Cardiac Screening in the Noncardiac Surgery Patient

Capturing Original Preanesthetic Comprehensive History and Physical Assessments with the use of Video Telehealth: A Quality Improvement Project for Student Nurse Anesthetists

PURPOSE

Beginning January 1, 2022, the Council on Accreditation is requiring student registered nurse anesthetists (SRNAs) matriculating into nurse anesthesia programs to track preanesthetic comprehensive history and physical (H&P) assessment completion numbers. This quality improvement (QI) project aimed to create a new clinical rotation for SRNAs to practice their preanesthetic H&P assessment skills through video telehealth.

DESIGN

A quality improvement project.

METHODS

Likert-style and free-text surveys were administered to both the SRNA students and the expert provider to assess for improvements, viability, and effectiveness of the clinical rotation. SRNAs used a curated library of evidence-based resources and instructions for conducting their assessments. Expert guidance was provided through a single experienced provider.

FINDINGS

Eight SRNAs performed one preanesthetic telehealth H&P assessment and four of the eight performed a second assessment. Pre-QI surveys indicated 75% were not comfortable with their ability in performing a competent assessment. Initial post-QI surveys indicated 88% were more comfortable with their abilities and 100% of those who completed a second-time post-QI survey 100% were more comfortable. Provider feedback indicated full-day clinical rotations were feasible and important.

CONCLUSIONS

Results revealed SRNAs desire and need for more preanesthetic comprehensive H&P appointments. Expansion into full-scale, full-day, and in-person assessments was also indicated. QI projects at other clinical sites can determine if similar rotations can also create similar clinical rotations.

30-day Major Adverse Cardiac Events (MACE) after elective bariatric surgery: the development and validation of the Bari-MACE clinical predictive tool

BACKGROUND

Major adverse cardiac events (MACEs) after bariatric surgery are poorly understood yet are thought to be associated with significant morbidity and mortality.

OBJECTIVES

To evaluate the prevalence and clinical impact of short-term, 30-day MACE and to develop a pragmatic clinical predictive MACE scoring tool.

SETTING

This retrospective study was conducted using all the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited center data from 2015 to 2019.

METHODS

Primary Roux-en-Y and sleeve gastrectomy procedures were included, and prior revisional surgeries and emergency surgeries were excluded. Multivariable logistic regression modeling was used to examine the risk factors associated with 30-day MACE. Using forward regression, a Bari-MACE clinical prediction model was generated.

RESULTS

A total of 750,498 patients were included in our analysis of which 959 (.1%) experienced a MACE. MACE patients were older (54.0 ± 11.5 yr versus 44.4 ± 12.0 yr, P < .0001), and comprised a higher proportion of males (36.3% versus 20.4%, P < .0001) and patients of White racial status (74.0% versus 71.6%, P < .0001). The MACE cohort also had a higher body mass index (46.6 ± 9.7 kg/m² versus 45.2 ± 7.8 kg/m², P < .0001), higher rates of sleep apnea (56.8% versus 38.2%, P < .0001), and a higher proportion of insulin-dependent diabetes (26.1% versus 8.4%, P < .0001) than non-MACE patients. Derivation of our clinical predictive Bari-MACE scoring model revealed 12 variables associated with development of MACE with a specificity of 97.8% using a 55-point threshold.

CONCLUSION

Thirty-day major adverse cardiac events after elective bariatric surgery are rare, occurring in approximately .1% of all patients, but are associated with significant morbidity and mortality. Using the MBSAQIP, we developed a Bari-MACE clinical predictive tool to risk-stratify patients with the aim to better guide perioperative care and foster improved surgical outcomes.

[Preoperative cardiovascular risk evaluation before elective noncardiac surgical interventions]

A careful and standardized but nevertheless individually adapted and targeted medical history and physical examination are essential components of a preoperative evaluation. The individual cardiovascular risk profile characterized by noninvasive diagnostics requires a targeted further assessment with noninvasive and invasive diagnostic investigations, which should be targeted to the medical needs of the individual patient. The aim is to assess the individual risk of undesired major adverse cardiac events (MACE). The preoperative examination procedures should be limited to the medically necessary needs in order to be able to optimally utilize the material and personnel resources. This review article presents a practical guide for preoperative cardiovascular risk evaluation in patients scheduled for elective, noncardiac surgery.

Recommendations for Preoperative Assessment and Shared Decision-Making in Cardiac Surgery

Purpose of review

Recommendations about shared decision-making and guidelines on preoperative evaluation of patients undergoing non-cardiac surgery are abundant, but respective recommendations for cardiac surgery are sparse. We provide an overview of available evidence.

Recent findings

While there currently is no consensus statement on the preoperative anesthetic evaluation and shared decision-making for the adult patient undergoing cardiac surgery, evidence pertaining to specific organ systems is available.

Summary

We provide a comprehensive review of available evidence pertaining to preoperative assessment and shared decision-making for patients undergoing cardiac surgery and recommend a thorough preoperative workup in this vulnerable population.

Prediction of Postoperative Surgical Risk: A Needs Assessment for a Medical Student Curriculum

OBJECTIVE

Medical students' abilities to predict postoperative complications and death are unknown. We hypothesize that medical students will lack confidence in determining surgical risk and will significantly overestimate surgical risk for post-operative morbidities and mortality.

DESIGN

Participants were invited to participate in an electronic, anonymous survey to assess their ability to predict surgical risk. The survey presented 7 complex clinical scenarios representative of a diverse general surgery practice. Participants were asked to assess the likelihood of different morbidities and mortality on a 0-100% scale, and predictions were compared to the ACS NSQIP risk calculator.

SETTING

Yale School of Medicine, New Haven, Connecticut; Tertiary medical center PARTICIPANTS: Third year medical students on their surgery clerkship as well as general surgery residents were invited to participate.

RESULTS

Most students were not confident about predicting postoperative complications (83.3%) or mortality (70.8%). Most students did not feel that the surgery clerkship adequately prepared them to assess surgical risk (69.6%). When compared to surgical residents for most presented cases (57% of cases), students and residents similarly overestimated postoperative morbidities and mortality. Estimates varied significantly, with wide 95% confidence intervals. Only 17% of NSQIP predicted estimates fell within the 95% confidence intervals.

CONCLUSIONS

Medical students overestimate morbidity and mortality following surgery in complex patients. Additionally, they lack confidence in their ability to predict surgical complications. A formal curriculum for risk prediction is needed for medical students.