obvious enough and enticing enough to motivate the surgeons to change from their outdated routines. The trust of the surgeons in the anesthesiologist’s assessments manifests as a willingness to discontinue unnecessary admissions. This is a significant change in behavior that attests to how much the surgeons value the services that are provided in anesthesiologist-directed outpatient preoperative evaluation clinics.
John Pollard, MD
1. van Klei W, Moons K, Rutten C, et al. The effect of outpatient preoperative evaluation of hospital inpatients on cancellation of surgery and length of hospital stay. Anesth Analg 2002; 94: 644–9.
2. Pollard JB, Garnerin P, Dalman RL. Use of outpatient preoperative evaluating to decrease length of stay for vascular surgery. Anesth Analg 1997; 85: 1307–11.
3. Tsen LC, Segal S, Pothier M, Bader AM. Survey of residency training in preoperative evaluation. Anesthesiology 2000; 93: 1134–7.