Preoperative Assessment in PrivatePractical Pointers for Private Practitioners
Dr Adam Molnar
MBBS FANZCA
Victorian Anaesthetic Group
Victorian Anaesthetic
Group
Conflict of Interest
Family member owns MediTrust I have no financial interest in the product I act as a medical consultant to MediTrust I have never received a payment in the past from
MediTrust I will not receive a payment in the future from
MediTrust I pay a commercial rate to use the product
My Practice
Full time private practice Victorian Anaesthetic Group Inner Melbourne Major orthopaedic, colorectal, reconstructive plastic,
gynaecology and endoscopy. IT interest
Private Practice in Australia
Around 2 million anaesthetics are given privately in Australia per year
4% increase in procedures per year Increasing complexity of cases Increasing age of patients Little or no current research on preoperative
assessment in private
Preoperative Evaluation
Cardiac –Fleischer LA et al. ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 2007
Respiratory-Bapoje SR et al. Preoperative evaluation of the patient with pulmonary disease. Chest 2007
Diabetes OSA Airway
The Problem
Approaching 100% same day admission Staggered admission Increasing pressure to provide more information Compared to public there is a decrease waiting period Surgeons notify anaesthetists late regarding particular
cases Patient information is on multiple systems which do not
interface
Preoperative Assessment
Establish Rapport ✔
History ✔
Examination ✔
Investigations ✔
Anaesthetic Plan ✔
Informed Consent ✔
Anaesthetic
Australian Incident Monitoring Study
Kluger MT et al Inadequate preoperative evaluation and preparation: A review of 197 reports from AIMS. Anaesthesia 2000
3.1% of adverse events Preventable in 57% of cases 23 major cases of morbidity. 7 deaths 10% of patients had not been seen 29% poor airway assessment
Victorian Consultative Council on Anaesthetic Mortality and Morbidity
Continually emphasis the contribution of poor preoperative assessment to morbidity and mortality
“These included failure to identify patient information details, poor medical status evaluation, inadequate airway assessment, and failure to adequately assess the cardiovascular system.”
15%anaesthetic related mortality 12%anaesthetic related morbidity
Preoperative Assessment in Private
Anaesthetic Consults
Total Services Distribution
17610 < 15 minutes 1935086 92.6 %17615 15 to 30 minutes
102746 4.9%
17620 30 to 45 minutes
13418 0.6%
17625 >45 minutes 2617 0.1%17690 In Rooms 36437 1.8%
Preoperative AssessmentTechniques
Rely on surgeon assessment and investigation In room consultations Perioperative physicians Phone consultations Hospital Pre-anaesthetic Clinics Online solutions
Preoperative Assessment in Rooms
State % Total Anaesthetic Consultations
Tasmania 4.5%Western Australia 3.1%New South Wales 2.9%South Australia 2.2%ACT 1.5%Queensland 0.5%Victoria 0.4%Northern Territory 0.3%
Preoperative Assessment in Rooms
2008 2009 20100
0.51
1.52
2.53
3.54
4.55
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In Rooms Consultation
Probably the gold standard Costly Difficult to see all patients – need to screen May see patients too late
In Rooms Consultation
In Room Consultation
Perioperative Physician
Renal or general physician Patient referred by the surgeon Complete 24/7 cover Advantages- organise appropriate investigations, optimise
medical conditions, send summary to anaesthetist prior to surgery, provide cover.
Disadvantages-lack understanding of the operative process, no anaesthetic discussion, inadequate pain control.
Phone consultations
Patients like them Advantages- History, anaesthetic discussion, screen
patients prior to seeing in rooms Disadvantage – Inefficient, examination and
investigation problems, late referrals
Hospital Pre-anaesthetic Clinic
Set up by hospitals Run by nursing staff Advantages- History, screen patients prior to seeing in
rooms Disadvantages- Late referrals, no examination or
investigations, no anaesthetic discussion
On-line assessment
Increase use of internet, smart phones and tablets Capture patient at time of surgical booking Anaesthetist introduced Specific anaesthetic information Provides specific informed financial consent Health survey Screen for in room consultation
Day of Surgery Admission
Appropriate facilities Access to rapid investigations Access to ICU/HDU beds Willingness to cancel
Preoperative Assessment
Challenging Anaesthetists need to be prepared to adapt Anaesthetists must maintain their high professional
standards Anaesthetists must be involved in the process of
change