Implementation of outpatient preoperative evaluation clinics: facilitating and limiting factors.

BACKGROUND: Several studies have shown that outpatient preoperative evaluation by anaesthetists increases quality of care and is cost-effective. The aim of this study was to gain insight into the factors that positively or negatively influence the implementation of outpatient preoperative evaluation clinics (OPE clinics). METHODS: After an extensive literature study and pilot interviews, we constructed written questionnaires that were sent to all Dutch hospitals. The respondents were members of the board of directors, members of the medical staff, anaesthetists, internists, and surgeons. RESULTS: Cooperation of anaesthetists was most frequently mentioned as facilitating factor for implementation of an OPE clinic across all medical specialists interviewed. Lack of finance was most frequently reported as limiting factor in all categories of hospitals (with a complete, partial, or no OPE clinic), but it was significantly more often reported in hospitals without OPE clinic (P<0.01). Perceived benefits and disadvantages, financial rewarding system, and organizational structure played a clear role in the implementation of OPE clinics. CONCLUSIONS: A variety of factors play a role in the implementation of an OPE clinic. Besides the more obvious ones, such as financing and cooperation of the professional groups involved, underlying factors, such as perceptions of the professionals involved, were found to be related to implementation of an OPE clinic. These underlying factors explain differences between different kinds of hospitals and between professional groups, regarding their resources and motivation to implement an OPE clinic.

The effect of national guidelines on the implementation of outpatient preoperative evaluation clinics in Dutch hospitals.

BACKGROUND AND OBJECTIVES: Preoperative evaluation performed by anaesthesiologists primarily aims to estimate the risk of perioperative complications and to create opportunities to optimize the patients' condition before surgery. In this study an inventory was made of the current practice of preoperative evaluation in Dutch hospitals. It was estimated how many hospitals had implemented an outpatient preoperative evaluation clinic in 2004. Subsequently, current practice was compared with the results of a previous inventory (2000). It was also evaluated to what extent the guidelines of the Dutch Health Council and the Netherlands Society of Anaesthesiology were followed. METHODS: The study consisted of two phases. First, a literature research was performed and pilot interviews were constructed. The interviews were conducted face-to-face with anaesthesiologists in a sample of Dutch hospitals. Based on the results, written questionnaires were constructed. In the second phase these questionnaires were sent to all general and academic hospitals in the Netherlands. RESULTS: In 2004, 74% of the hospitals had an outpatient preoperative evaluation clinic, compared with 50% in 2000. The percentage of hospitals with an outpatient preoperative evaluation clinic available for all elective patients increased from 20% to 52%. CONCLUSIONS: The Dutch guidelines on preoperative evaluation seem to have influenced current practice. An increase in the number of outpatient preoperative evaluation clinics was seen after the guidelines were published. The implementation of an outpatient preoperative clinic seems to warrant that anaesthesiologists are carrying out the activities prescribed by the guidelines. Most hospitals without a clinic aim to implement one in the future.

Pre-operative detection of valvular heart disease by anaesthetists.

We prospectively estimated the prevalence of heart murmurs in 2522 consecutive adult non-cardiac surgery patients during pre-operative evaluation. Factors that contribute to the detection of a heart murmur were identified, and echocardiography was used to evaluate to what extent a murmur reflected presence of valvular heart disease. A cardiac murmur was detected in 106 patients (prevalence 4.2%, 95% CI: 3.5-5.1%). Multivariable logistic regression analyses showed that age and general physical impression were independently associated with detecting a murmur (p-values < 0.01). In 83 (79%) of the patients with a murmur, an echocardiographic diagnosis was available: 39% had aortic valve abnormalities, 24% had mitral valve regurgitation, 7% had other valvular heart disease and 30% did not have any abnormality. Thus, 58 of the 83 patients had valvular heart disease (positive predictive value using routine cardiac auscultation for diagnosing VHD: 70%, 95% CI: 59-79%). Murmurs in patients younger than 40 years never reflected valvular heart disease. Pre-operative cardiac auscultation seems only reasonable in patients aged 40 years or older. Subsequent echocardiography in these selected patients is necessary.

Role of history and physical examination in preoperative evaluation.

BACKGROUND AND OBJECTIVE: Since reports have shown that outpatient preoperative evaluation increases the quality of care and cost-effectiveness, an increasing number of patients are being evaluated purely on an outpatient basis. To improve cost-effectiveness, it would be appealing if those patients who are healthy and ready for surgery without additional testing could be easily distinguished from those who require more extensive evaluation. This paper examines whether published studies provide sufficient data to determine how detailed preoperative history taking and physical examination need to be in order to assess the health of surgical patients and to meet the objective of easy and early distinction. METHODS: A MEDLINE search was conducted from 1991 to 2000 with respect to preoperative patient history and physical examination. Altogether, 213 articles were found, of which 29 were selected. Additionally, 38 cross-references, 7 articles on additional testing and 4 recently published papers were used. RESULTS: It is questionable to what extent an extensive history is relevant for anaesthesia and long-term prognosis. With respect to physical examination, it seems unreasonable to diagnose valvular heart disease based on cardiac auscultation only, and it is unclear which method should be used to predict the difficulty of endotracheal intubation. The benefits of routine testing for all surgical patients before operation are extremely limited and are not advocated. CONCLUSIONS: The amount of detail of preoperative patient history and the value of physical examination to obtain a reasonable estimate of perioperative risk remains unclear. Although not evidence based, a thorough history taking and physical examination of all patients before surgery seems important until more evidence-based guidelines become available. Diagnostic and prognostic prediction studies may provide this necessary evidence.

Validation of a clinical prediction rule to reduce preoperative type and screen procedures.

BACKGROUND: We have developed a prediction rule for the occurrence of perioperative red blood cell transfusion to help to reduce the number of unnecessary preoperative type and screen procedures. We evaluated the robustness of this prediction rule in patients from another hospital. METHODS: The rule was retrospectively applied to 1282 consecutive patients ('validation set') who underwent similar surgical procedures to the patients in the derivation study. The outcome was similarly defined as any allogeneic transfusion on the day of surgery or during the first postoperative day. The predictive value of the rule was assessed using a Receiver Operating Characteristic curve (ROC) and compared with the results of the derivation study. Subsequently, the number of correctly predicted transfusions was compared. RESULTS: The patient characteristics did not differ between the two sets, except for the incidence of transfusion (derivation study: 18%; present study: 8%). In the validation set, the ROC area of the prediction rule was 0.78 (95% confidence intervals [CI]: 0.73-0.82), which was within the CI of the ROC area found in the derivation study (0.75; 95% CI: 0.72-0.79). In total, 35% of the type and screen procedures could be omitted (derivation study: 50%), with 13% missed transfused patients (derivation study: 20%). CONCLUSIONS: After comparing the results of this validation study with that of the derivation study, the prediction rule was robust and may work in other clinics as well.

[Short preoperative health assessment proposed by the Health Council not useful in clinical practice]. / De korte preoperatieve gezondheidsbeoordeling zoals voorgesteld door de Gezondheidsraad in de praktijk niet bruikbaar.

OBJECTIVE: To evaluate the value of the short questionnaire drawn up by the Dutch Health Council for the classification of patients to an ASA class (a 5-point scale according to the American Society of Anesthesiologists, on which the patient's preoperative physical condition can be scored) and to propose an anaesthesia care plan for surgery patients aged between 16 to 40 years old. DESIGN: Observational. METHODS: From June 1999 through to May 2000, all 2090 preoperative patients aged 16 to 40 years at the academic hospital of Utrecht, the Netherlands, were asked to complete the Dutch Health Council's short questionnaire. In addition, the usual extensive preoperative health assessment was carried out on these patients. Of the 379 (18%) who were found by the short questionnaire to be 'healthy', 100 were selected. A panel of 10 anaesthesiologists was asked to preoperatively evaluate these 100 patients twice: once using the short questionnaire and once using the usual extensive health evaluation. The primary outcome was the percentage of patients who could be classified to an ASA class and for whom an anaesthesia care plan could be drawn up. The secondary outcome was the information judged by the anaesthesiologists to be either 'redundant' or 'missing' when drawing up an anaesthesia care plan. RESULTS: Using the short questionnaire, 63% of the patients could not be assigned to an ASA class, compared to 22% with the extensive health evaluation (p < 0.0001). On the basis of the information obtained with the short questionnaire, it was not possible to draw up an anaesthesia care plan for any of the patients, while the extensive health evaluation enabled an anaesthesia care plan to be drawn up for 65% of the patients (95% CI: 62-68%). Using the missing information deemed 'necessary', recommendations were made for the minimum scope of a preoperative health assessment for use in patients aged 16 to 40 years old. CONCLUSION: The short questionnaire as proposed by the Dutch Health Council was not found to be useful in practice.

A reduction in type and screen: preoperative prediction of RBC transfusions in surgery procedures with intermediate transfusion risks.

In many patients, a 'type and screen' procedure is routinely performed before surgery. However, most patients are not transfused after all. Can we predict, which surgical patients will and will not be transfused, to reduce the number of these investigations? We studied 1482 consecutive surgical patients with intermediate risk for transfusion. Multivariate logistic regression modelling and the area under the Receiver Operating Characteristic curve (ROC area) were used to quantify how well age, gender, surgical procedure, emergency or elective surgery and anaesthetic technique predicted transfusion, and whether the preoperative haemoglobin concentration had added predictive value. Gender, age > or =70 yr, and type of surgery were independent predictors of transfusion, with a ROC area of 0.75 (95% CI: 0.72-0.79). Validating this model with an easily used prediction rule in a second patient population yielded a ROC area of 0.70 (95% CI: 0.63-0.77). With this rule type and screen could correctly be withheld in 35% of these patients. In the remaining 65% of the patients, a further reduction in type and screen investigations of 15% could be achieved using the preoperative haemoglobin concentration. Using a simple prediction rule, preoperative type and screen investigations in patients who have to undergo surgery procedures with intermediate transfusion risk can be avoided in about 50%. This may reduce patient burden and hospital costs (on average: 3 million US$ per 100 000 procedures).

[Limited effect of Health Council guideline on outpatient preoperative evaluation clinics in the Netherlands: an inventory]. / Gering effect van Gezondheidsraadrichtlijn over preoperatieve poliklinieken in Nederland; een inventariserend onderzoek.

OBJECTIVE: To investigate the current status of preoperative evaluation in the Netherlands and the implementation of the Health Council recommendations. DESIGN: Cross-sectional study. METHOD: All Dutch anaesthesiologic partnerships and their hospital managers in February 2000 received a structured questionnaire about the existence of an outpatient evaluation clinic, possible problems in creating such a clinic and the contents of preoperative evaluation. RESULTS: We received responses of 101 (80%) and 111 (87%) from anaesthesiologists and managers, respectively. From 119 hospitals (94%) we received at least one useful questionnaire. On January 1, 2000, 24 (20%) hospitals had a complete and 36 (30%) a partial outpatient clinic. Within one year, 44% of the hospitals without a preoperative outpatient clinic expected to create one. The most common problem concerned financing this clinic. In hospitals with a complete clinic, anaesthesiologists were more often in employment (odds ratio (OR): 2.5; 95% confidence interval (95% CI): 1.0-10.0) and a routinely performed physical examination by the anaesthesiologist (or under his or her responsibility) was also conducted more often (OR: 5.0; 95% CI: 1.6-15.0). Not every patient saw an anaesthesiologist before entering the operating room in 70% of all hospitals. In hospitals without outpatient clinic, 57% of the day-surgery patients contacted the anaesthesiologist in the operating room. CONCLUSION: The recommendations of the Health Council of the Netherlands with respect to contents and organisation of the preoperative evaluation had, 3 years after being published, limited effect.

[Preoperative outpatient evaluation of young adults by anesthesiologist: anamnesis and physical examination are satisfactory--short questionnaire of Dutch Public Health Council is not]. / Poliklinisch preoperatief onderzoek door de anesthesioloog bij jonge volwassenen: anamnese en lichamelijk onderzoek volstaan, de korte vragenlijst van de Gezondheidsraad niet.

The report of the Netherlands Health Council 'Preoperatief onderzoek; een herijking van uitgangspunten' recommends that the health status of patients aged 16-39 years can be investigated preoperatively by the anaesthesiologist using a short questionnaire (6 questions). However, it is not clear whether such an abbreviated preoperative investigation will be informative enough for a safe and balanced anaesthesiologic management. An overview of relevant literature on the subject of preoperative investigation indicates that the preoperative physical status of patients as reflected by the American Society of Anesthesiologists (ASA) classification is a predictor of perioperative complications. Patients can be classified accordingly on the basis of an extended history and physical examination only: any routine additional investigation, such as ECG, chest X-ray or laboratory investigations, seem superfluous. Only blood group, rhesus factor and the presence of irregular antibodies may need to be determined if indicated by the kind of surgery. Currently, however, there is not sufficient evidence to demonstrate that the short questionnaire of the Netherlands Health Council is informative enough.

[Link between indication for cesarean section and need for resuscitation of the neonate]. / Samenhang tussen indicatie voor sectio caesarea en noodzaak van reanimatie van de neonatus.

OBJECTIVE: To study the relationship between the indication for caesarean section (CS) and the need for resuscitation of the infant. DESIGN: Prospective cohort study. METHODS: During one year the following information was collected for each CS in a secondary teaching hospital (Isala klinieken/Weezenlanden Hospital), Zwolle, the Netherlands: indication for the CS, Apgar scores after 1 and 5 min and measures taken by the attending paediatrician at birth. These measures were divided into two groups: resuscitation (bag and mask ventilation or endotracheal intubation and ventilation) or no resuscitation (stimulation, supplemental oxygen, or no action at all). RESULTS: During the study year 202 CS were carried out. In the 50 CS carried out because of a narrow pelvis or a previous CS and in the 61 CS carried out for non-progressive labour there was little need for resuscitation of the newborn (4 and 3.3%, respectively), similar to resuscitation requirements after vaginal birth. The need for resuscitation of the newborn was significantly greater in the other indication groups, namely in 6/37 (16%) of cases of foetal malposition, in 3/10 (30%) of placental dysfunction, and in 11/44 (25%) of foetal distress. One infant had to be intubated directly after birth. The 1-minute Apgar score was lower in infants born after CS under general anaesthesia than under spinal anaesthesia (p = 0.002), regardless of the indication for the CS. CONCLUSION: Based on the indication for a CS, a paediatrician or physician experienced in neonatal resuscitation is required for a high-risk CS (foetal malposition, placental dysfunction, foetal distress, and general anaesthesia).

[Outpatient preoperative examination by the anesthesiologist. I. Fewer procedures and preoperative hospital days]. / Het poliklinische preoperatieve onderzoek door de anesthesioloog. I. Minder verrichtingen en preoperatieve opnamedagen.

OBJECTIVE: To study the effect of the reorganisation of the preoperative screening on the volume of laboratory and function tests, and on preoperative hospital days. SETTING: General Hospital De Weezenlanden, Zwolle, The Netherlands. DESIGN: Retrospective study. METHOD: In The Netherlands the surgeon is responsible for the preoperative screening (anamnesis and general examination). In 1992 the preoperative screening was reorganised and it was carried out in the outpatient department under the responsibility of the anaesthesiologist. Laboratory and function tests were only performed if indicated. Data on 3122 patients, operated in 1991, were compared with the data on 3258 patients from 1992. Multiple regression analysis and chi-square test were used. RESULTS: The proportions of the patients subjected to laboratory tests, ECG or a chest X-ray decreased from 90%, 55%, and 50% respectively in 1991 to 53%, 43% and 10% in 1992 (p < 0.05). Admission on the day of surgery increased from 13% in 1991 to 21% in 1992 (p < 0.01). Clinical preoperative evaluation with admission more than 1 day before surgery, decreased from 5% in 1991 to 4% in 1992 (p = 0.02). The mean duration of the hospital stay before the operation decreased from 0.79 day per patient in 1991 to 0.65 in 1992 (p = 0.02). CONCLUSION: If the preoperative screening is carried out by the anaesthesiologist, all the patients have the opportunity to meet the anaesthesiologist before the operation. The number of preoperative hospital days can be reduced by outpatient preoperative screening. Laboratory and function testing on only if indicated reduces the volume of the laboratory tests, ECGs and chest X-rays.

[Outpatient preoperative examination by the anesthesiologist. II. Patient satisfaction]. / Het poliklinische preoperatieve onderzoek door de anesthesioloog. II. Tevredenheid bij patiënten.

OBJECTIVE: To determine patient satisfaction after the reorganisation of the preoperative screening. SETTING: General Hospital De Weezenlanden, Zwolle, The Netherlands. DESIGN: Retrospective patient interview. METHOD: Before the reorganisation, the preoperative screening was performed clinically under the responsibility of the consultant surgeon. Thereafter it was performed in the outpatient department by the anaesthesiologist. Patients who had had two similar operations within two and a half years, one before and one after the reorganisation, were interviewed at home regarding the different methods of preoperative screening (n = 94). RESULTS: The preoperative screening had a reassuring effect on patients. 72% considered preoperative anaesthesia information important. The number of hospital visits before the operation did not significantly increase after the screening was reorganised. There was little objection to attending the hospital for preoperative screening (12%). Most patients (60%) had no preference for the previous or the present method of screening. Patients who remembered the interview with the anaesthesiologist (56%) preferred the new method (score: 8.2 on a scale 0-10; score of the former method: 7.6; p < 0.01). A larger number of these had the opportunity to ask questions (p = 0.01) and more patients had received attention from the anaesthesiologist (p < 0.01). 75% of the patients had received sufficient preoperative anaesthesia information. 28% of the patients wanted to see the anaesthesiologist again after admission. CONCLUSIONS: Preoperative screening reassures and informs the patient. The patients who could remember the interview with the anaesthesiologist preferred the preoperative screening in the outpatient department. A considerable number of the patients wanted to see the anaesthesiologist again after admission.

Propofol for induction and maintenance of anaesthesia: comparison between younger and older patients.

The propofol requirements for the induction and maintenance of anaesthesia were compared in groups of younger and older patients. Side effects, influence on the cardiovascular system and recovery times were compared between 20 unpremedicated ASA I-III, 25-40-yr-old patients and 20 65-80-yr-old patients all scheduled to undergo elective surgery. After induction with propofol, anaesthesia was maintained with a continuous infusion of the drug. Vecuronium and fentanyl were administered as required. In the young group propofol 2.2 mg kg-1 and in the elderly 1.7 mg kg-1 were needed for induction (P less than 0.05). The maintenance doses were 10.0 mg kg-1 h-1 and 8.6 mg kg-1 h-1, respectively (P less than 0.01). Side effects were more pronounced in the younger patients. Influences on the cardiovascular system were definite, but mild. The younger patients awoke sooner: 7.8 v. 14.3 min (P less than 0.01) after the discontinuation of the infusion of propofol.

The comparative neuromuscular blocking effects of some aminoglycoside antibiotics.

The neuromuscular blocking effects of aminoglycoside antibiotics were tested in the isolated phrenic nervediaphragm preparation of the rat. The neuromuscular blocking potencies were netilmicin equals sisomicin much greater than neomycin much greater than gentamicin much greater than tobramycin. The EC 50's (concentration resulting in 50 percent depression of the original twitch tension) were respectively 13.3 x 10(-4); 13.4 x 10(-4); 13.6 x 10(-4); 15.1 x 10(-4); and 95.3 x 10(-4) Mol/l for netilmicin, sisomicin, neomycin, gentamicin and tobramycin. When a threshold dose of pancuronium was added to the bathing fluid the EC 50's were diminished respectively by a factor of 0.4 (sisomicin and neomycin) 0.5 (tobramycin) and 0.6 (netilmicin and gentamicin). Addition of a threshold dose of Org-NC45, a new steroidal non-depolarizing muscle relaxant, diminished the EC 50's to the same extent. The neuromuscular blocking effects of pancuronium and Org-NC45 themselves were potentiated by pretreatment of the preparations with a threshold dose of the aminoglycoside. Comparison of the results demonstrated the following potentiating effects: netilmicin equals sisomicin much greater than neomycin much greater than gentamicin greater than tobramycin. Which is in the same sequence s the neuromuscular blocking potencies of these drugs.