Designing and Running a Preoperative Clinic

Systems of Care Delivery and Optimization in the Preoperative Arena

Key elements of an effective preoperative process include the following: history-taking, risk assessment, shared decision making, effective interdisciplinary communication, preoperative optimization of modifiable conditions, longitudinal care coordination, contribution to population health aims, and collection of outcomes-driven metrics. Perioperative medicine tenets can be applied by health systems of all sizes and demographics to improve quality and safety.

Differences between patients in whom physicians agree versus disagree about the preoperative diagnosis of heart failure

STUDY OBJECTIVE

To quantify preoperative heart failure (HF) diagnostic agreement and identify characteristics of patients in whom physicians agreed versus disagreed about the diagnosis.

DESIGN

Observational cohort study.

SETTING

Patients undergoing major non-cardiac surgery at an academic center between 2015 and 2019.

PATIENTS

40,659 patients undergoing major non-cardiac surgery, among which a stratified subsample of 1018 patients with and without documented HF was reviewed.

INTERVENTIONS

Via a panel of physicians frequently managing patients with HF (cardiologists, cardiac anesthesiologists, intensivists), detailed chart reviews were performed (two per patient; median review time 32 min per reviewer per patient) to render adjudicated HF diagnoses.

MEASUREMENTS

Adjudicated diagnostic agreement measures (percent agreement, Krippendorf's alpha) and univariate comparisons (standardized differences) between patients in whom physicians agreed versus disagreed about the preoperative HF diagnosis.

MAIN RESULTS

Among patients with documented HF, physicians agreed about the diagnosis in 80.0% of cases (consensus positive), disagreed in 13.8% (disagreement), and refuted the diagnosis in 6.3% (consensus negative). Conversely, among patients without documented HF, physicians agreed about the diagnosis in 88.0% (consensus negative), disagreed in 8.4% (disagreement), and refuted the diagnosis in 3.6% (consensus positive). The estimated agreement for the 40,659 cases was 91.1% (95% CI 88.3%-93.9%); Krippendorff's alpha was 0.77 (0.75-0.80). Compared to patients in whom physicians agreed about a HF diagnosis, patients in whom physicians disagreed exhibited fewer guideline-defined HF diagnostic criteria.

CONCLUSIONS

Physicians usually agree about HF diagnoses adjudicated via chart review, although disagreement is not uncommon and may be partly explained by heterogeneous clinical presentations. Our findings inform preoperative screening processes by identifying patients whose characteristics contribute to physician disagreement via chart review. Clinical Trial Number / Registry URL: Not applicable.

Expanding the Role of the Surgical Preoperative Evaluation Clinic: Impact on Risk and Quality Outcome Measures

Objective

To prove that inpatient-adjusted surgical risk and quality outcome measures can be considerably impacted by interventions to improve documentation in the preoperative evaluation (POE) clinic.

Patients and Methods

We designed a quality improvement project with a multidisciplinary team in our POE clinic to more accurately reflect surgical risk and impact expected surgical quality outcomes through improved documentation. Interventions included an improved patient record acquisition process and extensive POE provider education regarding patient comorbidities' documentation. For patients admitted after their planned operations, POE clinic comprehensive evaluation notes were linked to inpatient History and Physical notes. High complexity patients seen from October 1, 2018 to December 31, 2018 were the preintervention cohort, and the patients seen from January 1, 2019 to December 31, 2019 were the postintervention cohort.

Results

The primary outcome measures included the total number of coded diagnoses per encounter and the number of coded hierarchical condition categories per encounter. The secondary outcomes included the calculated severity of illness, risk of mortality, case-mix index, and risk-adjustment factor. Postintervention results show statistically significant increases in all primary outcomes with a P<.05. All secondary outcome measures reported positive change.

Conclusion

Our interventions confirm that a comprehensive POE and thorough documentation provide a more accurate clinical depiction of the preoperative patient, which in turn impacts quality outcomes in inpatient surgical settings. These results are impactful for direct and indirect patient care and publicly reported hospital and provider level performance data.

Preoperative Evaluation in the 21st Century

This review aims to provide a conceptual framework for preoperative evaluation and to highlight the clinical evidence available to support perioperative decision-making.

Cerebrovascular Accident Manifesting as Altered Mental Status During a Telehealth Visit: Preoperative Evaluation in the COVID-19 Era

We present the case of a 91-year-old patient scheduled for a preoperative telehealth evaluation who was found to have altered mental status from an acute stroke. Her care, if delayed, could have caused permanent morbidity during the coronavirus disease 2019 (COVID-19) pandemic. This case highlights the digital leap the pandemic spurred: 1. telehealth in the elderly, 2. meaningful history and physical during telehealth visit, 3. family engagement and education, and 4. meaningful impact on patient outcomes.