Preadmission testing is the key to successful surgery
Publish Date: 3/26/2012
Jerry Stonemetz, MD, Assistant Professor and Medical Director of Anesthesiology at Johns Hopkins Medical Center, Baltimore, Md., and a consultant for Hospital Corporation of America (HCA), believes preoperative screening of all preoperative patients when their surgeries are booked can help identify those who need more aggressive testing before surgery. By determining if the patient is in good health (ie, not overweight, able to ambulate and tolerate moderate exercise), asking leading questions (ie, what medications are you taking? Have you had any previous surgeries?), and performing a physical assessment on patients with red flags, most surgical cancellations or delays on the day of surgery could be prevented.
Historically, he noted, most surgeons order “shotgun testing,” that is, they test for everything as a matter of habit or based on a previous bad experience. In Stonemetz’s opinion, most healthy patients need only a hematocrit and hemoglobin level. He gave the example of surgeons routinely testing prothrombin times (PT) and partial thromboplastin times (PTT) on all patients and said that almost no patient needs these test unless he or she has a history of bleeding, excessive bruising, or some familial history of a clotting disorder. Screening patients when their surgeries are booked allows a seven to ten day window to test as indicated by a patient’s history. Preoperative screening by telephone can alert the screening staff members to arrange for the patient to come into the preoperative testing unit for further evaluation.
Appropriately screening surgical patients can reduce surgical cancellation and delay rates. Fewer delays and cancellations increase patient and surgeon satisfaction, reduce unnecessary testing and its expense, and provide better preoperative patient care and outcomes. Stonemetz noted that unnecessary testing currently amounts to a cost of approximately 30 billion dollars per year and is a National Patient Safety Goal for 2012. At Johns Hopkins, there is a threefold increase in cancellations or delays if a patient is not screened through the preoperative testing clinic. Metrics are important data for a hospital to have and he emphasized that without them, it can be hard to get a hospital, its surgeons, or its anesthesia care providers to support the need for preoperative screening. Metrics that Stonemetz identified as important are the
- percent of patients going through the preoperative testing unit (ideal is 100%),
- percent reduction in surgical delays (ideal is 100% but it should be at least 80%),
- number of cancellations (the national benchmark is 3% to 4%),
- number of delays resulting from poor preoperative education, and
- length of time require to see patients in the preoperative testing unit (ideal is 30 to 45 minutes per patient).
These metrics will help justify the need for a preoperative testing unit and see that it functions well by identifying areas needing improvement.
The preoperative testing programs that Stonemetz is involved with at Johns Hopkins and HCA, use nurse practitioners, physician assistants, and specially educated perioperative nurses to question patients over the telephone based on a script used to screen for important issues. If these issues are noted (eg, morbid obesity, exercise intolerance, hypertension, heart disease, medications), then the patient is asked to come into the clinic for further screening. If a patient is a low surgical risk (ie, ASA I or II, scheduled for low risk surgery) then he or she can bypass the preoperative testing unit. A patient with an ASA III or IV scheduled for a high-risk surgery requires an anesthesia care provider consult. Tests required for all patients include hemoglobin and hematocrit for all healthy menstruating female patients and a urine pregnancy test. No electrocardiograms are ordered based solely on patient age, no chest x-rays are performed unless the patient has pulmonary disfunction, and no PT or PTT without a history of bleeding problems or excessive bruising or unless the patient is on blood thinning medications.