When a health condition needs to be addressed and surgery is necessary, how and where does a patient begin their wellness journey? What information is shared and with whom? How does a patient get through the PeriOperative process and arrive in the operating room in the most efficient manner possible?
A surgical procedure does not just ‘happen.’ It involves a process that, thankfully, is foreign to most people. This process requires answers to specific questions, decisions made about specific tests that need to be ordered and paperwork that needs to be filled out. This information, ideally, is collected and shared with the medical team members who will be taking care of you. This process needs to occur in a timely and coordinated fashion to ensure an optimal outcome without delays or cancellations.
In an elective surgery, a scheduled procedure that does not involve medical emergency or urgent care, there is time to get the homework done before the patient goes “under the knife.” But is that time always used effectively? If it was, we would have fewer day-of-surgery (DOS) cancellations. When executed properly, pre-op workflows could minimize (if not completely eliminate) DOS cancellations.
“Prior to consideration of surgical intervention, it is necessary to prepare the patient as fully as possible so as to optimize him according to his co-morbidities,” said Dr. Ifrah Ahmad Qazi in his paper on Preoperative Optimization of Patients for Surgery. “To obtain satisfactory results in general surgery requires a careful approach to preoperative preparation of patients,” he added.
Let’s consider how we optimize the patient.
1. Patient Education
Just like anything in life, preparing for a surgery also begins with education. The patient must have a clear understanding of what is involved. Preparation begins as soon as diagnosis is made and the need for surgery is determined.
Pre-op care and the extent that it will be provided will depend on the nature of the surgery, whether it is minor or major, invasive or non-invasive, the type of anesthetic care and the facilities available.
A better-informed patient is in everyone’s interest. Educating the patient helps manage expectations through a realistic understanding of the proposed surgery. Alternative treatment options should be discussed as well as the possible complications (and probability of such complications) during the perioperative period or the three stages of the surgery – before, during and after the operation.
Patient education begins in a pre-op consultation that aims to map out the preparations. The interaction between the patient and physician is important to risk-stratify them early, and identify appropriate measures taken to reduce complications.
The pre-op visit is an opportunity for patient education, to evaluate the patient’s health condition, identify risk factors and discuss the procedure in detail. According to Linda M. DeLamar, CRNA, MSN, MS, “often the patient is anxious and may have difficulty understanding or remembering the instructions.”
In her paper on Preparing Your Patient for Surgery published by Medscape in Topics in Advanced Practice Nursing eJournal, DeLamar said pre-op consultation can enhance patient preparation by reinforcing instructions on preoperative fasting, medications, anesthesia, and postoperative care.
The time and effort invested in preoperative evaluation determines the efficiency of pre-op care rendered. And efficiency is measured by the effect of that preparation on the likelihood that the patient makes it to the surgical table, without cancellations or delay, having successfully completed all required tests and optimized for surgery.
Patient education is not limited to basic information about the procedure …the type, purpose, duration, hospitalization, costs, preparation, risks, medication… it all factors into the likelihood that the surgery won’t be cancelled, that the patient arrives optimized for surgery, and that the post-operative care will be most efficient. Connecting everyone around this education is key. The healthcare team must be connected – wired in the same communication loop.
2. Anesthesia Care
Anesthesia care and pain management are indispensable twins in surgery. The patient will appreciate the surgical care according to how pain is managed preoperatively, intra-operatively and postoperatively.
Who determines what type of anesthesia the patient will receive and what is appropriate for the patient's medical condition is the call of the anesthesia provider.
“Be sure your anesthesia care is led by a physician anesthesiologist. A physician anesthesiologist is a medical doctor who specializes in anesthesia, pain management and critical care medicine, and works with your surgeon and other physicians to develop and administer your anesthesia care plan,” the American Society of Anesthesiologists (“ASA”) stated in its Preparing for Surgery Checklist.
ASA deems that anesthesia care be left to highly-trained medical experts as they have at least 12-14 years of education and 12,000 to 16,000 hours of clinical training. If possible, patients should meet them before the surgery to discuss the appropriate anesthesia options in a pre-op interview. “They will closely monitor your anesthesia and vital functions during the procedure and take care of you after to assure your recovery is smooth and your pain is controlled,” ASA stated in its checklist.
In an academic paper on "Preoperative Patient Assessment and Care" by Australia’s Queen University School of Medicine, Department of Anesthesiology and Perioperative Medicine, the following are done in a pre-op evaluation:
- Identify any previous ongoing illnesses, which may influence the anesthetic or surgery, in particular cardiac, and respiratory diseases. Renal, hepatic, gastrointestinal, endocrine, neurological, and musculoskeletal conditions may also influence perioperative management
- Elicit any possible concerns about previous anesthetics or any family history of problems with anesthetics.
- Any adverse drug reaction and current medications.
- Examine the patient and in particular assess the airway
- Review any investigations and order others needed.
- Plan the anesthetic technique.
- Provide information for the patient and relatives about the anesthetic and postoperative care including pain management.
3. Pre-Anesthesia Survey or Questionnaire
Pre-op evaluation can take the form of surveys or questionnaires along with pre-op visits. There is also the consent form that has to be signed, a pre-requisite for any surgery.
An example of a manual pre-op checklist is Cedars-Sinai’s Preparation Checklist, a form is required to be downloaded and filled out before proceeding to the pre-op consultation. The "Anesthesia Pre-Procedure Evaluation Center (APEC) Patient Pre-Anesthesia Questionnaire" is among the exhaustive list of things and documents to bring, and forms to complete in preparation for a surgery.
Other anesthesia and pain clinics have adapted to the digital age and adopted digital solutions to declutter the pre-op evaluation. East Carolina Anesthesia Associates, for example, championed patient care with an interactive communication platform for surgical population management. LifeWIRE’s protocol for anesthesiologists has helped ECAA reduce DOS cancellations and improve patient outcomes.
With its pre-op, patient is able to choose how they want to communicate, such as text messaging, emails, or any other form of digital communication. Through LifeWIRE, everyone involved in a patient's care is kept in the loop from day one, helping to ensure they're pre-optimized for surgery and decrease day-of-surgery cancellations.
4. Laboratory Investigations
There are two types of laboratory investigations prior to elective surgery: Routine or screening; and indicated or diagnostic. Crucial in the detection, diagnosis, and treatment of patients, these are key elements of pre-op evaluation. This determines the fitness and readiness for anesthesia by a patient. It can also pre-identify patients at high risk of postoperative complications.
As per ASA’s definition, routine tests are intended to discover a disease or a disorder even with the absence of any symptoms. They include a panel of blood, urine tests and X-ray chest, electrocardiogram while indicated tests are done to confirm a clinical diagnosis. A 2011 research on the Role of Routine Laboratory Investigations in Preoperative Evaluation stated that indicated tests “are generally well accepted as they affect perioperative care and outcome.”
The same research has found that a large number of investigations, which are costly to pursue, often detect minor abnormalities of no clinical relevance but may be risky to patients, cause unnecessary delays, cancellation of surgery, and increase medico-legal liability.
“An approach of selective testing reduces cost without sacrificing safety or quality of surgical care,” said Aditya Kumar and Uma Srivastava in their study that was published in the Journal of Anaesthesiology Clinical Pharmacology.
One of the key points of their study pointed out that “tests should be done only if results are likely to affect patient management and postoperative outcome. They should not be guided by tradition, vested interest, or cost alone.”
The authors said that screening lies heavily on clinician’s assessment based on patient's interview, examination, review of medical records and the type, and invasiveness of proposed surgery and anesthesia. Only then that selective tests are ordered.
“Performing routine tests in all surgical preoperative patients as a screening tool is inefficient, unnecessary, and expensive…adoption of guidelines for testing can maximize the yield and prevent waste of resource and time,” the study concluded.
ECAA partner and anesthesiologist Dr. Perrin Jones said risk-stratifying the patients is a pre-op solution that doesn’t require a battery of tests. Surgical population management, through an automated protocol, such as LifeWIRE, has helped him in his practice decreased the need for additional pre-op testing by 60-65%.
“LifeWIRE has allowed us to have that first touch as early as we can in the pre-op process, then as soon as we can onboard patient data, we're able to risk stratify our patients almost from the day the decision is made to operate. We can determine which patients can safely be done in an outpatient setting versus an inpatient setting, which patients need to have a visit to our pre-op testing center, which ones don't,” said Jones.
Required premedication (all essential routine medications, in fact) may be ordered at any time before the day of surgery. Antibiotic therapy for pre existing infections or a pretreatment of asthmatic patients with steroids, for example, play a part in optimizing the patient for surgery.
Pulling from his 20 years of clinical practice experience, Anesthesiologist Gregory Davis suggests that another big problem for why cases are cancelled is medications to stop or continue prior to surgery.
“There are a number of cancellations that occur because somebody forgot to stop taking their antiplatelet medicine, or their anticoagulation medicine because a third party not directly involved in the surgical care has told them,” said Davis.
He added that a patient mishearing the information about the medication, or writing it down incorrectly, can be a disaster. Not having that information beforehand, not optimizing the patient, is going to lead to increased risks and adverse outcomes.
“It's frustrating for everybody. Frustrating for the surgeon, for the anaesthesia provider, for the hospital administrator, and for the patient and their family member. All those things can be avoided with new technologies,” said Davis.
6. Confirming Medical History
Medical history is the backbone of the pre-op evaluation. A clear picture of the patient’s health status past – along with the present condition – can change the future of a surgical procedure. More than assessing the patient’s overall health status, medical history is about perioperative risk determination.
And the complete picture includes not just past and current medical history, or surgical history, but also the family history, especially when adverse reactions are associated with anesthesia.
Then there’s the patient’s social history related to use of tobacco, alcohol and illegal drugs. Or a history of allergies, current and recent drug therapy, unusual reactions or responses to drugs, and any problems or complications associated with previous anesthetics.
Documenting or uncovering pre-existing conditions is especially important when prepping for anesthesia. Cardiovascular diseases such as ischemic heart disease, congestive heart failure, hypertension, and problems in the respiratory systems like reactive airways disease, indicate fitness levels for anesthesia and surgery. Diabetes mellitus can also be an issue.
7. Pre-operative Interventions
While pre-operative interventions are aimed at improving the overall health status of a patient leading to surgery, many result in improved postoperative outcomes.
It can be as simple as smoking cessation (at least 2 months before surgery) or drinking, to doing exercises preoperatively, to adopting a diet plan. These have a dramatic impact on the readiness and fitness of a patient going into surgery. They have also contributed to more effective weight management post-operatively.
Creating a protocol for the collection, monitoring, and reporting of preoperative interventions will effectively improve post-operative care and outcomes.
The Crux of Preoperative Care
Preoperative care runs the whole gamut of preparation - physical, psychological, and educational. Effectively educating the patient as part of the preoperative care protocol becomes critical to the resulting outcomes, patient satisfaction, and bottom-line revenue for your business.
The challenge is to not burden an already anxious and fearful patient by overloading him or her with information that they can’t process. At the very least they should be eased into the communication flow with health care providers, ideally automating as much of the process as possible so they have to rely less on their memory and notes.
This is where LifeWIRE fits in.
"With LifeWIRE I get a communication platform that links me with the patient, links the providers associated with the care of that patient onto one easy to use format that can reach out to me based on if need be. It closes the loop of communication with everyone,” said Davis.
Heading some 60 doctors and about 200 Certified Registered Nurse Anesthetists under ECAA, Davis said their use of LifeWIRE’s protocol has been most effective in streamlining the information gathering process preoperatively. It has eliminated a lot of the extra labor-intensive requirements that were associated with gathering information prior to surgery.
“And it allows me to continue to communicate with that patient up until the day of surgery and postoperatively to limit complications, make sure patients are okay, identify potential issues earlier so that we can intervene early,” said Davis.
He added this dramatically lowered the cost of care, but more importantly, it will improve the patient's experience with their surgical process. “And when you have a satisfied patient, now you have that branding, that loyalty. You have a bond with the surgeon. You have a bond with the care providers and the facility at which they receive that care. That positive experience has the ripple effect in the opposite way of a cancellation does."
Discover how LifeWIRE Anesthesiology as an interactive communications platform for surgical population management, help ensure patients pre-optimized for surgery.