Services on Demand
On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.57 no.2 Campinas Mar./Apr. 2007
Implementation of a Preanesthetic Evaluation Service in a University Hospital. Difficulties and results*
Implantación del Servicio de Evaluación Preanestésica en Hospital Universitario. dificultades y resultados
Flora Margarida Barra Bisinotto, TSAI; Maurício Pedrini JúniorII; Alírio Alex Rosa AlvesII; Maria Abadia Pereira Roso AndradeIII
Adjunta da UFTM; Responsável pelo CET/SBA da UFTM; Doutora em Anestesiologia
pela FMB UNESP
IIME (2003-2005) do CET-SBA da UFTM
IIIAnestesiologista Assistente do CET-SBA da UFTM
OBJECTIVES: Preoperative evaluation is the key for a good preoperative preparation
and intraoperative handling. When done in the outpatient clinic, it allows for
better analysis and further investigation, improving the quality of the preparation
and decreasing hospital costs. The aim of this study was to analyze the implementation
of the Serviço de Avaliação Pré-Anestésica
(SAPAN Preanesthetic Service) in a University Hospital, and to determine
the difficulties and positive results.
METHODS: The data regarding patients seen at the SAPAN clinic, by the residents, under the supervision of an attending physician, in the first nine months after its implementation was reviewed. The consultation followed a standard form. At the end of the preanesthetic evaluation, patients were either cleared for surgery or referred to other specialties for the treatment of specific diseases. The items analyzed were: number of patients evaluated, number of elective surgeries performed during this period, surgical specialties involved, percentage of patients whose surgeries were cancelled due to the need to control underlying diseases, and clinical specialties requested the most to evaluate and treat those patients.
RESULTS: Nine hundred and thirteen outpatient consultations and 5,409 elective surgeries were performed. In 11.9% of the cases, the surgeries were cancelled for medical reasons, and the most frequent specialties involved were cardiology (43.08%), pneumology (25.74%), hematology (21.65%), and endocrinology (9.52%).
CONCLUSIONS: Although the majority of patients was not referred by the surgical specialties, the initial SAPAN data demonstrated the benefits of a preanesthetic evaluation service.
Key Words: PREANESTHETIC EVALUATION: ambulatorial.
JUSTIFICATIVA Y OBJETIVOS:
La evaluación preoperatoria es la clave principal para una buena preparación
preoperatoria y el manoseo intraoperatorio. Cuando se realizada en un nivel
ambulatorial permite un mejor análisis, posibilitando investigaciones
adicionales, mejorando la calidad de la preparación y disminuyendo los
costes hospitalarios. El objetivo de este estudio fue analizar la implantación
y el desarrollo del Servicio de Evaluación Preanestésica (SAPAN)
en Hospital Universitario, verificando cuáles fueron las dificultades
y los resultados positivos encontrados.
MÉTODO: Se evaluaron los datos relativos a los pacientes atendidos en el ambulatorio del SAPAN, por los médicos en especialización con supervisión de un docente, en los primeros nueve meses de instalación. La consulta era hecha siguiendo una ficha estándar. Al término los pacientes eran liberados para el procedimiento quirúrgico o enviados para consulta con otros especialistas para control de enfermedades específicas. Se analizó el número de pacientes evaluados y el número de procedimientos quirúrgicos electivos realizados en ese período y las diversas especialidades quirúrgicas, el porcentaje de pacientes con intervención quirúrgica suspendida por necesidad de control de enfermedades, y las especialidades clínicas más solicitadas.
RESULTADOS: Se realizaron 913 consultas ambulatoriales y 5.409 intervenciones quirúrgicas electivas. Varias clínicas no enviaron sus pacientes para evaluación. Por necesidad clínica 11,9% de los pacientes tuvieron el procedimiento quirúrgico suspendido, siendo que las clínicas involucradas fueron cardiología (43,08%), neumología (25,74%), hematología (21,65%) y endocrinología (9,52%).
CONCLUSIONES: Aunque una gran parte de los pacientes no hayan sido enviados por las especialidades quirúrgicas, los datos iniciales del SAPAN permitieron demostrar los beneficios de un servicio de preparación ambulatorial de los pacientes.
Preoperative evaluation has, traditionally, followed laboratory and radiological investigation protocols that generated several guidelines 1-4, computer softwares 5, and algorithms to help choose the tests, and a great number of them are done at the hospital. Thus, the clinical evaluation is not always considered a screening element for exams and complementary evaluations, which often times are not necessary 6-8. Promoting high quality and cost effective preoperative evaluation is the key for a good preoperative preparation and to define intraoperative conduct. It warns anesthesiologists for the clinical conditions of the patients, facilitating the pre, intra, and postoperative planning necessary in especial conditions. When this evaluation is done as an outpatient basis, it allows for a better analysis, making it possible further investigation and improvement of the clinical condition of the patient, decreasing hospital costs and improving quality of care 9.
The concept of outpatient preanesthetic evaluation was proposed, initially, more than 50 years ago 10 and, despite all these years and the large number of studies that have demonstrated its advantages (reduction in the number of surgeries cancelled, increased number of daily admissions, reduction in hospital stay and hospital costs, etc.), it is not routine yet.
There are several reasons why outpatient evaluation of surgical patients is not implemented. Among them we can include the lack of referral by the surgeon, no anesthesiologist available, and lack of physical space.
Since University Hospitals are responsible for training a large number of physicians, the implementation of high quality anesthetic services in those teaching institutions, to improve the care offered to the community, will be gladly accepted.
The aim of this study was to analyze the implementation and development of the Serviço de Avaliação Pré-Anestésica (SAPAN Preanesthetic Evaluation Service) of the Anesthesiology Department at the Centro de Ensino e Treinamento em Anestesiologia of Universidade do Triângulo Mineiro (UFTM) nine months after its implementation, determining the difficulties and positive results.
SAPAN was implemented in March 2005 in the outpatient annex of the UFTM, after the residents of the different surgical specialties and gynecology were oriented to refer patients scheduled for elective surgeries to the new clinic for anesthetic evaluation. The evaluation was done by 2nd or 3rd year Anesthesiology residents supervised by Anesthesiology Professors. The consultation, recorded in the appropriated formulary, included history of the current illness, evaluation of the central nervous, cardiovascular and respiratory systems, endocrine/metabolic evaluation, history of allergies, personal habits, and past medical history, including prior surgical and anesthetic history (such as difficulty to be intubated, nausea and/or vomiting, prolonged muscular paralysis, etc.), current medication, and family history of diseases and anesthesia (history of malignant hyperthermia). The consultation was followed by the physical exam (first upper airways, heart, and lungs, followed by other organs and systems that could compromise or be exacerbated during the surgical period), review of laboratory exams, decision regarding the need for referral to other clinical specialties. Finally, the physical status (ASA) of the patient was determined and he/she was cleared for surgery, advised regarding further care, such as fasting, and medications that he/she should not take, take, or start before the surgery.
Depending on the nature and complexity of the data obtained regarding the presence of coronary heart disease, the guidelines of the ACC/AHA for preoperative evaluation for noncardiac surgical intervention were followed 11. The patient was then referred to a cardiologist. Clinical criteria were also used to refer patients to the pneumology, endocrinology, hematology, and etc.
After approval by the Ethics Committee of the Hospital Escola da Universidade Federal do Triângulo Mineiro, the charts of the patients seen in the first nine months were reviewed, and the following items were evaluated:
- Number of patients evaluated at the SAPAN in the first nine months after its implementation;
- Number of elective surgeries performed in this period to determine the number of outpatient appointments necessary in the future in order to include every patient scheduled for surgery;
- Specialties that referred patients for evaluation;
- Specialties that did not refer patients for evaluation;
- Reasons for not clearing patients for surgery in the first appointment;
- Clinical specialties that were referred to more often.
During the 9-month period, there were 913 consultations at the SAPAN clinic, with a mean of 101.4 consultations a month. Meanwhile, there were 5,409 surgeries with the participation of the anesthesiologist, with a mean of 601.0 surgeries a month. The number of surgeries was approximately 6 times greater than the number of evaluations (Table I).
There was a large difference among the surgical specialties regarding the requisitions for preanesthetic evaluation, and some of them did not request any evaluation during this period. Table II shows the relationship between the number of preanesthetic outpatient evaluations per specialty and the elective surgeries performed in the same period. Pediatric surgery, neurosurgery, otolaryngology, and cardiac surgery did not refer any patient to be evaluated.
One hundred and nine patients (11.9%) were not cleared for surgery in the first appointment because they had to be evaluated by other clinical specialties (Table III). Therefore, the surgery was postponed until the patient returned after treatment of the coexisting disease.
The clinical specialties involved more frequently in the evaluations were cardiology (43.08% of the referrals), pneumology (25.74%), hematology (21.65%), and endocrinology (9.52%) (Table IV).
Before the implementation of the SAPAN, hospitalized patients were seen by the anesthesiologist in the ward the day before the surgery, when the medical history and physical exam were performed, and the patient was given pertinent information about the anesthesia. Patients scheduled for outpatient surgery were seen by the anesthesiologist before the procedure, most of the times in the operating room.
This study is a description of the data regarding the first nine months after the implementation of the preanesthetic evaluation service at the Hospital Universitário. The small number of patients seen in this period is the most striking factor, showing the need for a 6-fold increase in the number of evaluations, if we consider that the number of evaluations should be close to the number of surgeries.
Most of the surgeons did not refer their patients. This can be due to a lack of information regarding the preanesthetic evaluation service, which can be related to the rotation of the residents in the several surgical specialties, making it difficult to standardize the process, similar to what had happened in other university hospitals 12. We also observed resistance from some surgical specialties, which insisted in referring patients to the cardiologist for evaluation, or to evaluate the patient only after he/she was admitted to the hospital.
Although the number of preanesthetic evaluations were not close to the ideal number, it was possible to demonstrate that 11.9% of the patients needed treatment of their clinical condition when they were first evaluated. Their surgeries would probably be cancelled and postponed if it were not for the prior evaluation.
The most common clinical specialties patients were referred to, included cardiology (43.08%), pneumology (25.7%), hematology (21.6%), and endocrinology (9.5%). Considering the number of surgeries performed in this period (5,409), there would have been a total of 645 (11.9%) surgeries postponed by the anesthesiologist.
The need for a six-fold increase in the number of patients seen at the SAPAN clinic reflects the slow implementation of the service because, as we have seen, several surgical services did not refer their patients, evaluating them routinely after they were admitted to the hospital. It is obvious that people need time to adapt to new procedures. It is also necessary to define new clinical ways to reduce the variability among specialists by explaining the benefits of the outpatient service. Thus, it can be noticed that the SAPAN is being introduced gradually. The availability of a physical space and of anesthesiologists (residents, assistants, and professors) should be taken into account, which also contributed for the large difference between the number of evaluations and the number of surgeries in this period.
The outpatient preanesthetic evaluation performed by anesthesiologists is a relatively new phenomenon, and it has not been universally implemented. Traditionally, surgical patients were admitted to the hospital at least one day before the surgery and they were seen by the anesthesiologist for the preanesthetic evaluation. The outpatient preanesthetic evaluation is a consequence of the need for a better use of laboratory exams 13 and also to increase the frequency of outpatient surgeries, or to hospitalize the patient on the same day of the surgery, justified by cost reduction 14.
Several studies demonstrated that the reduction in the number of surgeries cancelled and in the number of preoperative exams are the main consequences of the outpatient preanesthetic evaluation 15-18. Fisher et al. 19 demonstrated that the number of laboratory exams and clinical consultations decreased more than 50% when the responsibility of the surgical preparation was transferred to the Anesthesiology service.
In the outpatient evaluation, there is more time to evaluate the patient and his/her present diseases are treated before the surgery. This improvement in medical status decreases the number of surgeries cancelled 20, reduces the length of hospitalization and the number of laboratory exams performed 15,21,22, and reduces the incidence of postoperative complications 23,24. As expected, hospital costs decrease considerably, which was demonstrated by Pollard et al. in patients who underwent carotid endarterectomy and revascularization of the lower limbs, were evaluated in the outpatient clinic and prepared to be admitted on the day of the procedure 21, resulting in a reduction in hospital costs and hospital stay by 4.5 days without increasing mortality. Several studies also demonstrated 16,25,26 a reduction of up to 60% in the number of surgeries cancelled, which increases hospital costs and causes patient dissatisfaction.
Anticipating the evaluation allows for better patient orientation, since studies indicate that the orientation is better assimilated when given a few days before the procedure 23, and that patient satisfaction regarding anesthesia increases 14. Other benefits include anxiety reduction 27, decrease in analgesic doses, greater patient satisfaction regarding the surgery, decrease in the incidence of postoperative complications, such as nausea and feeling of discomfort, more contact with the anesthesiologist, and greater patient satisfaction with the anesthesiologist 28-32.
This initial analysis did not evaluate hospital costs, but in view of the limited resources of public hospitals, one can infer that the optimization of surgical patients is economically viable at a time when analysis of the cost/benefit ratio is applied to every aspect of the medical practice. We should recognize that the implementation of an outpatient evaluation in a public institution could lead to a substantial reduction in costs, which has already been shown by other studies 25,34. Understanding and accepting the importance of the outpatient preanesthetic evaluation and patient hospitalization in the same day of the surgery stimulate physicians and administrators to improve hospital efficiency while maintaining, or improving, patient evolution.
The number of surgeries cancelled by the anesthesiologist, when the patient was already in the operating room, was not analyzed, and no comparisons were made with preanesthetic evaluations done before the implementation of the SAPAN due to technical difficulties, since the reasons for the cancellations are diverse and not consistently recorded.
Although the effects of the implementation of the SAPAN have been slow, it already shows some results, especially regarding the clinical improvement of patients, which will reflect a reduction in morbidity and mortality, in hospital stay, and in hospital costs. We also should add the academic consequences, since Anesthesiology residents were exposed to the outpatient clinic and became involved with the clinical history of the patients. The cases are discussed during the evaluation and those that have significant diseases are further evaluated and discussed in clinical sessions before the anesthesia, improving the quality of the professionals and anesthetic conduct. This training in preanesthetic evaluation during the residency has been considered fundamental to change the negative attitude of anesthesiologists regarding preanesthetic evaluation 23.
Preanesthetic evaluation performed by the anesthesiologist is more efficient than when patients are referred to other clinics 35. Fischer 19 examined the costs and benefits of the preanesthetic evaluation done by the anesthesiology unit and demonstrated that the number of laboratory exams and medical consultations showed a reduction greater than 50% when the Anesthesiology service was responsible for preparing the patient for surgery.
We should stress that surgeons frequently refer patients to the cardiologist for preoperative evaluation. In 1998, Kats et al. 36 evaluated the expectations and intentions of anesthesiologists and surgeons regarding cardiologic evaluations, and demonstrated that the specialists disagree frequently regarding the reason for the referral. They also documented that cardiologic evaluations were seldom useful because there were no recommendations or only routine recommendations. Several studies, and clinical practice, showed that those evaluations were not always satisfactory. The study also demonstrated that 80.2% of the anesthesiologists considered the cardiologic evaluation more useful when requested by an anesthesiologist. Lee 37 documented that in 14% of the cases physicians disagreed about the reasons for the evaluation. Rudd et al. 38, in a study about preoperative evaluation of diabetic patients, found that doubts were not cleared in 24% of the cases and that in 12% of the cases the questions asked were ignored by the evaluating physician.
Recent studies 39,40 have the same ideas regarding preoperative evaluations performed by cardiologists. They concluded that cardiologists give routine orientations or make no recommendations. They also demonstrated that there were no differences between patients who went through preoperative cardiologic evaluation and those who were not. Medical-legal considerations could be partially responsible for the unnecessary referral to cardiology 36.
Although the advantages of preoperative evaluation were demonstrated, intrahospital delay or cancellation of surgical interventions cannot be avoided completely, due to several conditions that can get worse or appear after the complete evaluation. The anesthesiologist responsible for the anesthesia may have a different outlook on the risks than the one who performed the outpatient evaluation. There is probably a threshold above which the efficiency of the system cannot be improved.
Concluding, the SAPAN has been fundamental in the outpatient improvement of a great number of patients scheduled for elective surgeries, and this has contributed to improve training and education of anesthesiologists, although there are still some difficulties regarding the knowledgeability of everyone involved in its implementation.
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Dra. Flora Margarida Barra Bisinotto
Praça dos Lírios, 58 Morada das Fontes
38060-460 Uberaba, MG
Submitted em 19
de abril de 2006
Accepted para publicação em 27 de novembro de 2006
* Received from CET/SBA do Hospital Escola da Universidade Federal do Triângulo Mineiro (UFTM), Uberaba, MG