Effect of preoperative clinics on OR efficiency

AORN Journal, April, 2007 by George Allen

Anesthesiology December 2006

Cancellation of surgery can result in a significant loss in revenue, with one estimate suggesting that a minimum of approximately $1,500 per hour of revenues is lost. It is believed that proper risk assessment and optimization of medical conditions in a preoperative clinic may considerably reduce cancellations and delays on the day of surgery. In the preoperative clinic, optimal management of preexisting medical conditions may take place or new conditions may be diagnosed. Health care practitioners may discover that old medical records need to be reviewed; test results need to be obtained; or office notes not readily available at the time of the preoperative evaluation need to be acquired from nonaffiliated hospitals, clinics, or institutions. In effect, medical issues can be appropriately identified and the necessary information obtained so that the knowledge of a patient's status is complete before the day of surgery. Effective patient evaluation in a preoperative clinic has been shown to increase efficiency of perioperative resource utilization, increase patient satisfaction, reduce unnecessary testing and consultation, and decrease the duration of hospital stay.

The authors of this study noted that although a significant percentage of patients evaluated in their preoperative clinic have at least one known coexisting disease, a smaller percentage present with a change in their existing medical condition or with a previously undiagnosed disease process, which may require that a physician order new tests. In addition, many of their patients come from outside institutions, which may require that additional information be obtained from other institutions. The objectives of this retrospective study were to test the hypotheses that some of the information obtained during the preoperative clinic visit will be new and will apply to different medical and surgical fields, that obtaining previous diagnostic test results will modify the medical management of patients in the perioperative period, and that new problems will account for the majority of the changes in medical management. (3)

The charts of all patients evaluated in the preoperative clinic during a three-month period from Nov 1, 2003, through Jan 31, 2004, were reviewed. Data collected included

* patient demographics,

* type of medical issue uncovered during the preoperative clinic visit,

* information needed to resolve the issue,

* the length of time required to retrieve needed information,

* cancellation and delay rates for surgical procedures, and

* the effect on management of the patient's procedure.

Delays were defined as procedures that were eventually placed on the OR schedule at a later date than originally planned, and cancellations were procedures that were removed from the OR schedule and not rebooked for at least a three-month period. Common statistical procedures, including mean and standard deviation, were used to analyze the data.

Findings. During the three-month study period, 5,083 patients were seen in the preoperative clinic. A total of 647 patients (12.7%) had 680 medical issues that required additional information or management. Of these medical issues, 565 (83.1%) were known medical problems (ie, old problems) thought to require further information, and 115 (16.9%) were medical problems newly identified in the preoperative clinic (ie, new problems). All outstanding medical issues were identified and the necessary information was obtained for 93% and 96.1% of patients with old and new problems, respectively.

Medical conditions requiring further investigation were divided into general categories, including

* cardiac;

* anesthesia;

* pulmonary;

* hematologic;

* vascular;

* endocrine; and

* other (eg, significant laboratory abnormalities).

Cardiac issues represented the majority of issues identified (ie, 87% of old problems and 63.5% of new problems). The need to obtain existing information (eg, stress test, echocardiogram, electrocardiogram [ECG]) about known symptomatic coronary artery disease was the most frequently identified issue associated with incomplete information. Significant new abnormalities on ECG or the presence of new cardiac symptoms were the most common source of newly identified issues. The majority of the newly identified problems (ie, 80.3%) required that a new test or consultation be performed, whereas the majority of the old problems (ie, 84.3%) required that information be retrieved from other medical institutions. New problems were associated with a greater chance of delay (ie, 10.7%) or cancellation (ie, 6.8%) from the originally scheduled date than old problems (ie, 0.6% and 1.8%, respectively). A total of 15.8% of patients with old problems and 27.2% of patients with new problems had alterations in their perioperative management, with the most common change in management involving the initiation of perioperative beta blockers.

Clinical implications. The results of this study revealed that preoperative clinic evaluation can identify and resolve a number of medical issues that can affect the efficient use of resources in the OR. Overall, 17.6% of the patients seen in the preoperative clinic had alterations in their perioperative management. Perioperative managers who have determined that their cancellation or delay rates are high should consider instituting a preoperative clinic for all scheduled outpatient surgeries.