|Year : 2018 | Volume
| Issue : 1 | Page : 1-5
Could preanesthesia assessment clinics be of benefit in modern anesthetic practice in Nigeria?
Saidu Yusuf Yakubu
Department of Anaesthesia, ABU Teaching Hospital, Shika-Zaria, Nigeria
|Date of Web Publication||20-Jun-2018|
Dr. Saidu Yusuf Yakubu
Department of Anaesthesia, ABU Teaching Hospital, P. O. Box 154 (Yakubu Gowon Way Kaduna), Shika-Zaria
Preanesthesia assessment is the process of clinical evaluation conducted before anesthetic care. The benefits of outpatient preoperative assessment clinics were discovered and exploited in the developed world for more than 68 years. Surprisingly, these clinics have not been set up and used in Nigeria for the care of surgical patients. A review of operation records in a tertiary healthcare facility over an 18-month period revealed that about 35% of elective surgical cases were cancelled weekly due to reasons ranging from lack of power to lack of sterile gowns, lack of water, and the inadequate preparation of patients among others. Of these, the inadequate preparation of surgical patients accounted for one out of every five elective cases cancelled. These cancellation rates were high. Currently, preanesthesia assessment is routinely performed in the evening of the day preceding planned surgery. This does not allow sufficient time to fully optimize patients with preexisting morbid conditions such as diabetes mellitus, hypertension, thyroid disease, and other chronic illnesses, some of which may require specialist consultation. The pilot study also revealed that relevant investigations ordered by the anesthetists were not usually performed due to the short notice, which resulted in the cancellation of the planned surgery. This article reviewed relevant journals on the structure and benefits of preanesthesia assessment clinics with a view of determining whether the establishment of such clinics could address these shortcomings in surgical care delivery.
Keywords: Anesthetic practice, assessment, benefit, clinics, preanesthesia
|How to cite this article:|
Yakubu SY. Could preanesthesia assessment clinics be of benefit in modern anesthetic practice in Nigeria?. Sub-Saharan Afr J Med 2018;5:1-5
|How to cite this URL:|
Yakubu SY. Could preanesthesia assessment clinics be of benefit in modern anesthetic practice in Nigeria?. Sub-Saharan Afr J Med [serial online] 2018 [cited 2019 Jan 16];5:1-5. Available from: http://www.ssajm.org/text.asp?2018/5/1/1/234759
| INTRODUCTION/BACKGROUND|| |
The goal of every surgical procedure is to cure the patient of his/her ailment with minimal or no resultant complications. To accomplish this goal, anesthetists endeavor to assess the risk of anesthesia to the patient preoperatively and to institute measures to optimize the patient’s chances of having a favorable postoperative outcome.
In recent times, several systems and processes have been adopted in the preparation of patients for elective surgery. These processes vary depending on the facilities available to the particular health system, but there is a general consensus that it is necessary to maximize patient’s safety and improve the outcome of anesthesia and surgery. Thus, in the developed world, anesthesia preoperative assessment clinics (PACs) are an essential part of the perioperative pathway and have been shown to significantly reduce mortality.,, The current practice in this part of the world is that a surgeon decides on when to operate and a list is made and sent to the anesthetist a day before surgery. The anesthetist tries to review the patient and order some relevant additional investigations. This does not give sufficient time to evaluate and manage some patients with comorbidities. This practice has led to a high rate of day-of-surgery delay and the cancellation of cases.
Preanesthesia assessment is the process of clinical evaluation conducted before anesthesia care.
It comprises a visit to the patient, history taking, a review of medical, surgical, and anesthesia records, an examination of the patient, a review of current medication use and the results of investigations, and an attempt to allay patient’s anxiety about the planned surgical procedure. It provides an opportunity for the anesthetist to spot any dangers preoperatively, which might give rise to critical incidents intra- and postoperatively.
Preoperative assessment increases efficiency and improves patient satisfaction by decreasing the number of day-of-surgery cancellations and streamlining investigations.,,, Studies have also shown that outpatient preoperative assessment by anesthetists increases the quality of care and is cost-effective.
Despite these perceived benefits of preanesthesia clinics, a search of the literature did not reveal any hospital in Nigeria that operates PAC. Korle Bu Teaching Hospital, Accra, Ghana; Aga Khan University Hospital, Nairobi, Kenya; Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; and Jimma University Specialized Hospital in Ethiopia run PACs and have reported on their usefulness.
This study undertook a review of the literature to ascertain the structure and benefits, if any, of PAC with a view to recommending its use as a part of perioperative patient care.
| Materials and methods|| |
Existing literature was searched using Google Scholar. Relevant studies on PAC were selected for review. A total of 50 articles were reviewed to determine how PACs were run and what benefits accrued to the patients and hospitals as a result of operating preanesthesia clinics.
| Results|| |
Admission criteria of the clinic/structure
Patients presented at the PAC either on a referral basis or as a mandatory visit at a suitable time interval prior to their scheduled surgery. The surgeon was responsible for referring suitable patients to the PAC when he/she determined that there was need for thorough anesthesia review to fully optimize the patient’s condition prior to surgery.
The referred patient was received by a staff nurse, who administered a questionnaire to him/her before being seen by the medical officer. All patients with complex comorbidities were referred to the consultant anesthetist for further review and possible referral to other specialists if necessary. Essential team members included anesthetists, surgeons, physicians, and general practitioners. Specialist anesthetic preoperative assessment nurses have been shown to be safe and effective at preoperative screening and should be an integral part of the team. Equipment and infrastructural needs included at least two consulting rooms, a side laboratory, and a waiting room with all the necessary equipment and furnishings. PAC was either situated near the theatre complex or in the surgical clinics, and visits by patients were planned to coincide with clinic days.
Timing and staffing
Preanesthesia assessment was conducted either days or minutes before surgery and on an outpatient or inpatient basis. In the practice advisory on preanesthesia evaluation developed by the American Society of Anesthesiologists (ASA) Task Force on preanesthesia evaluation, it was recommended that preanesthesia evaluations be performed prior to the day of surgery for patients with a high severity of disease and/or undergoing the procedures of high surgical invasiveness.
The minimum staffing for PAC was one consultant anesthetist, one resident doctor/medical officer, two staff nurses, one clerk, and one attendant.
Benefits of outpatient PACs
Reduction in day-of-surgery delay or cancellation.
Reduction in the length of hospital stay.
Reduction in the rate of surgical complications.
Reduction in costs.
Increase in patient satisfaction regarding anesthesia and a reduction of anxiety.
Reduction in excessive preoperative testing.
Reduction in the use of costly subspecialty consults without affecting patient outcome.
Improvement in the efficiency of theatre room.
The most common limiting factors for the implementation of PAC were a lack of finance and a shortage of anesthetists to run the clinic.
| Discussion|| |
The primary advantage of a PAC is to provide a comprehensive anesthesia service for surgeons and their presurgical patients in one centralized location. The current structure in Nigeria regarding preanesthesia assessment a day before surgery does not satisfy the requirements of an outpatient assessment clinic. There are several reasons why the outpatient evaluation of surgical patients is not implemented. Among them are the lack of referral by the surgeons, an inadequate number of physician anesthetists, and the lack of physical space.
Preanesthesia assessments were conducted either days or minutes before surgery and on an outpatient or inpatient basis. In the practice advisory on preanesthesia evaluation developed by the ASA Task Force on preanesthesia evaluation, it was recommended that preanesthesia evaluations be performed prior to the day of surgery for patients with a high severity of disease and/or undergoing the procedures of high surgical invasiveness. The minimum staffing for PAC was one consultant anesthetist, one resident doctor/medical officer, two staff nurses, one clerk, and one attendant.
It has been suggested that PACs directed by anesthetists are more cost-effective, in part due to cost-efficient practices in preoperative testing.
A medical director of the PAC is responsible for policy administration, service development, and quality assurance. In most PACs, this director is an anesthetist. Increasing patient satisfaction through efficient practice is an appropriate objective of a healthcare system. A high cancellation rate for elective surgical procedures makes it difficult to accomplish this. Cancellation reduces operating room efficiency and increases costs., In definitions used by a number of articles, cancellations are considered to be any operation that appears in the operation list but is not performed.,
The provision of surgery by institutions requires both material and human resources, and the cancellations of elective surgery are a huge loss of revenue and scarce resources. Increasingly, the already extensive waiting lists have to accommodate the burden of cancelled operations.
The rate of cancellation for elective surgeries on the day of operation has been documented to be between 5 and 40%., The variety of reasons for cancellations between different institutions and different countries are due to factors such as differences in implementation policies, which explains the high number of cancellations in medically unfit patients in hospitals without preanesthesia assessment clinics. Several studies have demonstrated reduction in the number of cancelled surgeries and preoperative investigations following outpatient preanesthesia assessment.
In the outpatient assessment, there is more time to evaluate the patient and treat his/her coexisting diseases before the planned operation. The improvement in medical condition will help reduce the number of operations cancelled.
Reduction in the length of hospital stay was another perceived benefit of a PAC. Wijesundera et al. retrospectively evaluated patients aged 40 years and older who had major surgeries and found that routine anesthesia consultations significantly reduced the days of inpatient hospitalization, which hospitals can use as an advantage to reduce costs for inpatient care, to schedule more surgical procedures, or to use the hospital beds for other nonsurgical patients.
Furthermore, preanesthesia assessment clinics help to reduce the rate of surgical complications. Caplan et al. reported a 70% reduction in the rate of surgical wound infection from 16.3 to 5% when the hospitals’ elective surgical service was reengineered to include outpatient preoperative assessment and same-day surgery.
The outpatient preanesthetic assessment is an outcome of the need to increase the frequency of outpatient surgeries or to hospitalize the patient on the same day of the surgery justified by cost reduction. The implementation of an outpatient assessment clinic in a public institution could lead to a substantial reduction in costs, which has already been shown by several studies.,
PAC results in a reduction in excessive preoperative testing. It has been estimated that 60–75% of preoperative tests ordered are medically unnecessary, and they only add to the cost and delay of the procedure, as well as patients’ inconvenience and discomfort., A recent report from Europe suggested that although preoperative testing commonly deviated from recognized guidelines, the potential savings if all patients would be tested appropriately were approximately €26 per patient.
Residency training: The training in preanesthetic assessment during the residency program has been considered fundamental to change the negative attitude of anesthesiologists regarding preanesthetic assessment. Because University Teaching Hospitals are responsible for training most of the surgical workforce, the implementation of high-quality anesthetic/surgical services should be an integral part of such training. This will help produce anesthetists who are willing to set up and run PACs in their hospitals and organizations. Improvement in the theatre room efficiency: PACs have been found to improve the performance of theatre rooms. Preoperative assessment by anesthetists to obtain full information on the previous medical history, physical exam, investigations, and medications a patient is taking or has taken enables a full evaluation. The optimization of preexisting or recently diagnosed medical conditions plays a major role in reducing cancellations and delays on the day of surgery.
The most common limiting factors for the implementation of PAC were a lack of finance and a shortage of anesthetists to run the clinic. Lack of finance is a frequently reported problem with respect to the implementation of innovations in healthcare., Lemmens et al. found in their study on the effect of guidelines on the implementation of PACs a significant increase in assessment clinics between the years 2000 and 2004 in Dutch hospitals. They also found that there were efforts to set up the clinics in hospitals without one.
| Conclusion|| |
When preanesthesia assessment clinics are set up in public tertiary hospitals in Nigeria, they could be of immense benefits to the patients, surgeons, and anesthetists. They could also improve the performance and efficiency of surgical patient care just like what is obtainable in the developed world. With cooperation between anesthetists, surgeons, and other professional groups, the issue of lack of funds can be easily bypassed and a modified PAC implemented, whereby only high-risk patients are referred to the clinic. In view of the above, it is possible for the Nigerian healthcare system to operate a modified version of PAC.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lee A, Kerridge RK, Chui PT, Chiu CH, Gin T. Perioperative systems as a quality model of perioperative medicine and surgical care. Health Policy 2011;102:214-22.
The Association of Anaesthetists of Great Britain and Ireland (AAGBI). Pre-operative Assessment and Patient Preparation: The Role of the Anaesthetist. 2nd
ed. London: AAGBI; 2010.
Halaszynski TM, Juda R, Silverman DG. Optimizing post-operative outcomes with efficient preoperative assessment and management. Crit Care Med 2004;32:S76-86.
Kerridge R. Changing the preoperative process: A review of the evidence. In: Radford M, Williamson A, Evans C, editors. Pre-Operative Assessment and Perioperative Management. Cumbria: M&K Update Ltd; 2011. p. 319-34.
American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice advisory for preanesthesia evaluation. Anesthesiology 2002;96:485-96.
Lew E, Pavlin DJ, Amundsen L. Outpatient preanaesthesia evaluation clinics. Singap Med J 2004;45:509-16.
Ravindra P, Fitzgerald E. Surgical preoperative assessment: What to do and why. Stud Br Med J 2012;20:d 7816.
NHS Modernisation Agency. National Good Practice Guidance on Pre-Operative Assessment for Inpatients having Surgery: Operating Theatres and Pre-Operative Assessment Programme. London: Department of Health (DH); 2002.
The Association of Anaesthetists of Great Britain and Ireland (AAGBI). The Anaesthesia Team. 3rd
ed. London: AAGBI; 2010.
The Association of Anaesthetists of Great Britain and Ireland (AAGBI). The Role of the Anaesthetist. London: AAGBI; 2001.
Lemmens LC, Kerkkamp HE, Vanklei WA, Klazinga NS, Rutten CL, Van Linge RH et al.
Implementation of outpatient preoperative evaluation clinics: Facilitating and limiting factors. BJA 2008;100:645-51.
Robert D, George A, Raymond E, Vincent G, Ebenezer OD, Christian O et al.
Patients’ knowledge and perception of anaesthesia and the anaesthetist at a tertiary health care facility in Ghana. South Afr J Anaesth Analg 2017;23:11-16.
Kamau A, Mung’ayi V, Yonga G. The effect of a preanaesthesia clinic consultation on adult patient anxiety at a tertiary hospital in Kenya: A cohort study. Afr Health Sci 2017;17:138-47.
Buley HE, Bishop D, Rodseth R. The appropriateness of preoperative blood testing: A retrospective evaluation and cost analysis. S Afr Med J 2015;105:487-90.
Belihun A, Alemu M, Mengistu B. A prospective study on surgical inpatient satisfaction with perioperative anaesthetic service in Jimma University Specialized Hospital, Jimma, South West Ethiopia. J Anesth Clin Res 2015;6:514.
Fischer SP. Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology 1996;85:196-206.
Rushforth H, Burge D, Mullee M, Jones S, McDonald H, Glasper EA. Nurse-led paediatric pre-operative assessment: An equivalence study. Paediatr Nurs 2006;18:23-9.
Starsnic MA, Guarnieri DM, Norris MC. Efficacy and financial benefit of an anaesthesiologist-directed university preadmission evaluation centre. J Clin Anesth 1997;9:299-305.
Ivarsson B, Larsson S, Sjöberg T. Postponed or cancelled heart operations from the patient’s perspective. J Nurs Manag 2004;12:28-36.
McIntosh C, Dexter F, Epstein RH. The impact of service specific staffing, case scheduling, turnovers, and first-case starts on anesthesia group and operating room productivity: A tutorial using data from an Australian hospital. Anesth Analg 2006;103:1499-516.
Pandit JJ, Westbury S, Pandit M. The concept of surgical operating list ‘efficiency’: A formula to describe the term. Anaesthesia 2007;62:895-903.
Ferschl MB, Tung A, Sweitzer B, Huo D, Glick DB. Preoperative clinic visits reduce operating room cancellations and delays. Anesthesiology 2005;103:855-9.
Schofield WN, Rubin GL, Piza M, Lai YY, Sindhusake D, Fearnside MR et al.
Cancellation of operations on the day of intended surgery at a major Australian referral hospital. Med J Aust 2005;182:612-5.
Haana V, Sethuraman K, Stephens L, Rosen H, Meara JG. Case cancellations on the day of surgery: An investigation in an Australian paediatric hospital. ANZ J Surg 2009;79:636-40.
Nasr A, Reichardt K, Fitzgerald K, Arumugusamy M, Keeling P, Walsh TN. Impact of emergency admissions on elective surgical workload. Ir J Med Sci 2004;173:133-5.
Griffin X, Griffin D, Berry A, Hunter D. Cancellation of elective surgery any improvement after ten years? Ann R Coll Surg Engl 2006;88:28-30.
Zafar A, Mufti TS, Griffin S, Ahmed S, Ansari JA. Cancelled elective general surgical operations in Ayub teaching hospital. J Ayub Med Coll Abbottabad 2007;19:64-6.
van Klei WA, Moons KG, Rutten CL, Schuurhuis A, Knape JT, Kalkman CJ et al.
The effect of outpatient preoperative evaluation of hospital inpatients on cancellation of surgery and length of hospital stay. Anesth Analg 2002;94:644-9.
Wijesundera DN, Austin PC, Beattie WS, Hux JE, Laupacis A. A population-based study of anesthesia consultation before major non-cardiac surgery. Arch Intern Med 2009;169:595-602.
Caplan GA, Brown A, Crowe PJ, Yap SJ, Noble S. Re-engineering the elective surgical service of a tertiary hospital: A historical controlled trial. Med J Aust 1998;169:247-51.
Foss JF, Apfelbaum J. Economics of preoperative evaluation clinics. Curr Opin Anaesthesiol 2001;14:559-62.
Boothe P, Finegan BA. Changing the admission process for elective surgery: An economic analysis. Can J Anaesth 1995;42:391-4.
Roizen MF, Klock PA, Klafta J. How much do they really want to know? Preoperative patient interviews and the anesthesiologist. Anesth Analg 1996;82:443-4.
Kumar A, Srivastava U. Role of routine laboratory investigations in preoperative evaluation. J Anaesth Clin Pharmacol 2011;27:174-9.
Flamm M, Fritsch G, Seer J, Panisch S, Sonnichsen AC. Non adherence to guidelines for preoperative testing in a secondary care hospital in Austria: The economic impact of unnecessary and double testing. Eur J Anaesthesiol 2011;28:867-73.
Tsen LC, Segal S, Pothier M, Bader AM. Survey of residency training in preoperative evaluation. Anesthesiology 2000;93:1134-7.
Correll DJ, Bader AM, Hull MW, Hsu C, Tsen LC, Heppner DL. Value of preoperative clinic visits in identifying issues with potential impact on operating room efficiency. Anesthesiology 2006;105:1254-9.
Fitzgerald L, Ferlie E, Wood M, Hawkins C. Interlocking interactions, the diffusion of innovations in health care. Hum Relat 2002;55:1429-49.
Van Klei W, Rutten C, Moons K, Lo B, Knape JT, Grobbee DE. Limited effect of Health Council guideline on outpatient preoperative evaluation clinics in the Netherlands: An inventory [in Dutch]. Ned Tijdschr Geneeskd 2001 145:25-9.
Lemmens LC, van Klei WA, Klazinga NS, Rutten CL, van Linge RH, Moons KG et al.
The effect of national guidelines on the implementation of outpatient preoperative evaluation clinics in Dutch hospitals. Eur J Anaesthesiol 2006;23:962-70.