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Boring Is Beautiful in Preoperative Assessment

Nielsen, James FANZCA

doi: 10.1213/ANE.0000000000002412
Letters to the Editor: Letter to the Editor

Published ahead of print August 11, 2017.

Department of Anaesthesia and Pain Management, Concord Repatriation General Hospital, Concord, New South Wales, Australia,

Published ahead of print August 11, 2017.

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To the Editor

In a meticulous study, Manji et al1 evaluated the quality of 17,500 preanesthetic assessments at Massachusetts General Hospital. Only 1.4% received negative scores.

This subject is important. Preoperative clinics lack the drama of an anaphylaxis or cannot-intubate-cannot-ventilate rescue, but can prevent such problems by their quiet work. Measuring the quality of that work is difficult, however. Even in this famous institution, 25% of cases marked as “not assessed” actually had been—and in 25% of the evaluations it was unclear when or even if a preassessment had occurred

The main study measure was subjective rating by anesthetic staff on the day of surgery. They judged the preoperative assessment as exemplary, satisfactory, or unsatisfactory. These terms were not defined: what was “satisfactory” to one may have been inadequate to another. This method contrasts with the approach in a previous Massachusetts audit, which began with explicit definition by the whole department of the standard expected.2 Use of that consensus definition approach here might have increased the reliability of quality ratings. More importantly, this process in itself might help staff to improve their preoperative assessments.

Finally, it is worth noting 2 points not covered in this thoughtful paper. First, the focus on assessments done before the day of surgery actually excluded the majority of anesthetic cases. Selective preassessment is necessary, but the selection process also needs appraisal. Second, study evaluations were all made by anesthetic staff. Patients may think differently, so we should measure their satisfaction too.

James Nielsen, FANZCADepartment of Anaesthesia and Pain ManagementConcord Repatriation General HospitalConcord, New South Wales,

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1. Manji F, McCarty K, Kurzweil V, Mark E, Rathmell JP, Agarwala AV. Measuring and improving the quality of preprocedural assessments. Anesth Analg. 2017;124:1846–1854.
2. McCarty LK, Saddawi-Konefka D, Gargan LM, Driscoll WD, Walsh JL, Peterfreund RA. Application of process improvement principles to increase the frequency of complete airway management documentation. Anesthesiology. 2014;121:1166–1174.
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