PREOPERATIVE PREPARATION: Value, Perspective, and Practice in Patient Care

doi:10.1016/S0889-8537(05)70180-2

Anesthesiology Clinics of North America

Volume 18, Issue 3, 1 September 2000, Pages 551-574

https://doi.org/10.1016/S0889-8537(05)70180-2 Get rights and content

First among Standards of the American Society of Anesthesiologists is Basic Standards of Preanesthesia Care.² Approved by the American Society of Anesthesiologists (ASA) House of Delegates on October 14, 1987, these standards are considered “minimum requirements for sound practice” based on “generally accepted principles for patient management.”

As stated in the guidelines, “An anesthesiologist shall be responsible for determining the medical status of the patient, developing a plan of anesthesia, and acquainting the patient or the responsible adult with the proposed plan.” The standards call for a review of medical records; an interview and examination of the patient; a discussion of the patient's medical history, previous anesthetic experiences, and current drug therapy, and provisions for obtaining and reviewing laboratory and diagnostic tests indicated for the conduct of anesthesia. They also require that the responsible anesthesiologist verify that the above requirements have been “properly performed and documented in the patient's record.” They provide for modification and documentation of the reasons for modification in the patient's record under unusual circumstances, such as extreme emergencies.

Can the official statement of the ASA on the subject of preoperative preparation be summarized? How these standards can be best implemented is a subject of debate. Some authors believe that a preinduction assessment satisfies these requirements; others advocate a preparation process that begins days before a planned anesthetic.³⁵ Common sense and experience suggest that these published standards do not address the full range of possible issues surrounding preoperative preparation.

Changes in health care delivery, health assessment standards, information management, and perioperative care patterns have resulted in the reconceptualization of virtually every aspect of preoperative preparation. The vocabulary used to discuss issues has changed to reflect the shifting emphases of perioperative care better. In a report due in 2000 from the Task Force on Preanesthesia Evaluation, the ASA is expected to make an expanded statement on what constitutes acceptable preanesthetic care.

In this article, preoperative preparation is presented as having distinct but overlapping preanesthetic and preprocedural components. Value is discussed, and the roles of various perspectives are considered as determinants of the practices that shape the structure and function of preparation processes. Preanesthesia preparation then is discussed as a practical activity. A discussion of future issues concludes this article.

Section snippets

DEFINITIONS OF TERMS

Before a discussion of value, perspective, and practice in preoperative preparation, terms used in this article must be defined that appear interchangeable in use— preoperative, preanesthetic, and preprocedural—but, in fact, are different in meaning. The need to define these terms precisely arises from four truths that shape contemporary anesthesia service delivery.

First, anesthesia is safer than it has ever been. Hospital and ambulatory surgical center anesthesia mortality rates are now

VALUE

Whether one receives, delivers, or pays for a service, the question always exists: what is the value of the service? As in common usage, value, used here, implies satisfaction of needs linked to but beyond those accessible to straight economic measure. Subjective assessments of value do not translate neatly into objective measures, yet the exercise of developing semi- or quantitative representations of value is useful.

Orkin³¹ first advanced the notion, in the anesthesia literature, that value

PERSPECTIVE

Viewed as a service, preanesthesia preparation means different things to different people. Lagasse et al,¹⁹ using quality indicators for anesthesia providers derived from the 1992 Joint Commission on Accreditation of Healthcare Organizations recommendations, found that the major determinant of patient care quality was the system through which services are delivered and not the individual anesthesia care provider. (They do not address the question of what happens when system failures are the

PRACTICE

The practice of preanesthesia preparation is being pulled in many directions. The earliest published call for development of an anesthesia-run outpatient clinic came in 1949.²⁰ With the advent of extensive outpatient services, the usefulness of this approach became evident—which was certainly the case at the author's institution, the University of North Carolina (UNC) Health System. There, the concept of an ambulatory surgical center has been operational since 1982, some form of preanesthesia

FUTURE TRENDS

Preanesthesia preparation clinics, of which PreCare is only one organizational model, are not limited to academic or governmental medical centers. Lerner²¹ reported the result of a survey sent to 183 Pennsylvania facilities in which 78% of 79 completed surveys indicated the use of formal clinic mechanisms, 50% of which were run by the anesthesia service, to conduct preanesthesia preparation. Nonetheless, Roizen reports that fewer than 15% of patients currently are evaluated in such centers in

SUMMARY

Preanesthesia preparation will continue to stimulate creativity and debate. Strategies for process improvement will take various shapes and require tools previously unfamiliar to many medical managers. At UNC Health System, anesthesiologists currently are committed to the centralized preanesthesia clinic approach used in PreCare. To date, their strategies have been validated by their institutional measures of success: a 0.7% first-case am work-up rate, a 5% no PreCare visit rate, a 5% consent

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Strategies to Relieve Patients' Preoperative Anxiety Before Anesthesia: Experiences of Nurse Anesthetists
2020, Journal of Perianesthesia Nursing
To investigate nurse anesthetists' experiences of strategies that alleviate adult patients' preoperative anxiety before anesthesia administration.
The study has a qualitative approach wherein the data were collected through semistructured interviews. The study included interviews with six active nurse anesthetists with at least 5 years of experience who worked in a hospital in southern Sweden.
Critical incident technology was used to analyze the data.
Four different categories emerged: behavior of nurse anesthetist, preoperatively providing information, diverting attention to create security, and medicine as an alternative.
Awareness can increase the use of different strategies by both new and experienced nurse anesthetists, as well as by nurses in preoperative units, which in turn alleviates patient anxiety about anesthesia. This may result in a better perioperative experience for the patient.
Perioperative Medicine in the United States
2009, Perioperative Medizin
Improving management of chronic medical conditions has contributed to increased life expectancy and a rising prevalence of severe comorbidities among surgical patients. Not surprisingly, the concept of perioperative medicine remains topical, in part due to this increase in patient acuity, coupled with imperatives to improve outcomes while controlling costs. Perioperative medicine is a relevant concept with increasingly overlapping boundaries between the traditional specialties. However, there has not been a uniform approach towards delineating the exact boundaries of, and the actual implementation of the relevant components of perioperative medicine. In this paper, we present an overview of our institution's approach developed according to the needs of a main tertiary referral center for a sparsely populated but geographically widespread largely rural state.
Die zunehmende Häufigkeit von chirurgischen Patienten mit relevanten Systemerkrankungen, das steigende Durchschnittsalter der Bevölkerung und die berechtigten Ansprüche der Patienten auf eine optimale Behandlung nach einem operativen Eingriff bedingen eine zunehmende Komplexität der perioperativen Behandlung. Wir beschreiben den interdisziplinären Ansatz in unserer Klinik, der gemäß den Anforderungen an ein “main tertiary referral center” in einem dünn besiedelten Flächenstaat (Iowa) entwickelt wurde.
Patient perception of the utility of the preanesthetic clinics in a Caribbean developing country
2009, Revista Brasileira de Anestesiologia
Perception of the patients regarding the utility of the Preanesthetic Clinics and flow time in clinics has not been widely studied in the developing world. The present study aims to study this aspect.
A self-administered 15-item questionnaire survey was conducted among patients attending the Preanesthetic Clinics at a tertiary care teaching hospital in Trinidad. The questionnaire was also distributed to the patients attending the General Surgical Clinic for comparison. Another questionnaire was distributed among the staff of the Preanesthetic Clinic. Patient demographics including age, gender, and educational status and American Society of Anesthesiologists physical status were noted. Other data recorded were patient flow time and details of attending staff.
Of the 220 patients who attended the Preanesthetic Clinics, 92.7% participated in the study. The reliability of the questionnaire was supported by Cronbach's alpha coefficient (0.67). The median time for referral from the surgical clinic to Preanesthetic Clinic was 50 days, median waiting time in the clinic was 2.7 hours, and the median waiting time for surgery after acceptance in the clinic was 13 days. The patients’ opinions regarding the benefits of the clinic, length of the waiting time was independent of their age and educational status. Patients felt that attending the Preanesthetic Clinic was beneficial and not costly to them, although the waiting times were found to be longer.
Patients perceive that attending the Preanesthetic Clinic has been useful before the surgical procedure and the care they received in the clinic was satisfactory.
A percepção dos pacientes a respeito da utilidade do Ambulatório de Avaliação Pré-anestésica e o fluxo de pacientes não foram extensamente estudados no mundo em desenvolvimento. O objetivo deste estudo foi analisar esse aspecto.
Foi realizada pesquisa aplicando-se questionário entre pacientes atendidos no Ambulatório de Avaliação Pré-anestésica de um hospital terciário de ensino em Trinidad. A título de comparação, esse questionário também foi distribuído aos pacientes atendidos no Ambulatório de Cirurgia Geral. Os parâmetros demográficos, incluindo idade, sexo, nível escolar e estado físico ASA foram anotados. Outros dados registrados incluíam o fluxo de pacientes e detalhes a respeito da equipe médica.
Dos 220 pacientes atendidos no Ambulatório de Avaliação Pré-anestésica, 92,7% participaram do estudo. A validade do questionário foi apoiada pelo coeficiente alfa de Cronbach (0,67). O tempo médio para o encaminhamento do Ambulatório de Cirurgia para a Clínica Pré-anestésica foi de 50 dias; a espera média na clínica foi de 2,7 horas e da espera pela intervenção cirúrgica após a aceitação pelo ambulatório foi de 13 dias. As opiniões dos pacientes a respeito dos benefícios da clínica e tempo de espera não foram influenciadas pela idade nem pelo nível educacional. Na opinião dos pacientes, o atendimento no Ambulatório de Avaliação Pré-anestésica foi satisfatório, mas os tempos de espera foram considerados longos.
Na opinião dos pacientes, a consulta no Ambulatório de Avaliação Pré-anestésica antes do procedimento cirúrgico foi útil e o atendimento foi considerado satisfatório.
La percepción de los pacientes respecto de la utilidad del Ambulatorio de Evaluación Preanestésica como también el flujo de pacientes, no fueron extensamente estudiados en el mundo en desarrollo. El objetivo de este estudio fue analizar ese aspecto.
Se realizó una investigación aplicando un cuestionario entre los pacientes atendidos en el Ambulatorio de Evaluación Preanestésica de un hospital subcontratado de enseñanza en Trinidad. Como comparación, ese cuestionario también se distribuyó a los pacientes atendidos en el Ambulatorio de Cirugía General. Los parámetros demográficos, incluyendo edad, sexo, nivel escolar y estado físico ASA se registraron. Otros datos registrados incluían el flujo de pacientes y los detalles respecto del equipo médico.
De los 220 pacientes atendidos en el Ambulatorio de Evaluación Pré-anestésica, un 92,7% participaron del estudio. La validez del cuestionario fue apoyada por el coeficiente alfa de Cronbach (0,67). El tiempo promedio para la derivación al ambulatorio de cirugía para la Clínica Preanestésica fue de 50 días; el tiempo promedio de espera en la clínica fue de 2,7 horas y el de espera por la cirugía después de la aceptación por parte del ambulatorio fue de 12 días. Las opiniones de los pacientes respecto de los beneficios de la clínica y tiempo de espera no tuvieron ningún influjo por la edad ni por el nivel cultural. Según los pacientes, la atención en el Ambulatorio de Evaluación Preanestésica fue benéfica, pero los tiempos de espera fueron considerados extensos.
Según los pacientes, la consulta en el Ambulatorio de Evaluación Preanestésica antes del procedimiento quirúrgico fue útil y la atención fue considerada satisfactoria.
The impact of pre-operative assessment clinics on elective surgical case cancellations
2009, Surgeon
Pre-operative assessment clinics prepare patients for elective procedures. Little is known about their impact on elective case cancellations. We investigated whether a pre-operative assessment clinic would reduce surgical case cancellations. A retrospective review of all surgical cases over a one year period prior to and subsequent to establishment of the clinic was performed. Case cancellations during both periods were compared. Statistical analysis was performed using the chi-square test. There was a 12.7% increase in the number of elective adult procedures performed following establishment of the POAC (815 vs 723), although this was not significant (p>0.05). Pre-assessment resulted in a significant reduction in case cancellations (114 vs 256, p<0.001). When we analysed the data in terms of the reason for cancellation, we found that cancellations for medical, but not patient reasons were significantly reduced following pre-assessment (p= 0.013 and p= 0.180, respectively). The data suggest that establishment of a pre-operative assessment clinic reduces elective case cancellations. In particular we found a significant reduction in cancellations for medical reasons.
Informed consent for labor epidurals: A survey of Society for Obstetric Anesthesia and Perinatology anesthesiologists from the United States
2006, International Journal of Obstetric Anesthesia
Ethicists agree that informed consent is a process rather than just simply the signing of a form. It should provide the patient with needed information and understanding to authorize a procedure. Essential elements of informed consent for women requesting labor epidurals include a description of the procedure, the risks and benefits, and alternative treatments for analgesia including the associated risks and benefits. The purpose of this pilot study was to determine practices and opinions of obstetric anesthesiologists regarding informed consent for parturients.
Questionnaires were sent to 885 anesthesiologists who were members of the Society of Obstetric Anesthesia and Perinatology based in United States institutions in 2002.
Of the 885 questionnaires sent, 448 (51%) were returned with 47% from academic and 47% from private practice institutions. Forty-six percent worked as part of an obstetric anesthesia team; 51% worked in centers where there were >3000 deliveries/year. Sixty-eight percent suggested that “parturients in active labor are able to give informed consent for labor epidural analgesia.” Thirteen percent recommend antenatal anesthesia consults for parturients inquiring about labor epidurals and 41% participated in childbirth classes. Responses did not differ significantly between physicians in academic vs. private practice. More obstetric team practices than non-team practices participated in childbirth education (54% vs. 30%, P < 0.0001).
Despite the painful, stressful circumstances confronted by parturients, many respondents (76% in academic, 64% in private practice) thought that women in active labor are able to give informed consent.
The accreditation council for graduate medical education's outcome project and its effects on graduate medical education in anesthesia
2005, Advances in Anesthesia

View all citing articles on Scopus

: Address reprint requests to Vincent J. Kopp, MD, Department of Anesthesiology, Campus Box 7010, 223 Burnett-Womack Building, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC 27599–7010, e-mail: [email protected]

^*: Departments of Anesthesiology and Pediatrics, and Social Medicine, School of Medicine, University of North Carolina at Chapel Hill; and PreCare, UNC Hospitals, University of North Carolina Health System, Chapel Hill, North Carolina

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PREOPERATIVE PREPARATION: Value, Perspective, and Practice in Patient Care

Section snippets

DEFINITIONS OF TERMS

VALUE

PERSPECTIVE

PRACTICE

FUTURE TRENDS

SUMMARY

Mayo Clin Proc

J Clin Anesth

J Clin Anesth

Executive summary of the ACC/AHA Task Force report. Guidelines for perioperative cardiovascular evaluation for noncardiac surgery

Anesth Analg

Practice guidelines for management of the difficult airway: A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway [comments]

Anesthesiology

Streamlining the preoperative process: The telephonic preanesthetic assessment

Anesthesiology

Unsolicited ‘thank you’ notes: Insight into elements of patient satisfaction

Anesth Analg

An application of health services research to anesthesiology [editorial; comment]

Anesthesiology

Design of appointment systems for preanesthesia evaluation clinics to minimize patient waiting times: A review of computer simulation and patient survey studies

Anesth Analg

Looking back on the millennium in medicine [editorial]

N Engl J Med

Development and validation of a Monte-Carlo simulation model of a preoperative patient testing center (PTC)

Anesthesiology

Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital [comments]

Anesthesiology

Multicenter study of general anesthesia: Predictors of severe perioperative adverse outcomes [published erratum appears in Anesthesiology 77:222, 1992] [comments]

Anesthesiology

Measuring patient satisfaction with anesthesia care: A review of current methodology [comments]

Anesth Analg

Portable data acquisition combined with Web-based data access improves preoperative evaluations without compromising confidentiality

Anesthesiology 1998

Current understanding of patients' attitudes toward and preparation for anesthesia: A review [comments]

Anesth Analg

The utility of animated simulation modeling for assessing policy effects on predicted versus observed patient flow in a preanesthesia consult clinic

Anesthesiology

Defining quality of perioperative care by statistical process control of adverse outcomes

Anesthesiology

The anesthetic outpatient clinic

Anesthesia