Preoperative consultations by anesthesiologists

Clinician perspectives on the perioperative roles and responsibilities of anesthesia, surgery, and primary care

BACKGROUND

Although high-risk older patients benefit from a multidisciplinary approach to perioperative care, the specific roles and responsibilities of the clinicians involved have yet to be adequately characterized.

METHODS

Qualitative analysis of semi-structured interviews with four anesthesia preoperative clinic providers, seven surgeons, and nine primary care providers in northern New England.

RESULTS

The analysis revealed both distinct and overlapping roles and responsibilities. Anesthesia providers were described as a "safety net" and surgeons as "captain of the ship", in charge of getting "all the ducks in a row" to avoid surgery delays and cancellations. Primary care providers saw themselves as the "quarterback", ensuring care continuity and consideration of patient psychosocial factors.

CONCLUSIONS

While all have a shared responsibility for facilitating patient-centered decision-making and a safe perioperative course, each discipline has different areas of focus and expertise. Role clarification can help optimize the distribution of responsibilities and enhance perioperative communication and collaboration.

Does preoperative multidisciplinary team assessment of high-risk patients improve the safety and outcomes of patients undergoing surgery?

BACKGROUND

International guidelines recommend preoperative multidisciplinary team (MDT) assessment for high-risk surgical patients. Preoperative MDT meetings can help to improve surgical care, but there is little evidence on whether they improve patient outcomes.

METHODS

This paper aims to share our experience of MDT meetings for high-risk surgical patients to underline their added value to the current standard of care. An observational study of a retrospective cohort of preoperative high-risk MDT meetings of a tertiary referral hospital between January 2015 and December 2020. For 249 patients the outcomes preoperative data, MDT decisions, and patient outcomes were collected from electronic health records.

MAIN RESULTS

A total of 249 patients were discussed at high-risk MDT meetings. Most of the patients (97%) were assessed as having an American Society of Anesthesiology score ≥ 3, and 219 (88%) had a European Society of Cardiology and European Society of Anaesthesiology risk score of intermediate or high. After MDT assessment, 154 (62%) were directly approved for surgery, and 39 (16%) were considered ineligible for surgery. The remaining 56 (23%) patients underwent additional assessments before reconsideration at a high-risk MDT meeting. The main reason for patients being discussed at the high-risk MDT meeting was to assess the risk-benefit ratio of surgery. Ultimately, 184 (74%) patients underwent surgery. Of the operated patients, 122 (66%) did not have a major complication in the postoperative period, and 149 patients (81%) were alive after one year.

CONCLUSIONS

This cohort study shows the vulnerability and complexity of high-risk patients but also shows that the use of an MDT assessment contributes too improved peri- and postoperative treatment strategies in high-risk patients. Most patients underwent surgery after careful risk assessment and, if deemed necessary, preoperative and perioperative treatment optimization to reduce their risk.

Association of preoperative anaesthesia consultation prior to elective noncardiac surgery with patient and health system outcomes: a population-based study

BACKGROUND

Surgical volumes and use of preoperative anaesthesia consultations are increasing. However, contemporary data estimating the association between preoperative anaesthesia consultation and patient (days alive and at home [DAH30], mortality) and system (costs, length of stay, and readmissions) outcomes are not available.

METHODS

We conducted a population-based comparative effectiveness study using linked health administrative data among patients aged ≥40 yr who underwent intermediate-risk to high-risk elective, inpatient, noncardiac surgery in Ontario, Canada (2009-17). Our primary outcome was DAH30. Secondary outcomes included DAH90, 30-day and 1-yr mortality, 30-day health system costs, length of index admission, and 30-day readmissions. Propensity score overlap weights were used to adjust for confounders. Prespecified effect modifier analyses focused on high-risk subgroups.

RESULTS

Among 364 149 patients, 274 365 (75.3%) received a preoperative anaesthesia consultation. No adjusted association was found (22.5 days vs 22.5 days; adjusted ratio of means 1.00, 95% CI 1.00-1.00) between consultation and DAH30 in the full population. We identified significant effect modification (significantly more DAH30) among patients with ischaemic heart disease, ASA physical status ≥4, frailty index score ≥0.21, and who underwent vascular surgery. Secondary outcomes were associated with preoperative consultation, including greater DAH90, decreased length of stay, lower 30-day and 1-yr mortality, and reduced 30-day costs.

CONCLUSIONS

Preoperative anaesthesia consultation was not associated with greater DAH30 across the overall study population. However, important potential benefits were observed among high-risk subgroups. Research is needed to identify optimal patient populations and consultation processes.

Determinants of information provided by anaesthesiologists to relatives of patients during surgical procedures

Background

Data and interventions are lacking for family-centred perioperative care in adults. Perioperative information given to relatives by nurses or surgeons is associated with improved satisfaction and fewer symptoms of anxiety for relatives and the patient themselves. However, the frequency of the provision of information by anaesthesiologists to patients' relatives during surgery has never been reported.

Methods

A cross-sectional survey was sent to French anaesthesiologists in October 2020 to inquire how often they provided information to patients' family members during surgery and what factors led to them providing information frequently (i.e. in more than half of cases).

Results

Among 607 anaesthesiologists, 53% (319/607) were male, with median age 47 (36-60) yr and nearly half (43%, 260/607) reported more than 20 years of clinical experience; most responders (96%, 580/607) mainly treated adults. Forty-nine (8%) anaesthesiologists declared that they frequently provide information to relatives during surgery. After multivariate analysis, age >50 yr, female gender, and paediatric practice were associated with providing information more frequently. Reasons for not providing information included a lack of time and dedicated space to talk to relatives. Urgent surgery or surgery lasting >2 h were identified as factors associated with provision of information to relatives.

Conclusions

Giving information to relatives during surgery is not a common practice among anaesthesiologists. It depends on individual anaesthesiologists' personal characteristics and practice. Information during surgery could be provided systematically in situations identified as being the most important by anaesthesiologists in our survey. By creating new pathways of information, we could reduce stress and anxiety of patients and relatives.

Development, implementation and evaluation of high-quality virtual preoperative anaesthetic assessment during COVID-19 and beyond: a quality improvement report

BACKGROUND

Preoperative risk factor identification and optimisation are widely accepted as the gold standard of care for elective surgery and are essential for reducing morbidity and mortality. COVID-19 public health restrictions required a careful balance between ensuring best medical practices and maintaining safety by minimising patient face-to-face attendance in the hospital. Based on the successful implementation of telemedicine (TM) in other medical specialties and its feasibility in the preoperative context, this study aimed to develop, implement and evaluate a high-quality virtual preoperative anaesthetic assessment process.

METHODS

The three-step model for improvement was used. The specific, measurable, actionable, relevant, time aim (step 1) and measures for improvement (step 2) were defined at the onset of the project. The plan-do-study-act tool was used for the structured implementation of improvement interventions (step 3) in three phases. Data relating to virtual and in-person referrals, assessments, did-not-attend (DNA) rate, consultation time, day of surgery delays and cancellations, and service-user and provider experience surveys were recorded prospectively.

RESULTS

A total of 2805 patients were assessed in the preoperative anaesthetic assessment clinic between July 2020 and March 2021. The mean rate of virtual preoperative assessments was 50% (SD ±10) (1390/2805). 0.1% (30/2805) were inappropriately referred on the alternative pathway. The DNA rate was 0.4% (8/1398) and 3% (43/1458) for virtual and in-person pathways, respectively. The mean consultation times for virtual and in-person attendance were 19 (SD ±7) and 31 (SD ±13) min, respectively. There were five same-day surgery cancellations and one delay due to medical reasons. When asked about their experience with the virtual assessment, both service users and providers reported high satisfaction, minimal technical difficulties and shared concerns about limited opportunities for physical examination.

CONCLUSION

This is one of the first implementational studies to comprehensively outline the feasibility of TM in preoperative anaesthetic assessment during COVID-19.

Preoperative anesthesiology consult utilization in Ontario - a population-based study

RATIONALE, AIMS AND OBJECTIVES

Physician consultations are a limited resource. Anesthesiologists provide anaesthesia during surgery and procedures, prepare patients for surgery in preoperative clinics, and provide postoperative care. This study sought to evaluate current consultation usage patterns, with an aim to determine possible opportunities for efficiency.

METHOD

A retrospective comprehensive population-based cohort study was performed, evaluating all hospitals in the Canadian province of Ontario from 2002 to 2018. The main outcome measures were American Society of Anesthesiologists (ASA) classification of the patients, and whether the patients underwent surgery within 3 months following the anaesthesia consultation.

RESULTS

A cohort of 2,023,499 patients, and a total of 2,920,100 preoperative anaesthesia consultations was obtained. The number of consults per year doubled between 2003 (112,983/year) and 2017 (246,427/year), despite a less than 40% increase in practicing Canadian Anesthesiologists over this same timeframe. Each year, an average of 19.3% of the consults (range: 17.7-20.5%) were for patients that did not progress to having surgery. Of those that did have surgery following the anaesthesia consult, 37.2% were ASA Classification I or II. The most common surgical procedures (percent of total) following anaesthesia consult were: Knee arthroplasty (9.5%), hip arthroplasty (5.8%), cataract extraction (4.1%), repair of muscle of chest/abdomen (3.3%), hysterectomy (2.8%), and cholecystectomy (2.7%).

CONCLUSIONS

This study reveals data on utilization and trends over time of preoperative anaesthesia consultations. Potential opportunities for optimization were found, including patients who did not proceed to surgery, and healthier patients undergoing low to moderate risk surgery.

Preoperative assessment clinics and case cancellations: a prospective study from a large medical center in China

Background

Preoperative assessment clinics have great benefits in reducing surgical cancellations, saving hospital resources and improving patient satisfaction. However, previous studies did not focus on patients with comorbidities. With advancements in medicine and aging population, the number of elderly patients with multiple comorbidities is increasing. This study was designed to assess the effectiveness of a preoperative assessment clinic for patients with multiple comorbidities.

Methods

This prospective, observational study enrolled patients with multiple comorbidities from Nov 1, 2019 to Oct 31, 2020 in a tertiary teaching hospital in China. Patients either visited the preoperative assessment clinic before admission or received an anesthesia consultation after admission. The impact of clinic visits on operating room cancellations, length of hospital stay before surgery, length of hospital stay after surgery, major postoperative complications, incidence of postoperative intensive care unit (ICU) admission, readmission to any hospital within 30 days after surgeries and total in-hospital costs were analyzed.

Results

A total of 326 eligible cases were included. Eighty-seven of 108 cases who visited the clinic before admission were scheduled for selective surgeries. In all, 218 patients received an anesthesia consultation after admission. The cancellation rate in the inpatient group was 7.80%, while no surgeries were cancelled in preclinic group (P=0.016). A preoperative assessment clinic visit statistically decreased the length of in-hospital stays before surgery from 93.02 to 76.11 h (P=0.010). After propensity score matching, significant differences in operating room cancellations (0 vs. 6.48%; P=0.015) and length of stay before surgery (76.11 vs. 92.22 h; P=0.038) persisted between two groups. No significant differences between the two groups were found in terms of prognosis, including major postoperative complications, incidence of postoperative ICU admissions, and readmissions to any hospital within 30 days (P>0.05).

Conclusions

Among patients with comorbidities undergoing major surgeries, a preoperative assessment clinic visit was more efficient than an anesthesia consultation after admission. These findings may provide impetus for the opening of preoperative assessment clinics for critical patients in China.

Preanaesthetic assessment and management in the context of the district hospital

Preanaesthetic assessment and management allow for the systematic identification of perioperative risks and the implementation of interventions to mitigate them, such that the patient's physiological state is optimised for surgery or other procedures. This is a crucial activity for good perioperative outcomes, as patients not assessed are at a higher risk of unanticipated adverse perioperative events and are more likely to receive suboptimal management. The district hospitals in South Africa perform minor and moderately complex surgical procedures that require anaesthesia, administered mostly to healthy patients and those with stable diseases without functional limitations. A significant proportion of anaesthesia-related deaths reported in the district hospitals can be linked to poor risk assessment and management. In this article, we highlight the key clinical imperatives for optimal preanaesthetic assessment and management from the district hospital perspective.

The effects of a preoperative multidisciplinary conference on outcomes for high-risk patients with challenging surgical treatment options: a retrospective study

BACKGROUND

Surgical options for patients vary with age and comorbidities, advances in medical technology and patients' wishes. This complexity can make it difficult for surgeons to determine appropriate treatment plans independently. At our institution, final decisions regarding treatment for patients are made at multidisciplinary meetings, termed High-Risk Conferences, led by the Patient Safety Committee.

METHODS

In this retrospective study, we assessed the reasons for convening High-Risk Conferences, the final decisions made and treatment outcomes using conference records and patient medical records for conferences conducted at our institution from April 2010 to March 2018.

RESULTS

A total of 410 High-Risk Conferences were conducted for 406 patients during the study period. The department with the most conferences was cardiovascular surgery (24%), and the reasons for convening conferences included the presence of severe comorbidities (51%), highly difficult surgeries (41%) and nonmedical/personal issues (8%). Treatment changes were made for 49 patients (12%), including surgical modifications for 20 patients and surgery cancellation for 29. The most common surgical modification was procedure reduction (16 patients); 4 deaths were reported. Follow-up was available for 21 patients for whom surgery was cancelled, with 11 deaths reported.

CONCLUSIONS

Given that some change to the treatment plan was made for 12% of the patients discussed at the High-Risk Conferences, we conclude that participants of these conferences did not always agree with the original surgical plan and that the multidisciplinary decision-making process of the conferences served to allow for modifications. Many of the modifications involved reductions in procedures to reflect a more conservative approach, which might have decreased perioperative mortality and the incidence of complications as well as unnecessary surgeries. High-risk patients have complex issues, and it is difficult to verify statistically whether outcomes are associated with changes in course of treatment. Nevertheless, these conferences might be useful from a patient safety perspective and minimize the potential for legal disputes.

[Telehealth in peroperative medicine]

La télémédecine est en plein essor dans tous les domaines médicaux. En plus d’être l’une des priorités de l’OMS afin de répondre aux problèmes des coûts et de l’accessibilité à des soins de qualité, que ce soit dans les pays développés ou en voie de développement, la crise sanitaire récente liée au COVID-19 a montré qu’elle pouvait être un atout certain pour la permanence des soins en situation de crise. Si la télémédecine en anesthésie se développe pour l’ensemble de la prise en charge péri-opératoire des patients, cette mise au point vise à présenter les données récentes de la littérature concernant la place de la télémédecine en anesthésie pour l’évaluation pré-opératoire. Quatre points principaux sont abordés : (1) l’éligibilité et la faisabilité de la téléconsultation d’anesthésie; (2) son efficacité en terme de temps passé en consultation d’anesthésie, taux d’annulation d’intervention et concordance de l’examen physique; (3) la satisfaction des patients, et enfin; (4) son potentiel impact économique.

Client perceptions of the value of veterinary anesthesiologist involvement with anesthesia and pain management, benefits of a preanesthetic consultation, and quality of care for dogs undergoing elective orthopedic surgery

OBJECTIVE

To compare perceptions related to veterinary anesthesiologist involvement with anesthesia and pain management, benefits of a preanesthetic consultation (PAC) with an anesthesiologist, and quality of patient care between clients who did and did not participate in a PAC prior to their dogs' elective orthopedic surgery.

SAMPLE

80 dog owners.

PROCEDURES

Owners of dogs undergoing elective stifle joint surgery participated in the study. Participants were randomly assigned to PAC and control groups (n = 40 participants/group). The PAC group participated in a PAC with an anesthesiologist and completed a written survey (12 items with Likert-type response options). The control group completed a similar survey (identical except for 2 statements related to the PAC experience) without participating in a PAC. Results were compared between groups by statistical methods.

RESULTS

The proportion of clients in the PAC group who strongly agreed with the statements that a PAC was beneficial, their questions about the pet's anesthesia and pain management plan were answered, they knew who would perform anesthesia and what safeguards were in place, veterinary specialty hospitals should have an anesthesiologist on staff, they were willing to pay more to have an anesthesiologist supervise the anesthesia and pain management, and a PAC with an anesthesiologist should be standard of care in veterinary medicine was greater than that for control group clients. Responses to quality-of-care items did not differ between groups.

CONCLUSIONS AND CLINICAL RELEVANCE

Participating in a PAC was associated with more positive perceptions of anesthesiologists and knowledge about the anesthesia plan. Further research with a validated survey instrument is needed to confirm these findings.

Preoperative education reduces preoperative anxiety in cancer patients undergoing surgery: Usefulness of the self-reported Beck anxiety inventory

Background and objectives

Methods

Results

Conclusions

Reliability of focused cardiac ultrasound by novice sonographer in preoperative anaesthetic assessment: an observational study

Background

Use of preoperative echocardiography may help to identify patients with increased cardiac risk, who may benefit from modification of perioperative plan. The objective of our study was to evaluate the reliability of preoperative focused cardiac ultrasound (FoCUS) performed by an anaesthetist with basic ultrasound training and its impact on patient’s management.

Methods

The prospective observational study was conducted in 159 adult patients, scheduled for elective operations. Cardiac ultrasound was performed by one anaesthetist with a limited experience of FoCUS. A simple, mnemonic scheme was used for the final reporting of each study. The same scheme was used by a cardiologist who produced an independent report based on digital video loops stored in the machine memory. Anaesthetists in-charge made final perioperative plan.

Comparative analysis of anaesthetist and cardiologist performed ultrasound report was made. The incidence of modification of initial perioperative plan resulting from FoCUS report was analyzed.

Results

The average time required to complete the examination was 182 s 95 % CI [173–190]. Images of quality adequate to answer all questions from the scheme were obtained in 97.5 % (155/159) of patients. There was strong agreement between the anaesthetist and the cardiologist in 97.8 % (2274/2325) of the examined categories. In two categories (global and regional left ventricle contractility impairment) statistically significant discrepancies between both diagnosticians were confirmed (p McNemar <0.04). When compared with the cardiologist’s assessment the agreement of the anesthetist’s diagnosis had sensitivity of 0.84, specificity 0.99, positive predictive value 0.78 and negative predictive value 0.99. Kappa statistics showed good agreement between both examining doctors (κ = 0.797). Based on ultrasound findings, the preliminary anaesthetic plan was changed in relation to 20.8 % (33/159) of patients.

Conclusions

An anaesthetist with limited training in FoCUS can perform a reliable preoperative examination which alters the perioperative management.

Perioperative assessment of the cancer patient

The perioperative evaluation of patients with cancer differs from that of other patients in that the former may have received prior chemotherapy or radiation therapy. These cancer treatments have a wide range of side effects and complications that may affect patients' perioperative risks. The perioperative specialist who evaluates the cancer patient prior to surgery must be familiar with the effects of these treatments and their consequences for the major organ systems. The perioperative specialist must also be familiar with the natural history of cancer and have a basic understanding of how cancer affects the body. In this article, we review the perioperative concerns that are specific to the patient with cancer.