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Preoperative Assessment
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Preoperative assessment clinics were created to streamline patient assessment and evaluation before surgery, and they appear to be effective. Preoperative evaluation has been shown to enhance management of existing conditions, diagnose new conditions, and help in arranging follow-up care.5-8 They can reduce costs by facilitating rational use of preoperative testing and consultation. Medical specialties have created consultation services to ensure appropriate physician specialists are available to respond to requests for consultations in a timely manner. Clinical guidelines such as the American College of Cardiology/American Heart Association (ACC/AHA) 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery have also been helpful in guiding appropriate preoperative evaluation and care.9
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Consultation is usually performed by an anesthesiologist, internist, medical subspecialist, or a combination. Multiple studies have demonstrated improvement in surgical care from anesthesiologist-staffed preoperative clinics; less evidence has been generated from internist-staffed preoperative clinics.10-13 The surgical history and physical should be sufficiently detailed to identify the need for further workup. If indicated, the most appropriate specialist(s) should be consulted and specific clinical questions articulated. Internists and medical subspecialists are most appropriate for assessing and managing complex medical problems and for engaging in ongoing medical care. Anesthesiologists are best for assessing anesthetic risks, appropriate location for surgical care based on risk (eg, free-standing outpatient surgery center vs hospital), and whether patients are candidates for nurse sedation, monitored anesthesia care, or another type of anesthesia.
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Multiple studies have indicated that the most important factors in effective consultation relate to communication. The reason for the consultation should be stated precisely and confirmed by the consultant with the referring physician. One study showed that 14% of consultants and consultees disagreed on the reason for consultation.14 Miscommunication such as this at least partially explains compliance rates with consultant recommendations of only 54% to 77%.3,15 "Please clear for surgery" is not a meaningful consult request.16 It is unrealistic for any patient to be "cleared" because no patient is entirely without some medical risk. Additionally, regulations governing consult reimbursements require that a medically appropriate question be asked of a consultant.1 The physician requesting a consult should be clear as to the type of intervention being sought: consult with recommendations only, consult and treat immediate problems, consult and comanage care, and so on.
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Data suggest that in the preoperative period, patients are uniquely receptive to information on health and lifestyle. These educational opportunities should be exploited by all members of the health care team because these interventions can be especially effective for reinforcing other recommendations for a healthy lifestyle. Patients and their families should be counseled to stop smoking,17,18 limit alcohol intake19 and drug use, and improve diet and exercise. Referrals and supporting information should be provided whenever appropriate.
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As with all types of medical intervention, perioperative consultations are subject to three basic types of medical errors: overuse in patients unlikely to benefit, underuse in patients with clear potential for benefit, and misuse.
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Timing of the Preoperative Consultation
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Requests for consultation should ideally be made sufficiently ahead of the scheduled procedure to allow time for necessary investigations and for appropriate medical interventions if warranted. The most commonly diagnosed unexpected morbidities are cardiac related. Allowing sufficient time for evaluation avoids last-minute delays in the event that the patient requires additional evaluation (eg, stress testing or echocardiogram), medication adjustment, or management of abnormal laboratory findings.
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If a consultation is requested at the "last minute," the consultant should strive to fulfill their obligation to the patient and referring physician under the circumstances. It is appropriate to use these experiences as "teachable moments" for the referring service and to evaluate system issues that contribute to suboptimal timing.
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Immediate Perioperative Period
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The surgeon and anesthesiologist comanage patients in the recovery room. Consultation with other services in this setting is unusual. When it occurs, the consultant should be familiar with the normal range of physiologic changes in the recovery period when making their evaluations. More commonly, the consultant is requested de novo, or for follow-up after a preoperative consultation, after the patient returns to the ward or intensive care unit.
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A multimodal fast-track surgical care model to promote healing, earlier discharge and return to function, and fewer complications is being advocated.20,21 This approach requires carefully coordinated team-based care involving surgeons, anesthesiologists, nurses, and other clinicians. Consultants should be aware of this model and facilitate its use as indicated by the clinical situation. Most major postoperative complications occur in the first 72 hours; therefore, the consultant should be available to assist during this interval, and longer if their expertise is indicated in the management of subsequent complications.22 Further, the primary physician has an obligation to inform the consultant of any subsequent developments that may be relevant to the consultant's expertise.23,24 Increasingly, surgeons are engaging internists or others to assist or provide perioperative medical care while they focus on surgical management, so such engagement will likely be more common in the future.
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Increasingly, models of comanagement between surgeons and various medical specialists, including anesthesiologists, have been developed to enable more expedient and skilled medical care to be provided on the wards and to enable surgeons to concentrate their efforts on busier operative workloads. In one study, the frequency of comanagement by medicine-trained physicians for patients undergoing 15 common inpatient operations increased 11.4% annually from 2001 to 2006.25 Proposed models of comanagement have emphasized more efficient and cost-effective preoperative testing, shorter lengths of stay, and the potential for improved medical outcomes (all these are consistent with the fast-track approach described earlier). To date, studies of comanagement have not clearly demonstrated statistical benefits in outcomes beyond minor medical improvements such as decreased urinary tract infections and electrolyte abnormalities and improved staff satisfaction. Separate studies showed varying results in terms of outcomes such as cost of care, length of stay, time to surgery, and major medical complications.26-29
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Another role that is increasingly appropriate for consultants involves the need for effective communication at the time of patient transition out of the hospital. Literature focused on effective "handoff of care" and the medical errors occurring at the time of patient transition to home or to rehabilitation settings has shown the need for greater attention to this area.30 Traditionally, consultants have not always played a major role in this area, but their skills and experience suggest they could be valuable contributors, and the opportunity is consistent with their commitment to strive for the patient's best interests. They should be aware of the service they can provide for the patient by ensuring that issues related to their area of expertise are well communicated to the health care provider who will be responsible for the patient after discharge from the hospital. Checklists and "readback" are effective strategies to enhance transfer of information.30
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Rapid response systems or rapid response teams have also developed as a strategy for early identification of hospitalized patients with potentially unstable or deteriorating conditions. Depending on the medical center, these systems may or may not involve physicians on the team of emergency providers. If present on this team, internists (often hospitalists), intensivists, or anesthesiologists may practice in either a consultative or comanagement role. Literature to date remains inconsistent regarding the statistical benefits of these systems.31-34