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May 1996
Volume 60 |
Number 5
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| The Preoperative
Clinic and Perioperative Medicine |
Noel W. Lawson, M.D.
The Dean of Medicine and Provost of the University of Missouri
granted a change of title to the department of anesthesiology.
It became the Department of Anesthesiology and Perioperative
Medicine on December 1, 1995. The purpose for the new designation
was to redefine the practice of anesthesiology from that of nonphysicians
who administer anesthesia. The anesthesiologist is a physician
consultant with special technical skills as a result of longer
and more involved training. The transformation of the specialty
was publicly acknowledged by the actions of the University of
Missouri.
Perception of the anesthesiologist as a perioperative specialist
signals the maturation of anesthesiology. Maturity is defined
as "perfected by time or natural growth brought by time or
natural process to a complete state of development."
The catalyst that hastened the concept of the "perioperative
physician" was the "holy grail" of cost-containment.
The perioperative period can be divided into three intervals:
1) preoperative, 2) intraoperative, and 3) postoperative. Each
interval has its peculiar labor and costs. Anesthesiologists are
among the few who have the information and involvement to correlate
this triad with patient risk, cost, procedure and outcome.
Surgical services, of which anesthesia has been a font for surgical
progress since 1846, typically accounts for 50 percent of a hospital's
income. The success of the anesthesiologist and the hospital is
inextricably bound together. Economic survival depends upon proper
operating room (O.R.) management, which relies upon patient flow
through the perioperative period. The anesthesiologist, by training
and service, is in a unique position to serve as perioperative
manager as well.
Until recently, our role in the preoperative period was poorly
defined and sometimes was considered a nuisance by the enthusiastic
surgeon. Our burgeoning involvement in the preoperative arena
has closed the loop. This issue was forced by the explosive growth
of outpatient surgery, day-of-surgery admissions, litigation and
denial of payment for presurgical admissions. The traditional
"night before" visit by the anesthesiologist was history.
Clearly, the complexities of modern anesthesia obviated the cumbersome
practice of clearing patients for surgery by physicians other
than anesthesiologists. Third-party payers had shifted the time
and cost of the preoperative workup to the anesthesiologist and
hospital, and the time cost was injected into expensive prime
operating hours. Major economic losses were incurred from delays
or cancellations in the schedule when patients were first seen
at the moment of surgery. This was unacceptable to our patients.
Patients were being placed in peril, and we were losing the competitive
edge.
The choice was to lower standards of care or mutate. Anesthesiology
and the hospital administration made a leap of faith; we mutated
and discovered that Darwinian principles are alive and well -
organisms that vary in the direction favored by the environment
will survive.
Leon Martel, in Mastering Change, describes three common
traps that keep us from recognizing and fostering change: 1) believing
that yesterday's solutions will solve today's problems; 2) assuming
present trends will continue; and 3) neglecting the opportunities
offered by future change.
Preoperative Clinic Offers Balance
The University of Missouri Hospital and Clinics developed a full-service
clinic devoted to the preoperative financial, nursing and medical
preparation of patients for surgery. The clinic was opened in
November 1993. Medical direction is under anesthesiology with
nurse supervision provided by the clinic's administration. An
anesthesiologist or senior resident is in the clinic full-time.
The clinic is purposefully located within the surgical outpatient
clinics and provides precertification, nursing instruction, anesthesiology
examination and clearance. Patients can be scheduled for their
preoperative visit at their leisure any day before their scheduled
surgery or can be seen in the clinic on the same day that a patient
and his or her surgeon have decided upon the procedure. Further
consultation or laboratory examinations can be obtained when necessary.
Choices of anesthesia, consent and postoperative pain management
also are discussed.
If a delay were to occur, it would happen in the clinic rather
than during surgical time on the day of admission. The clinic
is open five days a week from 8 a.m. until 5 p.m. with a goal
of closing by 4 p.m. The byword is "patient friendly."
The majority of the clinic's patients (65 percent) have same-day
surgery or are admitted on the day of surgery. Until the clinic
was opened, the majority of patients were not otherwise available
for preoperative examination until arrival in the O.R. This included
pediatric patients. The opening of the preoperative clinic produced
immediate economic and medical benefits that assuaged many of
the critics who viewed this change as further bureaucratic bloat,
patient hassle or territorial grab.
Approximately 14,000 patients have been seen since opening day.
Fewer than 10 cases have been documented in which surgical delays
or cancellations occurred as a result of preoperative, administrative
or medical misadventures. The clinic has been enormously popular
with patients once they have attended and, unofficially, it has
been pronounced "the equivalent of two Prozac tablets."
The calming effect of the preoperative visit by the anesthesiologist
and nurse was well-established three decades ago but, until recently,
was ignored for "expediency."
In fact, the average time spent for a complete visit, including
waiting time, is 45 minutes, less if the patient and procedure
are low-risk and if no laboratory work is required. That time
represents 45 minutes per patient that was added back to prime
operating time. This translated into an additional 10 to 20 hours
of available surgical time per day that was formerly expended
in preoperative assessment. This is the equivalent of adding two
operating rooms. The O.R. schedule has accommodated a 12-percent
increase in case load for each of the first two years of the clinic's
operation without increasing full-time equivalents or overtime.
A savings of $250,000 was recognized in the first year by reducing
unnecessary and duplicate laboratory tests. Overall, the hospital
appreciated a significant increase in profit, of which 47 percent
flowed from the surgical services, between 1994 and 1995. The
clinic also has become a source of autonomy and patient flow for
the anesthesiology department in referrals for outpatient consultation
and inpatient consultation that includes high-risk pregnancies.
The preoperative clinic also serves as a source of referral to
other services in which consultation and further workup before
surgery is appropriate as determined by the surgeon and anesthesiologist.
We established a bridgehead as consultant-level physicians.
Grassroots attitudes toward the anesthesiologist by patients and
colleagues also have changed noticeably. We are no longer the
silent service cloistered in cold, tiled rooms out of sight and
mind, awaiting the tides of the schedule. We can commiserate with
the surgeons' problems in clinic management and scheduling. Consults
and case discussions are taken more seriously. We are a direct
influence in hospital management and the operating room.
Patients, too, are being influenced and educated, requesting "the
doctor that examined me in the clinic." Some elective cases
have been scheduled according to the availability of their selected
anesthesiologist. The improved patient perception of us as physicians
also is being discovered by residents when patient rapport is
established while dressed in appropriate civilian mufti. There
is no place for the proletariat fashion of dirty scrubs or rumpled
white coats in the preoperative clinic. There is only one chance
to make a good first impression.
Economics aside, this author further suggests that, in part, the
University of Missouri Dean of Medicine and Provost's enthusiastic
support in approving our request to add "perioperative medicine"
to our title was related to the performance of the preoperative
clinic in the context of hospital management. The Dean is a practicing
cardiothoracic surgeon as well as the chief executive officer
of the hospital.
This author began training at a time when anesthesiologists were
mostly confined to the O.R. Internists cleared the patients for
surgery. Surgeons protected their patients from us in the postoperative
period. Our medical training and expertise were being underutilized.
There are those today who maintain this carbon-dated attitude
while ignoring the conspicuous advances made by physicians in
the field of anesthesiology in the past three decades.
Technology has helped to release the anesthesiologist from the
O.R., but there is no intent to abdicate technical or medical
responsibility in the O.R. Progress has directed our conversion
from traditionalist to expansionist, for which there remains a
minor rift today. We must continue to make discriminating decisions
in areas that only we can make as physicians, such as the preoperative
clinic, O.R., postanesthesia care unit, intensive care unit or
pain clinic.
Drugs and anesthesia techniques are becoming safer, such that
we can rely more on technicians in the future to assist in the
demand for service while offering perioperative expertise. We
must learn to let go and delegate those nonmedical activities
that can be done by others at lower cost. This is the heart of
the team concept.
However, this expediency will not forsake safety provided that
there is physician oversight throughout the perioperative period.
The administration of an anesthetic is often the least taxing
part of patient care once patients are properly prepared and postoperative
problems are anticipated, including pain management. This is the
practice of perioperative medicine. The importance of defining
our niche is important to our growth.
"The professional and the technician have in common an expertise
not possessed by the layman, but the professional has undergone
a much longer period of preparation and knows much more than the
technician. The professional is capable of applying this knowledge
to a great variety of unforeseen problems, while the technician
does it in a routine manner and follows the instructions of the
professional. Though a clever technician may make small improvements
in techniques, fundamental advances in technology are almost without
exception, the work of professional people."
-Admiral H.G. Rickover
in Education and Freedom
Perioperative Workshop
The ASA Workshop on Perioperative Assessment and Management will
be held at the Marriott Pavilion Hotel in St. Louis, Missouri,
on November 16-17, 1996. The program has been designed for practitioners
who evaluate and care for surgical patients during the pre-, intra-
and postoperative periods.
Sessions will be devoted to preoperative risk assessment, focusing
on specific disease entities and selection of appropriate laboratory
testing, primarily of noncritical care patients. The impact of
value-based anesthesia care on the intraoperative and postanesthesia
periods will be discussed. Sessions will also highlight the skills
needed for operating room leadership and for the development of
administrative and managerial expertise necessary to promote the
anesthesiologist's role as a perioperative physician.
Registration forms for this meeting will be mailed in mid-May.
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