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.
Discussion
Question from the audience: Our anesthesia assessment department was approached by our surgeons to do both the anesthesia and surgical assessments, but we felt that would put us in a potential legal conflict if a patient who was assessed that way developed problems. Can you comment?
Dr. Bader: Although we do surgical assessments at our preoperative clinic, we don’t make any decisions about whether or not to proceed with an operation. We get an office note from the surgeon that is directed specifically toward the need for surgery, indications for surgery, and surgical consent. We perform the surgical history and physical examination. Our process is essentially the same as when surgeons have a physician assistant do the history and physical examination in their office. Our practitioners are employed by the hospital, so there is no conflict of interest there.
Comment from the audience: I’m a strong believer in hands-on patient contact. Over my 15 years of practice, we have encountered a lot of unexpected problems during the preoperative exam—aortic stenoses, infections, ventricular septal defects—all of which would never have been detected from a screening form.
Dr. Sweitzer: I agree that we pick up many things by seeing the patient in person. I’ve picked up more cases of aortic stenosis as an anesthesiologist in the preoperative clinic than I ever did as an internist, because the population is high-risk. But patients who have such problems tend to have risk factors and be in certain age groups. Studies indicate that the history is more important than the physical exam: the history suggests about 75% of conditions that are present. The physical exam adds only a little more—perhaps another 15%. Our recommendations are very much consistent with the American College of Cardiology and American Heart Association guidelines on preoperative cardiac evaluation.7 It is more important to identify whether a patient has risk factors for coronary artery disease than to find out whether a stress test or ECG is normal. One needs to do a really good history, but it can be done remotely. Based on certain risk factors identified, high-risk patients can be selected who need to come in and have a physical exam.
Question from the audience: Could you elaborate on the electronic medical record system used at the University of Chicago? I’ve heard there’s a steep learning curve when implementing these kinds of systems. They also are very expensive—I’ve heard that some cost $40 to $80 million. Has enhanced revenue flow offset the costs?
Dr. Sweitzer: We have a home-grown system developed with FileMaker Pro by a computer programmer at our institution. It was a lot easier to develop than people tend to think. There are many savvy computer programmers out there; I’ve had medical students assist me with updating it. We’re now considering developing it as a commercial system. Many systems are available for purchase, including Epic, Pyxis, one from General Electric, and many others. They are very expensive, so smaller institutions might want to use a pay-for-service system.
There definitely is a learning curve to switching to electronic medical records, but it is not nearly as steep as many believe. The extra time it takes a clinician to initially make a computer entry rather than write on paper is vastly recouped downstream: the electronic medical record is legible and organized, and it doesn’t get lost or need to be redone. You can bring up a patient record from 6 months before and reuse it as a template.
Dr. Bader: The discussion of cost savings from preoperative clinics usually focuses on savings from avoiding surgery cancellations and delays and from more efficient laboratory testing, but the biggest savings for an institution is better reimbursement through better diagnosis-related groups (DRG) coding. That’s an important reason our institution is funding our clinic. Electronic medical records allow standardization of information so that coders know exactly where to look for the comorbidities and other pertinent information. This increases payments for DRGs, which can be documented for the hospital. This literally runs into millions of dollars a year and more than offsets the costs of the system.
Question from the audience: Dr. Bader, I’m impressed with the number of patients going through your preoperative clinic. How many patients are seen per nurse practitioner in your clinic?
Dr. Bader: The nurse practitioners have 10-hour shifts and see one patient every 75 minutes. The process of seeing a patient takes a lot less time now than with the old system, in which patients saw an anesthesiologist plus a nurse. Our current system eliminates redundancy: questions need to be asked only once.
Question from the audience: My compliance office says that preoperative assessments for early-morning admission patients are good for only 7 days. Is that true?
Dr. Bader: There are sometimes differences between Joint Commission requirements and those of certain insurance companies. That kind of issue needs to be discussed with your hospital compliance office. We program rules into our scheduling system to accommodate different insurance policies and other requirements so that a patient is not scheduled beyond the allowable period.
