The impact of a consultant anaesthetist led pre-operative assessment clinic on patients undergoing major vascular surgery*

Excessive Preoperative Testing in Otolaryngology: A Retrospective Comparison of Primary Care and Perioperative Providers

OBJECTIVE

To assess the association between provider type (primary care provider [PCP] or perioperative provider) and excessive preoperative testing.

STUDY DESIGN

Cross-sectional study.

SETTING

Academic medical center.

METHODS

Electronic medical records of adult patients who obtained an outpatient preoperative assessment and underwent surgery in the Department of Otolaryngology-Head and Neck Surgery during the first 2 weeks of January 2019 (n = 94) were reviewed. Patients receiving preoperative tests beyond those recommended by the guidelines were deemed to have had excessive testing. Descriptive statistics were used to characterize the study population. Simple and multivariate logistic regression were used to analyze the association between the outcome and the predictor variables.

RESULTS

Overall, 44.7% of preoperative evaluations had excessive testing. Patients who had their preoperative evaluation performed by a perioperative provider had 89% lower odds of having excessive preoperative testing compared to those evaluated by a PCP (odds ratio = 0.11, 95% confidence interval: [0.03, 0.37], P < .001). Female sex, younger age, and higher risk of major adverse cardiac events were associated with greater odds of excessive testing.

CONCLUSION

Excessive preoperative testing is more commonly performed by PCPs compared to perioperative providers. These results give preliminary evidence in support of a potential shift in the clinical responsibility of preoperative evaluation from PCPs to perioperative providers in order to reduce excessive testing and promote high-value health care. The next steps include validating these findings, identifying reasons for differential guideline concordance, and intervening accordingly.

Effectiveness of pre-anaesthetic assessment clinic: a systematic review of randomised and non-randomised prospective controlled studies

OBJECTIVES

The aim of this systematic review was to examine the effectiveness of pre-anaesthesia assessment clinics (PACs) in improving the quality and safety of perioperative patient care.

DESIGN

Systematic review.

DATA SOURCES

The electronic databases CINAHL Plus with Full Text (EBSCOhost), Medline and Embase (OvidSP) were systematically searched on 11 September 2018 and updated on 3 February 2020 and 4 February 2021.

ELIGIBILITY CRITERIA

The inclusion criteria for this study were studies published in English or Scandinavian language and scientific original research that included randomised or non-randomised prospective controlled studies. Additionally, studies that reported the outcomes from a PAC consultation with the patient present were included.

DATA EXTRACTION AND SYNTHESIS

Titles, abstracts and full texts were screened by a team of three authors. Risk of bias was assessed using the Joanna Briggs Institute critical appraisal checklist for quasi-experimental studies. Data extraction was performed by one author and checked by four other authors. Results were synthesised narratively owing to the heterogeneity of the included studies.

RESULTS

Seven prospective controlled studies on the effectiveness of PACs were included. Three studies reported a significant reduction in the length of hospital stay and two studies reported a significant reduction in cancellation of surgery for medical reasons when patients were seen in the PAC. In addition, the included studies presented mixed results regarding anxiety in patients. Most studies had a high risk of bias.

CONCLUSION

This systematic review demonstrated a reduction in the length of hospital stay and cancellation of surgery when the patients had been assessed in the PAC. There is a need for high-quality prospective studies to gain a deeper understanding of the effectiveness of PACs.

PROSPERO REGISTRATION NUMBER

CRD42019137724.

Cancellation of elective surgery: rates, reasons and effect on patient satisfaction

Background

The cancellation of elective surgeries is a major problem that increases wait times, exacerbates costs and can negatively affect patients, both psychologically and physically. Our objectives were to investigate the reasons for cancellations across specialties at a single centre, to compare these reasons with previous data from the same centre between 2005 and 2009 and to examine how cancellations affected patients’ lives and views of the medical system in cases when the cancellations were potentially preventable.

Methods

Cancellation records of all elective surgeries scheduled between June 1, 2012, and Jan. 31, 2016, at a medium-sized, tertiary care, academic centre were retrospectively reviewed. We evaluated the rates and reasons for cancellation and interviewed a subset of patients whose surgery was cancelled for a potentially preventable reason (i.e., operating room running late, bed shortage, emergency case took place of scheduled surgery).

Results

Across 11 surgical specialties, 2933 of 20 881 surgeries (14.0%) were cancelled and of these, 2448 (83.5%) were for administrative or structural reasons. Compared with the data collected previously for general, gynecological and urological procedures, cancellation rates increased from 8.1% to 11.8%. Although patients reported inconvenience, they were generally satisfied with the availability and the quality of the health care they received.

Conclusion

Consistent with the previous study, our data suggest that most cancellations occur because of administrative or structural processes that are potentially preventable. Targeting these processes may help to reduce cancellations for elective surgeries and thereby improve economic efficiency and patient outcomes.

Patient-related reasons for late surgery cancellations in a plastic and reconstructive surgery department

Late cancellations of scheduled operations cause direct and indirect costs for a hospital and economic and emotional stress for the patient. Previously, late cancellation rates for scheduled operations in plastic surgery have been shown to be attributable to patient-related causes in the majority of cases.

In this retrospective study, we sought to examine specifically the patient-related reasons for the late cancellations in a plastic surgery operating theatre at Helsinki University Hospital in Finland from 2013 to 2014. We calculated latency between the date of decision for surgery and the scheduled operation day. In cases where the surgery was rescheduled and performed before 31 December 2015, the rescheduled waiting time latency was calculated. We aimed to improve our knowledge of the causes of late cancellations to further optimise the operating theatre efficiency and propose a strategic algorithm to avoid late cancellations

During the study period, 327 (5.5%) of all the scheduled operations were recorded as late cancellations. Of these, 45.3% were because of patient-related issues. Acute infection, change in medical condition not noticed before and operation no longer necessary were by far the most common causes of cancellation, comprising 63.5%. Sixty-six per cent of patient-related cancelled operations were performed later, especially when the specific reason was patient's acute illness. Root-cause analysis shows that most of the underlying reasons for the cancellations can be attributed to a failure in communication. The majority of these cancellations were considered to be preventable, thus emphasising the importance of communication and skilful multi-professional planning of the operating theatre list.

Measuring and Improving the Quality of Preprocedural Assessments

BACKGROUND

Preprocedural assessments are used by anesthesia providers to optimize perioperative care for patients undergoing invasive procedures. When these assessments are performed in advance by providers who are not caring for the patient during the procedure, there is an additional layer of complexity in ensuring that the workup meets the needs of the primary anesthesia care team. In this study, anesthesia providers were asked to rate the quality of preprocedural assessments prepared by other providers to evaluate anesthesia care team satisfaction.

METHODS

Quality ratings for preprocedural assessments were collected from anesthesia providers on the day of surgery using an electronic quality assurance tool from January 9, 2014 to October 21, 2014. Users could rate assessments as "exemplary," "satisfactory," or "unsatisfactory." Free text comments could be entered for any of the quality ratings chosen. A reviewer trained in clinical anesthesia categorized all comments as "positive," "constructive," or "neutral" and conducted in-depth chart reviews triggered by 67 "constructive" comments submitted during the first 3 months of data collection to further subcategorize perceived deficiencies in the preprocedural assessments. In May 2014, providers were asked to participate in a midpoint survey and provide general feedback about the preprocedural process and evaluations.

RESULTS

37,611 procedures requiring anesthesia were analyzed. Of the 17,522 (46.6%) cases with a rated preprocedural assessment, anesthesia providers rated 3828 (21.8%) as "exemplary," 13,454 (76.8%) as "satisfactory," and 240 (1.4%) as "unsatisfactory." The monthly proportion of "unsatisfactory" ratings ranged from 3.1% to 0% over the study period, whereas the midpoint survey showed that anesthesia providers estimated that the number of unsatisfactory evaluations was 11.5%. Preprocedural evaluations performed on inpatients received significantly better ratings than evaluations performed on outpatients by the preadmission testing clinic or phone program (P < .0001). The most common reason given for "unsatisfactory" ratings was a perception of "missing information" (49.2%). Chart reviews revealed that inadequate documentation was in reality the most common deficiency in preprocedural evaluations (35 of 67 reviews, 52.2%).

CONCLUSIONS

The overwhelming majority of preprocedural assessments performed at our institution were considered satisfactory or exemplary by day-of-surgery anesthesia providers. This was demonstrated by both the case-by-case ratings and midpoint survey. However, the perceived frequency of "unsatisfactory" evaluations was worse when providers were asked to reflect on the quality of preprocedural evaluations generally versus rate them individually. Analysis of comments left by providers allowed us to identify specific and actionable areas for improvement. This method can be used by other institutions to identify systemic deficiencies in the preprocedural evaluation process.

The Impact of System Factors on Quality and Safety in Arterial Surgery: A Systematic Review

OBJECTIVE

A systems approach to patient safety proposes that a wide range of factors contribute to surgical outcome, yet the impact of team, work environment, and organisational factors, is not fully understood in arterial surgery. The aim of this systematic review is to summarize and discuss what is already known about the impact of system factors on quality and safety in arterial surgery.

DATA SOURCES

A systematic review of original research papers in English using MEDLINE, Embase, PsycINFO, and Cochrane databases, was performed according to PRISMA guidelines.

REVIEW METHODS

Independent reviewers selected papers according to strict inclusion and exclusion criteria, and using predefined data fields, extracted relevant data on team, work environment, and organisational factors, and measures of quality and/or safety, in arterial procedures.

RESULTS

Twelve papers met the selection criteria. Study endpoints were not consistent between papers, and most failed to report their clinical significance. A variety of tools were used to measure team skills in five papers; only one paper measured the relationship between team factors and patient outcomes. Two papers reported that equipment failures were common and had a significant impact on operating room efficiency. The influence of hospital characteristics on failure-to-rescue rates was tested in one large study, although their conclusions were limited to the American Medicare population. Five papers implemented changes in the patient pathway, but most studies failed to account for potential confounding variables.

CONCLUSIONS

A small number of heterogenous studies have evaluated the relationship between system factors and quality or safety in arterial surgery. There is some evidence of an association between system factors and patient outcomes, but there is more work to be done to fully understand this relationship. Future research would benefit from consistency in definitions, the use of validated assessment tools, measurement of clinically relevant endpoints, and adherence to national reporting guidelines.

Development, Functioning, and Effectiveness of a Preoperative Risk Assessment Clinic

Lee first described the concept of preoperative assessment testing (PAT) clinic in 1949. An efficiently run clinic is associated with increased cost-effectiveness by lowering preoperative admission time and thus reducing the length of stay and the associated costs. The setup of the PAT clinic should be based on the needs, culture, and resources of the institution. Various models for the setup of PAT clinic have been described, including the concept of a perioperative surgical home, which is a patient-centered model designed to improve health and the delivery of health care and to reduce the cost of care. Although there are several constraints in the development of PAT clinics, with increasing awareness about the usefulness of pre-operative risk assessments, growing bodies of literature, and evidence-based guidelines, these clinics are becoming a medical necessity for the improvement of perioperative care.

Operation room management in Korea: results of a survey

Background

The current state of general hospital operation room (OR) in Korea and how these ORs are being operated remain unclear. Therefore, the aim of this study was to investigate and assess the current state of OR management and surgical scheduling in general hospitals of Korea.

Methods

A total of 92 anesthesiology training hospitals and 2 equivalent hospitals in Korea were targeted for the survey. Anesthesiologists in hospitals received questionnaires for OR, anesthetic managements and surgical scheduling directly or by phone from the beginning of October 2015 to the end of December 2015.

Results

Of the 94 hospitals that were targeted, 59 hospitals (62.7%) responded to the survey. Of the 59 hospitals, 40 (67.8%) had 500–1,000 beds, 36 (61.0%) had 11–20 ORs. Most OR arrangements were made by residents and specialists in Anesthesiology Department (90%). Most hospitals (47.4%) in the response set performed total surgeries in the range of 10,000 to 20,000 annually. The proportion of emergency surgeries in the total surgeries was 2.8–55.0%. Methods for predicting expected surgery time were arbitrarily decided by surgeons (61%), anesthesiologist's experience (20%), or by analyzing historical data using software (5%).

Conclusions

This survey study could trigger active operational researches for OR efficiency. It might help hospital policy makers manage OR resources more efficiently.

Ten Years Experiences With Preoperative Evaluation Clinic for Day Admission Cardiac and Major Vascular Surgical Patients: Model for "Perioperative Anesthesia and Surgical Home"

Admission on the day of surgery for elective cardiac and noncardiac surgery is the prevalent practice in North America and Canada. This approach realizes medical, psychological and logistical benefits, and its success is predicated on an effective outpatient preoperative evaluation. The establishment of a highly functional preoperative clinic with a comprehensive set up and efficient logistical pathways is invaluable. This notion in recent years has included the entire perioperative period, and the concept of a perioperative anesthesia/surgical home (PASH) is gaining popularity. The anesthesiologists as perioperative physicians can organize and lead the entire process from the preoperative evaluation, through the hosptial discharge. The functions of the PASH include preoperative optimization of medical conditions and psychological preparation of the patients and their support system; the care in the operating room and intensive care unit; pain management; respiratory therapy; cardiac rehabilitation; and specialized nutrition. Along with oversight of the medical issues, the preoperative visit is an opportune time for counseling, clarification of expectations and discussion of research, as well as for utilization of various informatics systems to consolidate the pertinent information and distribute it to relevant health care providers. We review the scientific foundation and practical applications of a preoperative visit and share our experience with the development of the preoperative evaluation clinic, designed specifically for cardiac and major vascular patients scheduled for day admission surgery. The ultimate goal of preoperative evaluation clinic is to ensure a safe, efficient, and cost-effective perioperative care for patients undergoing a complex type of surgery.

Using Visual Analytics to Determine the Utilization of Preoperative Anesthesia Assessments

BACKGROUND

Preoperative assessments are a required and essential element of anesthetic care, yet little is known about the utilization of these documents by clinicians who are not part of the anesthesia care team. As part of perioperative workflow restructuring, we implemented a data visualization technique of electronic medical record audit log data to understand the utilization of preoperative anesthesia assessments by non-anesthesia personnel.

METHODS

An audit log cache containing 140 days of data was queried for all accesses of preoperative anesthesia assessment documents for any patient who had a preoperative anesthesia assessment that was accessed during that period. User roles were aggregated into categories. Descriptive statistics and data visualization were generated using R (R Software Foundation, Vienna, Austria). Comparisons were performed with the Wilcoxon signed rank test with continuity correction.

RESULTS

During the study period, 73 802 (0.015%) of the 485 062 902 audit log accesses were preoperative anesthesia assessments representing 412 departments, 302 user roles, and 3 916 distinct users who accessed preoperative anesthesia assessments from 14 235 surgical cases. Each assessment was accessed 2.9 times on average. Assessments performed in the preoperative anesthesia assessment clinic were accessed more frequently than those created on the day of surgery in the preoperative holding room (3.58 ± 5.18 v. 1.98 ± 1.76 average views; p<0.0001). We observed accesses of these documents by pathology and general surgery researchers, as well as orthopedics attending physicians accessing documents that were two years old.

CONCLUSIONS

This approach revealed patterns of utilization that had not been previously identified, including usage by surgical residents, surgical faculty, and pathology researchers both before and after the surgical event for which the documents are generated. Knowledge of these dependencies directly informed perioperative workflow restructuring efforts. This visual analytic approach could be broadly utilized to understand documentation dependencies in a variety of clinical contexts.

A 5-year observational study of cancellations in the operating room: Does the introduction of preoperative preparation have an impact?

Background:

Preoperative preparation (assessment) of patients reduces cancellations on the day of surgery. A Center for Reviews and Dissemination review (2007) concluded “the evidence was weak and it was uncertain that preassessment reduced cancellations.” The aim of this study was to observe the impact of a preoperative preparation clinic on cancellations of operating room cases on the day of surgery, and in particular on those causes of cancellation on the day of surgery which were expected to be affected by preoperative preparation.

Materials and Methods:

Observational study conducted in a 194 bed District General Hospital in the United Kingdom from April 1, 2006 to March 31, 2011. 42,082 operating room cases were scheduled for operation during this period. Surgical sessions which did not require anesthetic input were excluded. Contemporaneous data were collected and analyzed on a monthly basis, and also grouped by year over a 5-year period. The cancellations on the day of surgery were divided into two groups: Those considered to be affected by preoperative preparation and those which were not. Comparisons were made between these two groups and between individual reasons for cancellation.

Results:

A total of 28,928 cases met the inclusion criteria. The clinic introduction reduced cancellations considered to be affected by preoperative preparation from 462 to 177 (78% and 42% total cancellations, respectively) (P < 0.001). There was a decrease in cancellations due to patients who did not arrive (P < 0.001) and medical reasons (P < 0.001), but an increase in the number of cancellations by the patients themselves (P = 0.002). Cancellations due to lack of beds and “other” reasons both increased (P < 0.001) across the study period.

Conclusions:

This study suggests that the introduction of preoperative preparation clinics for patients reduces cancellations on the day of surgery.

Inter-relationship of procedural mortality rates in vascular surgery in England: retrospective analysis of hospital episode statistics from 2005 to 2010

BACKGROUND

Wide variations in vascular surgical outcomes have been demonstrated in England. The objective of this study was to determine whether risk-adjusted postoperative mortality rates for elective and emergency vascular surgical procedures were inter-related.

METHODS AND RESULTS

A retrospective observational study using National Health Service administrative data on adult patients undergoing elective or emergency vascular surgery from 2005 to 2010. The 10 procedures covered the broad spectrum of workload for a vascular surgical service. The primary outcome measure was in-hospital mortality, and secondary outcomes were 30-day and 1-year mortality. Data were risk-adjusted using multilevel modeling. Analyses comprised a 2-level basket designed to evaluate variations in outcome and whether the outcome of each procedure could be predicted by the composite outcome of all other procedures. A total of 116,596 vascular surgical procedures were performed across 166 providers. For 9 of 10 procedures, there were hospitals lying outside 95% control limits for ≥1 mortality outcome. The key finding was that ≥1 risk-adjusted mortality outcome for any 1 of the 9 vascular surgical procedures could be predicted by the aggregated within provider performance of the other vascular surgical procedures combined.

CONCLUSIONS

Hospital-level risk-adjusted mortality for both elective and emergency vascular procedures in England varies considerably, and providers were globally high or low performers. The data should be made available to patients, relatives, and the purchasers of services to drive improvements in the provision of vascular surgical services.

Defining working patterns for UK consultant urologists: results of a national census

Objective

Our aim was to determine current working patterns for consultant urological specialists in the United Kingdom (UK), to create a contemporary job plan template for the ‘average’ UK urologist and to use this data to predict the workforce required to deliver UK Urology services in the future.

Patients and methods

A questionnaire-based study of 790 full British Association of Urological Surgeons (BAUS) members was undertaken. This was specifically designed to provide information on the demographics of the workforce, individual consultant job plans and service provision. Data was analysed in conjunction with independent BAUS workforce reports, UK national statistics and Hospital Episodes statistics data to model future Urology workforce activity and numbers.

Results

In total, 415 responses were completed, representing an overall response rate of 53%. The average job plan consisted of 11 programmed activities per week comprising eight direct clinical care sessions and two supporting professional activities, with a median on-call intensity of 1:6. Some 90% of consultants provide a general urology outpatient clinic, seeing a mean of 7 new and 9 follow-up patients; 67% of respondents provide some-sort of sub-specialist clinic. Dedicated day case operating lists are in the job plans of 56% of urologists and typically comprise five general anaesthetic cases. Inpatient theatre activity is in the job plan of 96%, with a mean activity of four surgical cases on a general urology half-day list and two cases on a subspecialist half-day list.

Conclusions

This workforce survey highlights the different ways consultants deliver a urological service across the UK. The survey has enabled BAUS to develop a template for the job plan of the ‘average’ urologist. This essential information can assist colleagues in their individual job plan negotiations and help BAUS prepare a comprehensive consultant workforce that can meet the future urological demands of the UK population.

Volume-outcome relationships in vascular surgery: the current status

Vascular surgery has been widely practiced in hospitals within a general surgical service, although the consequent workload of individual vascular units has been small. There is an increasing body of evidence in favor of a positive relationship between hospital and surgeon volumes and the outcome of arterial surgery. These relationships suggest that vascular surgical procedures might be best placed within a centralized model of care to increase volume and thereby attain best outcomes. This systematic review appraises the current evidence for volume-outcome relationships in vascular surgery from a number of healthcare systems to examine the basis for centralization of vascular surgical services. The index procedures addressed in this review are open or endovascular repair of abdominal aortic aneurysm (AAA), ruptured AAA, descending thoracic aortic aneurysm, and thoracoabdominal aortic aneurysm, along with carotid endarterectomy and lower extremity arterial bypass.

Integrated assessment and consultation for the preoperative patient

Assessment of the presurgical patient requires interdisciplinary cooperation over the continuum of documentation and optimization of existing disorders, determination of patient resilience and reserve, and planning for subsequent interventions and care. For many patients, evident or suspected morbidities or anticipated surgical disturbance warrant specialty consultation. There may be uncertainty as to the optimal processes for a given patient, a limitation attributable to myriad factors, not the least of which is that there is often a paucity of evidence that is directly relevant to a given patient in a given setting. The present article discusses these limitations and describes a framework for documentation, optimization, risk assessment, and planning, as well as a uniform grading of existing morbidities and anticipated perioperative disturbances for patients requiring integrated assessment and consultation.

The Need for Specialized Preanesthesia Clinics for Day Admission Cardiac and Major Vascular Surgery Patients

The majority of patients undergoing surgical procedures today are not admitted to the hospital prior to the morning of surgery. In a medical world that strives not only for patient safety, but also for cost containment, Day Admission Surgery (DAS) plays an important role in our healthcare systems. This is true even for patients undergoing cardiac and major vascular (CMV) procedures. However, CMV patients often present with more complicated pre-, intra- and post-operative issues than other surgical patients.

In order to optimize the preoperative evaluation and care of CMV patients, we developed a specialized Pre-Anesthesia Clinic (PAC). We believed that patients, surgeons, anesthesiologists, and intensive care unit (ICU) teams would all benefit when appropriate preoperative evaluations are thoughtfully performed by those specializing in the care of these complicated patients. Planning for this specialized clinic included a survey of other institutions’ practices. Following initiation of our clinic, we performed a patient satisfaction survey. We report these findings along with the demographic data concerning the patients and types of surgeries evaluated in our initial experience. Finally, we discuss the preoperative evaluation including various areas of assessment provided by our PAC.

Integrated assessment and consultation for the preoperative patient

Assessment of the presurgical patient requires interdisciplinary cooperation over the continuum of documentation and optimization of existing disorders, determination of patient resilience and reserve, and planning for subsequent interventions and care. For many patients, evident or suspected morbidities or anticipated surgical disturbance warrant specialty consultation. There may be uncertainty as to the optimal processes for a given patient, a limitation attributable to myriad factors, not the least of which is that there is often a paucity of evidence that is directly relevant to a given patient in a given setting. The present article discusses these limitations and describes a framework for documentation, optimization, risk assessment, and planning, as well as a uniform grading of existing morbidities and anticipated perioperative disturbances for patients requiring integrated assessment and consultation.

American College of Cardiology/American Heart Association perioperative assessment guidelines for noncardiac surgery reduces cardiologic resource utilization preserving a favourable clinical outcome

OBJECTIVES

The American College of Cardiology (ACC) and the American Heart Association (AHA) provided perioperative evaluation and management guidelines for assessing cardiac risk in noncardiac surgery. Even if previously validated as safe and effective in risk stratification, there is often a gap between clinical practice and the recommendations of the ACC/AHA guidelines. We evaluated the impact of strict application of ACC/AHA guidelines for cardiac risk assessment of patients undergoing elective noncardiac vascular surgery in a consultant anaesthesiologist-led preoperative clinic.

METHODS

One hundred and sixty-four consecutive patients who underwent elective vascular surgery after ACC/AHA guidelines implementation (from September 2004 to May 2005) were enrolled in the study and compared with a historical group of 166 patients operated from April 2002 to September 2002. Preoperative resources utilization (cardiologic consultations, non-invasive diagnostic tests, coronary angiograms, coronary revascularizations) and clinical events [all-cause death, acute myocardial infarction (AMI) and acute myocardial ischaemia] occurring within 30 days after surgical procedure were compared.

RESULTS

Guidelines implementation reduced preoperative cardiologic consultations by 21% (P < 0.001) and preoperative non-invasive diagnostic testing by 11% (P = 0.01), and increased utilization of preoperative beta-blockers by 13% (P = 0.01). Preoperative coronary angiograms (2% versus 4%) and coronary revascularizations (3% versus 2%) and all-cause death (1% versus 2%), AMI (2% versus 1%) and acute myocardial ischaemia (4% versus 2%) during follow-up were similar in both groups.

CONCLUSIONS

Implementation of the ACC/AHA guidelines for cardiac risk assessment prior to noncardiac surgery in a consultant anaesthesiologist-led preoperative clinic reduced preoperative resources utilization, improved medical treatment and preserved a low rate of perioperative cardiac complications.

Meta-analysis and systematic review of the relationship between volume and outcome in abdominal aortic aneurysm surgery

Background

This study investigated the volume–outcome relationship for abdominal aortic aneurysm (AAA) surgery and quantified critical volume thresholds.

Methods

PubMed, EMBASE and the Cochrane library were searched for articles on the operation volume–outcome relationship in elective and ruptured AAA surgery. UK Hospital Episode Statistics data were also considered. Elective and ruptured AAA repairs were dealt with separately. The data were meta-analysed, and the odds ratios (95 per cent confidence interval) for mortality at higher- and lower-volume hospitals were compared. Volume thresholds were identified from each paper.

Results

The analysis included 421 299 elective and 45 796 ruptured AAA operations. Significant relationships between mortality and annual volume were noted for both groups. Overall, the weighted odds ratio was 0·66 (0·65 to 0·67) for elective repair at a threshold of 43 AAAs per annum and 0·78 (0·73 to 0·82) for ruptured aneurysm repair at a threshold of 15 AAAs per annum, both in favour of high-volume institutions.

Conclusion

Higher annual operation volumes are associated with significantly lower mortality in both elective and ruptured AAA repair. This suggests that AAA surgery should be performed only at higher-volume centres.

Preanesthesia Clinics, Information Management, and Operating Room Delays: Results of a Survey of Practicing Anesthesiologists

BACKGROUND

One purpose of preanesthesia evaluation clinics (PECs) is to decrease the incidence of day-of-surgery delays and cancellations by ensuring that patients are medically ready for surgery. In several single-center studies, PECs have been shown to have a positive impact. However, limited information is available regarding their overall use and perceived effectiveness.

METHODS

A survey was distributed to attendees of the 2005 Annual Meeting of the American Society of Anesthesiologists. The survey addressed the national prevalence of PECs and the most common methods for referral to them. Respondents were also asked to address the impact of PEC visits on perceived prevalence of day-of-surgery delays caused by missing patient information.

RESULTS

One thousand eight hundred fifty-seven surveys were returned. Sixty- nine percent of respondents worked at institutions with a PEC. Fifty-seven percent of respondents indicated that delays occur in at least 1 in 10 patients not seen for preanesthesia evaluation prior to the day of surgery. For patients who had a PEC visit prior to surgery, the same frequency of delays was reported by 23% of respondents.

CONCLUSIONS

Day-of-surgery delays caused by missing information remain relatively common despite preanesthesia evaluation. Possible causes for these delays include failures of information transfer, lack of consensus on criteria for surgical readiness, or other institutional factors.