|Year : 2020 | Volume
| Issue : 3 | Page : 246-250
Setting up preanesthesia evaluation clinic – An experience of planning and establishment at a private medical college and hospital
Sathish Raju Nilakantam1, CL Gurudatt2, M Dayananda1
1 Department of Hospital Administration, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
2 Department of Anaesthesiology, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
|Date of Submission||12-Feb-2020|
|Date of Decision||18-Mar-2020|
|Date of Acceptance||16-Apr-2020|
|Date of Web Publication||28-Jul-2020|
Dr. Sathish Raju Nilakantam
Department of Hospital Administration, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, MG Road, Mysuru - 570 004, Karnataka
Source of Support: None, Conflict of Interest: None
BACKGROUND: Preanesthesia evaluation (PAE) (also called preanesthetic assessment or preanesthesia checkup) is a detailed medical checkup and laboratory investigations performed by the anesthesiologist before a surgical procedure, to assess the patient's physical condition and any other medical illnesses or diseases the patient might be suffering from. Dedicated outpatient PAE clinics are fairly latest phenomenon, and information is thin from developing world. The role of PAE clinic is to evaluate all patients for surgical procedures requiring general or regional anesthesia before hospital admission, whether for day-care surgical procedures or for inpatient surgical procedures. Optimal use of PAE clinic avoids unnecessary postponements, suboptimal utilization of operation theater, and personnel and parental time.
AIMS: The aim of this study was to describe the methods, challenges, and opportunities that we came across in setting up a PAE clinic in a university-based tertiary care teaching hospital attached to a medical college at Mysuru in South India.
MATERIALS AND METHODS: The PAE clinic was planned to set up in the outpatient department area of this medical college cum tertiary care hospital, manned by a multimodal team.
RESULTS: With the utilization of available resources, the establishment of daily PAE clinic was possible in this university-based tertiary care teaching hospital.
CONCLUSION: PAE is a clinical base and framework for perioperative patient management. This article describes a scalable model that can be replicated in similar resource-constrained hospitals/health-care organizations.
Keywords: Perioperative management, planning, preanesthesia evaluation, surgical procedures
|How to cite this article:|
Nilakantam SR, Gurudatt C L, Dayananda M. Setting up preanesthesia evaluation clinic – An experience of planning and establishment at a private medical college and hospital. Int J Health Allied Sci 2020;9:246-50
|How to cite this URL:|
Nilakantam SR, Gurudatt C L, Dayananda M. Setting up preanesthesia evaluation clinic – An experience of planning and establishment at a private medical college and hospital. Int J Health Allied Sci [serial online] 2020 [cited 2020 Sep 30];9:246-50. Available from: http://www.ijhas.in/text.asp?2020/9/3/246/290716
| Introduction|| |
Preanesthesia evaluation (PAE) clinic is a specialty clinic where patients are evaluated before surgical procedure to create a record for which risk assessment, optimization, and perioperative management choices can be made. PAE is the process of clinical assessment that precedes the delivery of anesthesia care for surgical and few nonsurgical procedures. It includes an interview and general physical examination of the patient, a review of previous medical, surgical, and anesthesia problems, a detailed history of current medication use, and necessities for obtaining and reviewing preoperative tests. An anesthesiologist is responsible for PAE. PAE is also called preanesthetic assessment, preanesthesia checkup, or simply preanesthesia.
Anesthesiology has evolved into a branch where it is in the route of being identical to perioperative medicine. The PAE clinic is a key aspect with respect to this practice. With the advent of outpatient care, the PAE clinic is becoming a vital component in today's competitive and resource-strained health-care environment. The anesthesiologist is the perioperative physician who provides medical care to patients throughout their surgical experience. Preanesthesia clinic evaluation is more effective than preanesthesia ward evaluation in reducing anxiety although this reduction may not be clinically significant.
Dedicated PAE clinics permit for initial patient access to anesthesiologists, better preoperative counseling, increased communication between providers and patients, anesthesiologist involvement in protocol development, and coordination of postoperative care to decrease pain, complications, morbidity, and mortality. Previous studies of well-designed anesthesiologist-directed preoperative evaluation clinics have revealed that these clinics can reduce preoperative consultations, decrease surgical cancellations due to inadequate preoperative preparation, and reduce costs associated with unnecessary testing.
Most importantly, the PAE clinic is a necessary prerequisite for the safe implementation of ambulatory and day of surgery admission (DOSA) by hospital administrators., There are also many published reports to show that these clinics have immensely helped to avoid inconvenience to the patients and staff alike., In a study conducted by Concannon et al., they have concluded that PAE establishment was associated with a substantial increase in the overall DOSA rates from 56% to 85%, surpassing their national target rate of DOSA (75%). PAE supports in maximizing safety of anesthesia and health-care delivery efficiency.
Various models have been projected and studied for the effective functioning of a PAE clinic. The optimal model is still unknown and may depend on certain individualities of the hospital such as varieties of specialty care provided, socioeconomic differences of the population being served, the expectations of the patients, and whether the hospital is public versus private or academic/nonacademic practice, etc.
Formerly PAE clinics were mainly nurse-led or primary care physician-led, with anesthesiologist-led screening happening on an ad hoc basis. However, there are evidences of low effectiveness for nurse-led preanesthesia checkups on a wide range of outcomes for patients who have undergone surgical procedures electively., However, anesthesiologist-directed PAE clinics have demonstrated that a well-designed PAE clinic can decrease the preoperative consultations as well as cancellations of surgical procedures due to inadequate preoperative preparation, and expenditures associated with unnecessary testing can be reduced. However, these studies do not specifically address the contribution of a PAE clinic to the improvement in clinical outcomes. However, Blitz et al. in their study theorized that the anesthesiologist-directed, standardized PAE process that patients had undergone in their PAE clinic was superior to the PAE process that happened outside with regard to patient clinical outcomes.
The significance of a PAE lies in its ability to improve the quality of the perioperative process through the establishment of an additional strong system of preanesthesia assessment and preparation. The functions and benefits of Pre – Anaesthesia Evaluation Clinic are described as follows.,,,,,
Goals and functions of preanesthesia evaluation clinic
- Documentation of the clinical condition(s) for which surgical procedure was advised
- Complete assessment of the patient's health conditions
- Uncovering of hidden conditions that could cause problems both during and after surgical procedure
- Perioperative risk determination
- Optimization of the patient's medical condition in order to reduce the patient's surgical and anesthetic perioperative morbidity or mortality
- Development of an appropriate perioperative care plan
- Education of the patient about surgical procedures, anesthesia, intraoperative care, and postoperative pain treatments in the hope of reducing anxiety and facilitating recovery.
Benefits of preanesthesia evaluation clinics
- Decrease in the length of hospital stay
- Decrease in day-of-surgery delay or cancellation
- Decrease in the rate of surgical complications
- Upturn in patient satisfaction regarding anesthesia and a reduction of anxiety
- Decrease in excessive preoperative investigations
- Reduction in the practice of other specialty consultations without affecting patient outcome
- Efficiency of operation theater can be improved.
Disadvantages of the PAE clinics may comprise extraconsultation costs and longer hospital waiting times after consultation in outpatient departments (OPDs) of surgical specialties.
In this article, we aim to describe our unique effort to set up a PAE clinic at this university-based tertiary care teaching hospital attached to a medical college, Mysuru, in South India, with the objective of providing complete perioperative services to patients who require surgical interventions.
| Materials and Methods|| |
JSS Hospital is a tertiary care teaching hospital located in Mysuru City, Karnataka State, in Southern India. Hospital services are accessed by patients from within the state and surrounding states in Southern India.
The establishment of a high quality and cost-effective PAE clinic requires planning and close teamwork between hospital administrators and the departments of anesthesiology, surgery, and allied specialties and department of nursing services. Success in its execution requires time, effort and money, defined organizational goals and objectives, alterations in support resources, and intradepartmental coordination. This phase included interactions with the director of the hospital, medical superintendent (who is the head of clinical services), heads of surgery, and its allied specialties and also with the chief of nursing services. The chief administrative officer along with the department of engineering and maintenance was also engaged.
Model of the preanesthesia evaluation clinic
Anesthesiologist-directed PAE clinic.
Context of the preanesthesia evaluation clinic
In 2019 our institution, an academic comprehensive health-care center established this PAE clinic with the goal of maximizing perioperative safety and efficiency. Hospital has all clinical specialties and diagnostics and imaging facilities running within its own building premises. Any patient can just walk in and avail all the services without any prior appointment. Before the commencement of the PAE clinic, circulars/letters were sent to all clinical departments informing them to its nature and scope to ensure prompt referrals.
Organization of the preanesthesia evaluation clinic
The PAE clinic was spread out in the OPD area for reasons of feasibility. The workflow of the PAE clinic is shown in [Figure 1]. It was planned as a daily clinic, dedicated for detailed assessment of patients who shall be scheduled for surgical procedure, whether for day-care surgery or inpatient surgery. The team operating the clinic comprised of a consultant anesthesiologist, one senior resident (equivalent to registrar), one junior resident trainee (equivalent to PG registrar) posted on rotation, a staff nurse as well as a second division assistant worker. The head of the department, anesthesiology, is responsible for policy administration, service development, and quality assurance. The consultant will supervise the complete functioning of the clinic and discuss the case workups. The senior resident was involved in providing clinical care and managing administrative concerns. Postgraduate trainees from the department of anesthesiology are posted to the clinic as part of their training to ensure training in PAE and optimization. Any inquiries regarding the optimization and fitness of the patient should be discussed with the consultant posted. Any case found to have a American Society of Anesthesiologists status score of >II should also be discussed with the senior anesthesiologist involved in giving anesthesia, so as to avoid last-minute cancellations. Workload may vary at different times, and flexibility in staffing is required so that staff can be redeployed between the clinic and other perioperative areas according to the clinical and administrative needs. Equipment and infrastructural requirements included are at least two consultation rooms, examination area, and a waiting room with all the necessary equipment and furnishings. At our institution, a comprehensive PAE clinic, standard operating Guidelines Booklet was developed to serve as a reference guide and is continually updated to reflect current guideline recommendations.
Evaluation and management
The surgeons are responsible for referring appropriate patients to the PAE clinic when he/she determined that there is a need for thorough anesthesia review to fully optimize the patient's condition before surgical procedure. When a patient requires an assessment in PAE clinic, this will be explained to the patient, and they will be referred to this clinic from various outpatient surgical specialties before the scheduled surgical procedure. They will come with their medical record in hand, which at a minimum, included a present-day surgeon's history and general physical examination, laboratory investigation reports, and a signed consent form for surgical procedure. As soon as patients arrive to the PAE clinic, they are advised to fill a self-administered questionnaire initially, and the nurse records and documents the vital parameters (i.e., pulse and blood pressure). Resident doctors clinically evaluate every patient who are referred to PAE clinic under the supervision of a consultant anesthesiologist. The assessment form is attached to the patient's clinical case notes. Laboratory tests and consultations if required any will be advised by the anesthesiologist and, with few exceptions, were obtained in the hospital on the same day. Next, written preoperative instructions will be given to the patient. The preoperative discussion with the patient will be held along with a family member present in the PAE consultation room to enhance the retention of the information. The patient as well as parent surgical department is informed for any additional referrals and/or investigations required, as well as the conclusion regarding the patient if the surgical procedure needs to be postponed due to anesthetic reasons.
| Results and Postimplementation Impact|| |
With the introduction of PAE clinic, coordination between preoperative surgical, anesthesia, nursing, and laboratory care has been improved and also efficiency of the perioperative care increased subsequently. There is improved attention to patient's individualized care based on the information obtained from patient's clinical case records, interview, general physical examination, type, and invasiveness of the planned surgical procedure.
| Discussion|| |
Challenges posed and opportunities provided by the preanesthesia evaluation clinic
Some of the challenges that have been experienced in running the clinic include: first, the poor referral rates (1 or 2 patients/day), and second, surgeons had to understand that the additional preoperative visit would actually lead to improved patient safety and efficiency on their operative days.
The PAE clinic serves as the opening point of interaction for the surgical patient with the anesthesiologist, and it offers opportunity for patients to make a lasting positive impression of not only our preoperative process but of the institution and the department of anesthesiology as a whole. The PAE clinic provides an opportunity to show expertise in perioperative patient care and systems design as perioperative medicine consultants. Many key components of a successful perioperative surgical home can be initiated in an anesthesiologist-led PAE clinic, such as early anesthesiologist contact to patients; increased preoperative counseling by anesthesiologists; increased communication between clinicians and patients; anesthesiologist involvement in protocol development; and coordination of postoperative care to reduce pain, complications, morbidity, and mortality., The PAE clinic also provides an opportunity to educate our patients and surgical colleagues about the importance of addressing coexisting disease and its impact on surgical risk and surgical care and to participate in shared decision-making. It also provides an opportunity to improve hospital resource utilization and streamlining surgical service provisions. Finally, such a dedicated PAE clinic may provide numerous research opportunities concentrating on PAE.
- The policy and clinic established strictly adheres only to this organization
- Challenges posed and opportunities provided by the preanesthesia evaluation clinicDepending on hospital size and level of care, other hospitals/health-care organizations can adapt this plan and layout after strict modifications according to their resources available.
| Conclusion|| |
PAE is a clinical base and framework for perioperative patient management. Optimal use of PAE clinic avoids unnecessary postponements, suboptimal utilization of operation theater, and personnel and parental time. However, with growing awareness about the usefulness of preoperative risk assessment and a growing body of literature and evidence-based guidelines, these clinics are becoming a medical necessity for the improvement of perioperative care. We hope that this article will provide practical insights to anesthesiologists/clinicians/hospital administrators working in various hospitals and health-care organizations, stem further research in this area, and also stimulate the development of more such clinics across the length and breadth of the country. This article describes a scalable model that can be replicated in similar resource-constrained hospitals/health-care organizations.
Areas of interest for future research
- PAE clinic OPD utilization rates
- Economic evaluation of PAE clinic care services
- Application of telemedicine technology for PAE consultations
- To study the prevalence of different comorbidities among patients reporting to PAE clinic.
The authors wish to acknowledge the institution for establishing our PAE clinic for patients.
We, the authors, are also grateful to authors, editors, and publishers from where the literature for this article has been reviewed and discussed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American Society of Anesthesiologists Task Force on Preanaesthesia Evaluation. Practice advisory for preanaesthesia evaluation: A report by the American Society of Anesthesiologists task force on preanesthesia evaluation. Anesthesiology 2002;96:485-96.
Kamau A, Mung'ayi V, Yonga G. The effect of a preanaesthesia clinic consultation on adult patient anxiety at a tertiary hospital in Kenya: A cohort study. Afr Health Sci 2017;17:138-46.
Blitz JD, Kendale SM, Jain SK, Cuff GE, Kim JT, Rosenberg AD. Preoperative evaluation clinic visit is associated with decreased risk of in-hospital postoperative mortality. Anesthesiology 2016;125:280-94.
Pollard JB, Garnerin P, Dalman RL. Use of outpatient preoperative evaluation to decrease length of stay for vascular surgery. Anesth Analg 1997;85:1307-11.
Tait AR, Voepel-Lewis T, Munro HM, Gutstein HB, Reynolds PI. Cancellation of pediatric outpatient surgery: Economic and emotional implications for patients and their families. J Clin Anesth 1997;9:213-9.
Fischer SP. Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology 1996;85:196-206.
van Klei WA, Moons KG, Rutten CL, Schuurhuis A, Knape JT, Kalkman CJ, et al
. The effect of outpatient preoperative evaluation of hospital inpatients on cancellation of surgery and length of hospital stay. Anesth Analg 2002;94:644-9.
Concannon ES, Hogan AM, Flood L, Khan W, Waldron R, Barry K. Day of surgery admission for the elective surgical in-patient: Successful implementation of the elective surgery programme. Ir J Med Sci 2013;182:127-33.
Yen C, Tsai M, Macario A. Preoperative evaluation clinics. Curr Opin Anaesthesiol 2010;23:167-72.
Tariq H, Ahmed R, Kulkarni S, Hanif S, Toolsie O, Abbas H, et al
. Development, functioning, and effectiveness of a preoperative risk assessment clinic. Health Serv Insights 2016;9:1-7.
Hines S, Munday J, Kynoch K. Effectiveness of nurse-led preoperative assessment services for elective surgery: A systematic review update. JBI Database System Rev Implement Rep 2015;13:279-317.
Roizen MF, Foss JF, Fischer SP. Preoperative evaluation. In: Miller RD, editor. Anesthesia. 5th
ed. Philadelphia: Churchill-Livingstone; 2000. p. 824-83.
Kitts JB. The preoperative assessment: Who is responsible? Can J Anaesth 1997;44:1232-6.
Zambouri A. Preoperative evaluation and preparation for anesthesia and surgery. Hippokratia 2007;11:13-21.
Gupta A, Gupta N. Setting up and functioning of a preanaesthetic clinic. Indian J Anaesth 2010;54:504-7.
] [Full text]
Yakubu SY. Could preanesthesia assessment clinics be of benefit in modern anesthetic practice in Nigeria? Sub-Saharan Afr J Med 2018;5:1-5. [Full text]
Vetter TR, Ivankova NV, Goeddel LA, McGwin G Jr., Pittet JF, UAB Perioperative Surgical Home Group. An analysis of methodologies that can be used to validate if a perioperative surgical home improves the patient-centeredness, evidence-based practice, quality, safety, and value of patient care. Anesthesiology 2013;119:1261-74.
Kash B, Cline K, Menser T, Zhang Y. The Perioperative Surgical Home (PSH): A Comprehensive Review of US and Non-US Studies Shows Predominantly Positive Quality and Cost Outcomes; The Milbank Quarterly; 2014 Dec;92:796-821.