Nuts and bolts of preoperative clinics: The view from three institutions
ABSTRACT
Three directors of dedicated preoperative assessment clinics share their experience in setting up and running their programs. Standardizing and centralizing all or part of the preoperative evaluation process—obtaining patient records; the history and physical examination; the surgical, anesthesiology, and nursing assessments; ordering tests; and documentation and billing—increases efficiency. The savings achieved from minimizing redundancy, avoiding surgery delays and cancellations, and improved reimbursement coding offset the increased costs of setting up and running the clinic.
KEY POINTS
- Standardizing the preoperative assessment process helps ensure that regulatory, accreditation, and payer requirements and guidelines are met.
- Careful triage based on a patient’s history can help avoid unnecessary assessment of low-risk patients and ensure that necessary assessments for higher-risk patients are completed before the day of surgery.
- Perioperative assessment and management guidelines for various types of surgery and patient risk factors should be developed, continuously updated, and made available online to all providers within the institution.
- Electronic medical records allow standardization of patient information, avoid redundancy, and provide a database for research.
MORE BENEFITS OF STANDARDIZATION
Standardized scheduling ensures reliability
The secretaries in each surgeon’s office schedule appointments through a central computer system after registration and insurance precertification. Our computer system does not allow an operation to be scheduled without an evaluation also being scheduled. The evaluation can involve either a visit or a telephone screen; we provide algorithms so that the surgeons’ secretaries know which is required. This system has substantially reduced the number of walk-ins, allowing for a more even distribution of patients and ensuring that medical records will be available when a patient is seen.
We watch our schedule carefully. Our computer system monitors the time that each patient is in our clinic to determine his or her waiting time and assessment time. It takes about 75 minutes to go through the whole process, including the time for a nurse practitioner to do the surgical history and physical examination and the anesthesiology and nursing assessments, a laboratory technician to do an ECG and laboratory tests if indicated, and completion of all required documentation. Accordingly, patients are scheduled in 75-minute blocks between 7:00 am and 6:30 pm. We do not have evening or weekend hours because of the difficulty of contacting surgeons and primary care physicians when questions arise. It is simply not cost-effective to have to do that type of follow-up on a case after the patient leaves.
Only about 10% of our patients are screened by telephone, since most of our operations are complicated and require in-person assessment (most low-acuity procedures are done at other hospitals). Of the patients who visit the preoperative clinic, about 75% undergo the single assessment model for surgery, anesthesiology, and nursing as described above. The remaining 25% of patients have their history and physical exam completed outside Brigham and Women’s Hospital for insurance reasons; the remainder of their assessment is conducted in our preoperative clinic by a registered nurse and an anesthesiology resident.
Multiple systems checks
Our model also incorporates standardization in the form of multiple systems checks:
- Case presentation. Every case is presented to an attending anesthesiologist, who reviews the ECG (if ordered) before the patient leaves the clinic.
- Post-visit chart check. A registered nurse or nurse practitioner signs off on each chart after the visit, confirming test results and resolution of all paperwork issues.
- Surgical checklist. The end result is a checklist that serves as the front sheet of the operating room chart.
Our ability to use this system of checks to get the chart completed comprehensively and reliably and deliver it to the operating room when needed was key to securing institutional support and funding for the preoperative clinic.
ROLE OF THE ATTENDING ANESTHESIOLOGISTS
Two full-time attending anesthesiologists are present in the preoperative clinic each day. One is responsible largely for supervising the nurse practitioner assessments and reviewing case presentations, while the other also oversees the education and supervision of residents. Residents rotate through the clinic for 2 weeks (one or two at a time) and have a designated curriculum consisting of daily lectures and competencies in preoperative evaluation.
Because our anesthesiologists are expert in preoperative assessment, we require very few outside consults. We can communicate directly with the cardiologists and other physicians and order tests when indicated. We have a clerical assistant who obtains all necessary paperwork and prior testing from outside providers so that the clinicians need not waste time on this.
A GROWING CHALLENGE: ASSESSMENT FOR PROCEDURES IN AMBULATORY SETTINGS
Looking forward, a rapidly growing challenge facing our clinic stems from the tremendous growth in patients who require anesthesia for procedures performed outside the operating room. In these situations, the proceduralists need a system for deciding whether an anesthesiologist must be present for any given case.
We have started to develop appropriate screening processes to ensure that the proceduralists in multiple departments know which patients to refer for preprocedure assessment. We hope to soon develop protocols for high-risk patients and for various procedures such as implanting a pacemaker or defibrillator, catheter procedures, interventional radiology, and endoscopy.
