Guidelines for preoperative investigations for elective surgery at Queen Elizabeth Hospital: effects on practices, outcomes and costs

OBJECTIVES: Patients who present for elective surgery are often subjected to routine preoperative investigations, which often lead to unnecessary costs, delays or cancellation of surgery. We assessed the current practices, and the impact of guidelines for preoperative investigations on outcomes, practices and costs. DESIGN AND METHODS: The patterns of preoperative testing were assessed by conducting an audit. Preoperative investigation guidelines developed were presented to all surgical departments. The audit was repeated post-intervention compared to the pre-guideline audit. RESULTS: A total of 304 patients (150 before and 154 after) was included. The mean number of tests per patient did not significantly change between the pre-guideline and post guideline groups. For younger patients (under 60 years), the mean number of tests decreased from 3.42 ñ 1.8 in the pre-guideline group to 2.89 ñ 1.98 in the post guideline group (p=0.042). The total number of Chest X-rays decreased by 14.8% (p=0.012) and of Full blood counts (FBC) by 7.6% (p=0.036). For the remainder of investigations, there was no difference. The implementation of changes lead to overall savings of $15,178 per 1000 patients ($81,491 BDS per annum). The most notable savings are due to decreased number of Chest X-Rays. CONCLUSIONS: This study demonstrated that preoperative investigations were performed as a routine even in the absence of any clinical indication. The introduction of guidelines for preoperative investigations significantly decreased costs to the institution without compromising the safety of patient care and without placing patients at risk.

Knowledge and fears of anaesthesia and surgery: the Jamaican perspective

This study was undertaken to assess patients' knowledge and perceptions, fears and concern regarding perioperative management. 300 patients were interviewed consecutively and a questionnaire was completed for each patient. 25 percent admitted to having anxiety about their upcomming operation. The prevalence of preoperative fear was significantly higher in younger patients (age <40 years, p<0.05) and in more educated patients (secondary and tertiary levels, p<0.001). The commonest fears were those of a morbid nature (eg. death on the operating table). 34 percent of the patients did not realize than anaesthetists were qualified doctors, and only 10 percent recognized the central role played by anaesthetists in the monitoring of vital signs throughout an operation. There is continuing need for public education on the role of the anaesthetists in health care, and anaesthetists must ensure that preoperative concerns of their patients are adequately addressed.(AU)

Perioperative nursing - the Jamaican perspective

Under constraints of a restricted economy Jamaica strives to deliver health care at the standard of developed countries. Nurses in Jamaica assume various roles as they provide perioperative nursing care;they work as a team and act as patient advocates. Bonds of caring and love are often established between patients, families, and the nursing staff. The quality of nursing care often determines the client's perioperative outcome, and Jamaican nurses strive to meet the challenges inherent in achieving positive outcomes.(AU)

Operative outcome following vaginal hysterectomy

The peri-operative factors surrounding the patient subjected to vaginal hysterectomy were reviewed. Most of the patients were post-menopausal, and the indication for surgery in all cases was utero-vaginal descent. Regional anaesthesia was associated with less blood loss, while lower blood losses were associated with fewer complications and shorter hospitalization. Overall, the morbidity was low (8 percent), and the mortality was zero (AU)

Accurate pre-operative diagnosis of ovarian cancer by a combination of clinical criteria, ultrasonography and CA 125 - abstract

Early pre-operative treatment of ovarian cancer is hindered by a lack of reliable criteria for its early diagnosis. This study was undertaken to assess the value of clinical criteria, ultrasonography and serum CA 125 values in the differential diagnosis of benign and malignant pelvic masses. Thirty-six consecutive patients who had elective surgery for investigation and management of an adnexal mass were enrolled in the study from May to October, 1988. All patients had a clinical examination, serum CA 125 measurement and ultrasound pre-operatively, and their menopausal status determined. Based on these findings, a scoring system was devised (Table). Twenty patients had serum CA 125 values < 35 U/ml and histology confirmed a benign ovarian lesion. The remaining 16 patients had serum CA 125 levels > 35 U/ml, and their tumours were confirmed to be malignant histologically. There were significant differences in age (p<0.01), menopausal status (p=0.01), clinical impression score (p<0.01), ultrasound score (p<0.001) and serum CA 125 level (p<0.001) in patients with benign as compared to malignant lesions. The most useful single diagnostic criterion was serum CA 125 levels, and diagnostic accuracy was increased by adding menopausal status and ultrasound findings (sensitivity > 90 per cent; specificty 95.2 per cent) (AU)

Abdominal hysterectomies at area hospital, Point Fortin, Trinidad, West Indies

A retrospective analysis of abdominal hysterectomies (3.08 percent of major operations) at the Area Hospital (52 beds), over a 5-year period revealed that the majority of the patients were multiparous in the reproductive age group. Menstrual irregularity is the most frequent indication, however, hysterectomy in these cases is not justified. High febrile morbidity (38 percent), blood transfusions and prolonged hospitalization were observed. Peer review, prophlactic antibodies and survey of the Island hospitals are recomended to make hysterectomy approprite, safe and to explain any racial variation.(AU)

The peri-operative management of the patient scheduled for open heart surgery

The perioperative management of 286 patients scheduled for open heart surgery has been described. Mortality associated with anaesthesia (0.4 percent), patient monitoring and measurement (0.4 percent) and cardio-pulmonary bypass (1.4 percent) has been low. Morbidity produced by these techniques has been reversed with supportive therapy. It is concluded that the techniques of anaesthesia, patient monitoring and measurement, and cardiopulmonary by-pass as reported herein are acceptable and safe for the patient undergoing open heart surgery. Operative mortality in the majority (114 patients) age group of 10-20 years has been relatively low (18 percent). However, cardiac failure is dominant as a major cause of early (operative) and late mortality. It is the authors' opinion that technical problems of intracardiac repair and cardio-pulmonary bypass in patients below 5 years, and errors in deciding operability have largely contributed to refractory cardiac failure. It is hoped that more critical selection of patients for operation and greater experience in operative techniques, would result in a decrease in operative deaths (AU)

Prophylactic antibiotics in elective gynaecological and obstetrical major surgery

A prospective controlled study of 580 patients who underwent non-radical major gynaecological or obstetrical surgery examined the use of prophylactic antibiotics. The test group of patients (290) showed a significantly lower (P=0.01) incidence of the total complications and the non-infective complication rate as against those among controls (290). The duration of hospitalisation was significantly reduced for both vaginal and abdominal surgery in the test group of patients as against those in the controls. There was no evidence of increased incidence of bacterial resistance or superinfection. The authors recommend the use of prophylactic antibiotic on a short term basis (for a total duration of 4 days), commencing preoperatively to achieve a significant reduction in the infective postoperative morbidity and a shorter stay by the patients. (AU)

Pathology and treatment of urethral structure and its complications in Jamaica

The pathology and treatment of 66 severe or complicated strictures of the urethra are reviewed. There is little evidence from this series that lymphogranuloma venereum is an important cause of urethral stricture and its complications. The importance of avoiding the formation of false passages with bougies is emphasized. Fistulous tracks fall into definite patterns. A study of these in association with the urethrograms will allow pre-operative assessment of the extent of the lesions, and therefore of the extent of resection likely to be required. The suggestion is made that when unilateral hydronephrosis is present, obstruction at the lower end of the affected ureter is sometimes the result of infection which spread from the prostate gland or which was initiated by the passage of a bougie outside the urethra posterior to the base of the bladder. Patients with long-standing cystitis in association with stricture of the urethra may develop a carcinoma which is usually squamous celled and situated away from the base of the bladder. Impassable strictures and those complicated by fistula and abscess formation are best treated by excision and anastomosis in one stage when short and situated in the bulbo-membranous urethra, and by two-stage excision and reconstruction when long, multiple or in the penile urethra. (Summary)