Experience in implementation of clinical guidelines: pre-operative chest radiography in non-cardiopulmonary surgery

In 1983, the All-Wales Management Efficiency Group (All-Wales MEG) published a report on pre-operative chest radiography (POCR) and made recommendations about the use of POCR in district health authorities in Wales. The object of this paper is to describe experience within one Welsh authority, highlighting both perceived problems and the difficulties encountered in the implementation of these recommendations.

Cost-effective application of the Centers for Disease Control Guideline for Prevention of Surgical Wound Infections

Surgical wound infections present a serious hazard to patients and an important legal and economic liability to health care providers. This Guideline furnishes infection control practitioners with several excellent cost-saving concepts and, if implemented, would result in a reduction in the rates of surgical wound infections.

Critical assessment of routine preoperative investigations

The use of routine investigations is widespread in medical practice, particularly for preoperative assessment. Recent studies showed that some routine preoperative investigations are uninformative when ordered without a clinical indication. The rationale for preoperative investigations includes emphasis on history taking and clinical examination, as well as specific targets correlated to the surgical situation. Investigations could fall into three broad categories: discretionary tests which complete clinical history, baseline tests for interpretation of anticipated perioperative disturbances and screening tests for conditions affecting perioperative morbidity and mortality. Each investigation should answer a specific question and the result should influence decision-making. Application of these principles should lead to elimination of unnecessary tests and better utilization of medical information but further studies are needed for evaluation of such strategies.

Techniques known to prevent post-operative wound infection

The most important factors in controlling postsurgical sepsis are appropriate surgical judgment and technique. Efficacious prophylactic antibiotics, when indicated, also significantly reduce the postoperative infection rate. Among the other techniques often heralded as important adjunctive measures, only duration of preoperative hospitalization, preoperative bathing, use of electrocautery, preoperative hair removal, use of prophylactic drains, and duration of operation are of proven significance.

Diminished operative morbidity and mortality in renal revascularization

From 1974 to 1980, one hundred consecutive patients with atherosclerotic renovascular disease underwent revascularization. There were two operative deaths and eight postoperative complications. This low operative morbidity is attributed to preoperative screening, correction of existing coronary or cerebrovascular disease, and reliance on methods of revascularization that obviate operation on a badly diseased aorta. The results in 78 patients with renovascular hypertension were 40% cured, 51% improved, and 9% failed. In 22 patients in whom revascularization was performed to preserve renal function, the postoperative serum creatinine levels were improved in 19 patients, remained stable in two patients, and increased in one patient.

Death associated with anaesthesia in Finland

The mortality associated with 338 934 procedures carried out in 1975 in 100 Finnish hospitals is reported. There were 626 deaths (1/541 or 0.18%). Mortality during the procedure was 1/5059 (0.02%). Twelve patients died primarily of anaesthesia during the procedures and 55 patients later (total anaesthetic mortality 1/5059, 0.02%). The frequency of cardiac arrest was 1/3808 (0.03%). Most of the 67 anaesthetic deaths were caused by inadequacy of management of fluid balance (17 patients) or respiratory insufficiency (15 patients). There were 12 deaths from cardiac complications, five each from technical errors and inadequate supervision after operation. The primary disease was responsible for approximately 72% of the reported deaths.

[The role of the physician in assessing fitness for surgery (author's transl)]

The decision regarding fitness of a person to undergo surgery and anaesthesia is made by the surgeon and anaesthetist according to agreed criteria. The physician takes part in the decision only in those cases where additional information regarding the type and extent of the disorder is required or when doubtful findings need further clarification. Closer co-operation between anaesthetist and physician regarding the indications for pre-operative tests and investigations is desirable.