ADVERTISEMENT

Nuts and bolts of preoperative clinics: The view from three institutions

November 1, 2009|Cleveland Clinic Journal of Medicine
Angela M. Bader, MD, MPH;BobbieJean Sweitzer, MD;Ajay Kumar, MD, MRCP, FACP, SFHM
Author and Disclosure Information

Angela M. Bader, MD, MPH
Director, Weiner Center for Preoperative Evaluation, Brigham and Women’s Hospital; and Associate Professor of Anaesthesia, Harvard Medical School; Boston, MA

BobbieJean Sweitzer, MD
Director, Anesthesia Perioperative Medicine Clinic; Associate Professor of Medicine; and Associate Professor of Anesthesia and Critical Care, University of Chicago, Chicago, IL

Ajay Kumar, MD
Director, IMPACT Center, Department of Hospital Medicine, Quality and Patient Safety Institute, Cleveland Clinic, Cleveland, OH

Correspondence: Angela M. Bader, MD, MPH, Brigham and Women’s Hospital, Department of Anesthesiology, Perioperative and Pain Medicine, 75 Francis Street, CWN L1, Boston, MA 02115 (abader@partners.org); BobbieJean Sweitzer, MD, Anesthesia Perioperative Medicine Clinic, University of Chicago, 5841 S. Maryland Ave., Chicago, IL 60637 (bsweitzer@dacc.uchicago.edu); Ajay Kumar, MD, Department of Hospital Medicine, Cleveland Clinic, 9500 Euclid Ave., A13, Cleveland, OH 44195 (kumara@ccf.org)

All authors have indicated that they have no financial relationships with commercial interests that have a direct bearing on the subject matter of this article.

This article was developed from an audio transcript of a joint presentation by the authors at the 4th Annual Perioperative Medicine Summit. The transcript was edited by the Cleveland Clinic Journal of Medicine staff for clarity and conciseness, and was then reviewed, revised, and approved by Drs. Bader, Sweitzer, and Kumar.

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.

Cleveland Clinic IMPACT Center

By Ajay Kumar, MD

Cleveland Clinic is structured differently from most other institutions in that its surgeons, anesthesiologists, and hospitalists are all direct employees of the institution. Despite this unique structure, many aspects of our preoperative clinic—known as the Internal Medicine Preoperative Assessment, Consultation and Treatment (IMPACT) Center—are applicable to other institutions.

Cleveland Clinic is a busy surgical hospital whose preoperative optimization system is designed to provide high-quality care. The IMPACT Center is consulted for most complicated noncardiac surgery patients, and its referral sources include most of the institution’s surgical specialties.

QUEST FOR A BETTER PATIENT EXPERIENCE

When the IMPACT Center was created in 1997, the aim was to focus on the same objectives highlighted by Drs. Bader and Sweitzer: safety, a positive patient experience, enhanced communication, better continuity of care, effective use of resources, and improving throughput by standardizing care.

A prime motivator was the desire to move away from the tendency for presurgical consults to simply “clear the patient for surgery,” and we have indeed evolved considerably from that point. The focus of our peri­operative care program today is to comprehensively evaluate risk by taking into account patient-, procedure-, and anesthesia-related factors.

We offer “one-stop shopping,” and our priority is for efficient throughput. We are located in a 12-story building that includes outpatient, preoperative, and surgical clinics and offices. The IMPACT Center is on the first floor along with the preoperative anesthesia consultation and evaluation (PACE) clinic, the laboratory, and ECG and stress-test labs. Patients can undergo radiographic studies on the second floor.

The patient experience counts for a lot. Many of our patients are from another state or country, so efficiency and convenience are especially important. Patients can usually get all assessment and testing done in a single day.

A TIGHTLY MANAGED PROCESS

A ‘smart’ questionnaire starts the process

Figure 1. Flow chart of the preoperative evaluation process at Cleveland Clinic.
Our process (Figure 1) begins in the surgeons’ offices, where a patient is seen by a surgeon and an operation is deemed necessary. There the patient is asked to fill out a computer-assisted health screening questionnaire available online. The questionnaire is very sophisticated: based on the patient’s answers, it asks further pertinent questions and requests details if the history is complicated. A patient with multiple health problems may take 20 minutes to complete it, while a healthy patient may take only 3 minutes.

A computerized report based on the questionnaire guides the surgical office in scheduling the patient to specific areas according to algorithms. Based on case complexity and clinical needs, patients are scheduled for the IMPACT Center along with the PACE clinic; if needed (based on the algorithms), patients also are scheduled for laboratory tests or imaging. This standardized approach helps create a safe passage for patients through the preoperative process with less confusion.

Patient is given a personalized binder

Once all appointments and tests are scheduled, the patient is given a binder containing specific information about the procedure and preoperative instructions. The medical appointment at the IMPACT Center is usually scheduled before the PACE clinic appointment. Patients receive an itinerary for all preoperative appointments and surgical office appointments before the planned surgery. The itinerary is planned so that if additional testing is requested, it can be accommodated on the same day.

At the end of the preoperative assessment, the patient receives printed information with specific preoperative instructions, including which medications to continue or stop.

Standardized, computer-based medical records

Our systems and processes have undergone a good deal of evolution. We have integrated our medical records and use a standard outside medical record retrieval process. The template for the history and physical exam is standard for all Cleveland Clinic patients and is used for all presurgical assessments before all noncardiac surgeries. The template is comprehensive, including the history of the present illness, the review of systems, the physical exam, and anesthesia-related issues. All outside documents are scanned into our electronic medical record system and are available for viewing prior to surgery from any computer connected to the system.

Our preoperative assessment guidelines are also kept updated at a central online location so that all providers have access to them.

Staff keeps process running efficiently

The IMPACT Center is managed by the department of hospital medicine and supported by at least 5.5 full-time physicians every day. We also have two registered nurses, two assistants who help with scheduling and testing, and three secretaries who support the doctors, obtain records, and make arrangements with outside doctors for testing if a patient wants to return home before our testing can be completed.

A secretary also keeps a log for each patient seen in the clinic, tracking all pending issues. The day before surgery, the secretary contacts the appropriate office for anything that is still pending. If she gets no response, the matter is transferred to one of our doctors so that the problem can be resolved at once. This strategy allows us to achieve a nearly 0% rate of surgery delay or cancellation attributable to unavailable test results.

Our patient volumes have increased significantly since we started in 1997. Last year more than 15,000 patients visited the IMPACT Center and now we have expanded our services to regional hospitals within the Cleveland Clinic Health System.

INTERDEPARTMENTAL COMMUNICATION IS CRITICAL

Interdepartmental communication is a must for patient safety, so we encourage a culture of communication between the hospitalist and the surgical team. The location of most of our surgical clinics within the same building as the IMPACT Center further facilitates communication, as does the proximity of the PACE clinic. Additionally, one of our IMPACT Center physicians is accessible around the clock to answer to our surgeon or anesthesiologist colleagues as needed.

We regularly assess our process and seek feedback from surgeons and anesthesiologists. We also conduct yearly patient experience surveys to make sure we are providing patients with the highest quality of care.

ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT