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Who Staffs the Perioperative Surgical Home?

Hooper, Vallire D. PhD, RN, CPAN, FAAN

doi: 10.1213/ANE.0b013e3182834728
Editorials: Editorial
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From Nursing Practice, Education, and Research, Mission Health, Asheville, North Carolina.

Accepted for publication December 10, 2012.

The author declares no conflicts of interest.

Reprints will not be available from the author.

Address correspondence to Vallire D. Hooper, PhD, RN, CPAN, FAAN, Nursing Practice, Education, and Research, Mission Health, 2300 F Kensignton Place, Asheville, NC 28803. Address e-mail to vallire.hooper@msj.org.

The preanesthesia evaluation is a critical element in the provision of safe, quality patient care in the surgical patient. The American Society of Anesthesiologists (ASA) defines the preanesthesia evaluation as “the process of clinical evaluation that precedes the delivery of anesthesia care for surgery and for non-surgical procedures.”1 In addition to gathering essential health information that is crucial to a safe anesthesia experience, this preanesthesia/preoperative evaluation period also provides an opportunity for patient education, resource planning and allocation, and the development of a comprehensive, multidisciplinary plan of care to assure safe traverse across the surgical continuum for the patient and family/significant other.1–3 ASA notes that the preanesthesia evaluation is the responsibility of the anesthesiologist, who may elect to consult with other health care providers to obtain a comprehensive overview of the patient’s status as it applies to their anesthetic care.1

Nursing specialty organizations such as the Association of periOperative Nurses and the American Society of Perianesthesia Nurses view this assessment as a comprehensive, multidisciplinary process designed to obtain a holistic view of the patient and his or her support system in order to not only provide safe anesthetic and surgical care, but also to assure the safe transition of the patient to home or the next level of inpatient care after surgery.2,3

The positive impact of the preanesthesia evaluation on patient and system outcomes has been well established in the literature. Research regarding the most effective delivery model for preanesthesia evaluation and care, however, is less prolific. Dexter et al.4 present an interesting study exploring whether the average practitioner preanesthesia evaluation time should influence the assignment of patients waiting for their evaluation. Although the results noted that there was not sufficient evidence to warrant consideration of this factor in patient assignment, the study does point to the need for consideration of multiple factors, and multiple models associated with the delivery of preanesthesia care.

Dexter et al.4 conducted their study using data from 2 preanesthesia evaluation clinics, one of which had evaluations (patient interviews) performed by midlevel providers (nurse practitioners) with no supporting registered nurses (RNs) or nursing assistants. In a survey conducted at the 2005 annual ASA meeting, Holt et al.5 questioned respondents to determine whether their preanesthesia evaluation clinic was “staffed” by the department of anesthesiology. In this survey, it was commonplace for evaluations to be done by providers other than RNs without advanced practice degrees (advanced RN practitioners, certified RN anesthetists). The larger research question that may have a more significant impact on the delivery and effectiveness of preanesthesia care, however, may be an exploration of what it means to be “staffed” by the department of anesthesiology, and the impact of this staffing model on patient and system outcomes.

Much of the data in the study by Dexter et al. comes from a preanesthesia evaluation clinic with evaluations being performed only by midlevel providers.4 More frequently noted preanesthesia evaluation staffing models in the nursing literature include a mix of RNs with midlevel providers and/or anesthesiologists. In these models, RNs typically conduct a comprehensive preoperative/preanesthesia assessment as well as provide preoperative patient education. Depending on the model, all patients may be seen by a midlevel provider (nurse practitioner, physician’s assistant, anesthesia assistant, or certified RN anesthetist) or anesthesiologist for a targeted evaluation based on the assessment conducted by the RN. In other models, patients are assessed by the RN and referred to the midlevel provider/anesthesiologist only if they meet certain preestablished criteria. In this latter model, the midlevel provider/anesthesiologist may be present and actively staffing the preanesthesia evaluation clinic, or they may be covering the clinic on an as-needed, on-call basis. Healthier patients who do not meet the screening criteria might not be seen by the anesthesia provider until the day of surgery.

Numerous questions have yet to be answered regarding these various delivery models for preanesthesia care. Possible areas of inquiry include:

  • Which delivery model is most effective in reducing adverse patient events and surgical cancellations?
  • Which delivery model is the most cost effective?
  • Which delivery model produces the highest level of patient satisfaction?

It may be that there are few differences in outcomes among the various delivery models, but clearly the current emphasis on patient-centered outcomes within the context of cost-effective care warrants exploration of these, and other questions. Dexter et al.4 present an evaluation of a singular model of care delivery during the preanesthesia evaluation period. They showed and discussed that their results and conclusions are insensitive to who performs the preanesthesia evaluations. Thus, research exploring other models of care delivery is encouraged. Safe, quality patient care coupled with cost effectiveness and an interdisciplinary team vision should constitute the priorities in the continued exploration of preanesthesia care delivery.

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DISCLOSURES

Name: Vallire D. Hooper, PhD, RN, CPAN, FAAN.

Contribution: This author wrote the manuscript.

Attestation: Vallire D. Hooper, PhD, RN, CPAN, FAAN approved the final manuscript.

This manuscript was handled by: Steven L. Shafer, MD.

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REFERENCES

1. American Society of Anesthesiologists. . Practice Advisory for Preanesthesia Evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012;116:522–38
2. AORN. AORN Guidance Statement: Preoperative Care in the Ambulatory Surgery Setting. 2005 Denver AORN
3. ASPAN. Perianesthesia Nursing Standards and Practice Recommendations 2010–2012. 2010 Cherry Hill, NJ ASPAN
4. Dexter F, Ahn HS, Epstein RH. Choosing which practitioner sees the next patient in the preanesthesia evaluation clinic based on the relative speeds of the practitioners. Anesth Analg. 2013;116:919–23
5. Holt NF, Silverman DG, Prasad R, Dziura J, Ruskin KJ. Preanesthesia clinics, information management, and operating room delays: results of a survey of practicing anesthesiologists. Anesth Analg. 2007;104:615–8
© 2013 International Anesthesia Research Society