SPAQI: New Logo, Same Mission, Needed Even More
What would you do if you were seeing a patient in a preoperative clinic a few days before surgery and found out the patient had a recent drug-eluting stent (DES) in one of his coronary arteries and his surgeon told him to stop aspirin and clopidogrel two days ago? This occurred to me recently in our preop center. The nurse practitioner and I could not believe that this still happens in spite of published guidelines. We called the surgeon. He was not aware of the DES and he thanked us for catching this potential problem. Fortunately, the patient had no symptoms of early stent thrombosis. We told him to restart his dual anti-platelet therapy and planned to make arrangements for him to see his cardiologist so a decision could be made between all parties involved as to the appropriate timing of his procedure. This is just one of numerous stories that occur every day in preoperative clinics. Despite knowing the evidence, proper execution does not always occur. There is still a need for improved perioperative communication and care.
SPAQI was formed in 2006 with the goal of bringing together a variety of professionals in various disciplines to work on all facets influencing optimal surgical outcomes. These elements include proper preoperative assessment and evaluation; optimization of pre-surgical status, and appropriate and efficient resource use; integration of proper planning for postoperative pain management; and appropriate use of alternative and complementary medicine techniques. Seven years later, this mission is more important than ever. As information technology infiltrates the delivery of health care, databases are being generated that can be analyzed to develop processes to improve outcomes. Consumers are being put back in charge of their health care by the Affordable Care Act. Our patients need assistance in making decisions about surgery. A team approach is best, as no one specialty knows all. Recently I heard an excellent lecture by a hospitalist on perioperative management of chronic corticosteroids. An anesthesiologist questioned the need for a one-time dose of hydrocortisone in outpatient surgery when patients frequently receive dexamethasone to prevent postoperative nausea/vomiting. The lecturer was unaware how common dexamethasone is given. Currently, SPAQI has over 200 members, most of whom are anesthesiologists or hospitalists/internists with some advanced nurse practitioners, administrators and surgeons.
In the spring, SPAQI cosponsors the Perioperative Medicine Summit. Highlights of this year’s meeting included keynote speaker Marin Makary, M.D. discussing how to improve patient safety and quality, updates on cardiac and pulmonary risk stratification by several experts, and perioperative management of cardiac devices by Marc Rozner, M.D. One of the winning abstracts at the evening poster session was by Jeffrey Frank, M.D. et al. They analyzed the benefits of a new program developed in a community hospital by a multidisciplinary team of physicians for managing hip fracture patients as soon as they arrive in the emergency department (ED). The program included femoral nerve block performed in the ED by anesthesiologists, rapid medical optimization by hospitalists and orthopedic surgeons scheduling surgery within 24 hours. The overall complication rate and length of stay (LOS) were decreased after implementing the program. Three abstracts were orally presented during the meeting. The best oral abstract presentation was by Sunghye Kim, M.D. She and her colleagues investigated the utility of a self-reported mobility assessment tool short form that is filled out by the patient preoperatively. The tool was found to be an efficient and cost-effective way to measure mobility disability in older patients for noncardiac surgery. Their next step is to confirm the relationship with LOS and prediction of morbidity and mortality leading to potential preoperative interventions to improve mobility.
The SPAQI website (www.spaqi.org) has a members-only section that includes several different learning venues. There is a template for starting a preadmission testing center. There are sample screening forms such as a nurse telephone screening form, guidelines for who needs to come to a preop clinic, maximum blood surgical ordering schedule, and sample competency forms for evaluating advanced nurse practitioners. For those who enjoy the feedback of social media, there is a forum where you can ask a question and members can answer. Questions have been as varied as asking if other preop centers screen for sickle cell disease to asking if there is maximum hemoglobin at which you should delay surgery due to increased thrombotic risk. In our summer newsletter, Jessica Booth, M.D. and Angela Edwards, M.D. presented a case of a patient who had anemia and was scheduled for a major operation. They discussed the pros and cons of treating the anemia preoperatively. Bobbie Jean Sweitzer, M.D., SPAQI President, wrote an editorial contending that the focus of preoperative clinics should be the most ill patients for the higher-risk surgeries where the biggest impact on improving morbidity and mortality can occur, not on the patients undergoing the lowest-risk surgeries. Lastly, on the website, there are education materials such as an anesthesiology resident curriculum for preoperative assessment and copies of important published guidelines.
These are some of the examples by which SPAQI tries to share best practices, promote research and provide a pathway for communication. Our next meeting is in conjunction with the 9th Annual Perioperative Medicine Summit to be held February 20-22, 2014 in Scottsdale, Arizona.