Today I reviewed another “low-risk clearance” checkbox note from an advanced practice registered nurse, for a topical cataract case, under monitored anesthesia care. Prior to the patient’s topical cataract extraction, my healthy 64-year-old patient had visited her primary care physician to be cleared for surgery. She had no risk factors, virtually no past medical history, and was an avid equestrian. She took time out of her busy life as a financial analyst to be cleared for a procedure under topical anesthesia. The result was a check in the box of the preoperative form labeled “cleared for surgery.” Why is this necessary?
Though a blatant example of unnecessary health care, it represents the tip of the iceberg of unneeded “clearances” still rampant in community surgical practices. Authors have opined about pivoting to the concept of “medical optimization” for years (Anesth Analg 2021;133:1431-6), but somehow this practice continues unabated. I and many colleagues over the years have lamented the lack of useful information in most “clearance notes,” waved in front of us by annoyed surgeons when we cancel a procedure in a patient with suspected heart failure, COPD exacerbation, or another clearly high-risk medical condition, despite the assessment of an unknown non-anesthesiologist (and frequently non-physician) who likely does not understand the perioperative pathophysiology and stresses the patient encounters.
Some anesthesiologists and surgeons still do look for a “clearance note,” hoping for some protection – from what, I am not sure. Lawsuit? Bad outcome? Decision-making? None will be forthcoming. Only physician experts in perioperative care can decide whether our patients are ready for the proposed anesthetic, sometimes with the input of specialists who weigh in about specific medical conditions.
How many “clearance notes” have you read that gave you useful information, that changed your patient management? “Avoid hypotension, tachycardia, and hypoxemia.” Right.
Larger academic centers may boast well-funded and well-staffed “preoperative assessment” centers, with physicians, residents, and anesthesiologist-supervised physician assistants and nurse practitioners evaluating higher-risk patients personally. That luxury is not available in most community hospitals and practices, so nurse-driven screening processes serve these venues with varying degrees of success to decrease postponements and cancellations. In my observation, the success is greatly dependent on the level of anesthesiologist input – far less by collection of faxed “clearance notes” from primary care physicians, cardiologists, pulmonologists, and frequently non-physician rubber stamps. For higher-risk procedures on more complicated patients, details of testing and physician evaluation may make sense. However, the bulk of outpatient procedures are low to moderate risk, and even patients with more complicated comorbidities can be screened effectively with a few key questions.
Preoperative testing is guided well by the American College of Cardiology/American Heart Association guidelines (JAMA 2020;324:279-90) and good clinical judgment (and should be zero to minimal for low-risk procedures). Publications and guides for risk stratification of pulmonary risk also abound. The National Surgical Quality Improvement Program yielded a fabulous tool (J Am Coll Surg 2013;217:833-42.e1-3) to estimate multiple outcome risks to patients and physicians alike, helping some with difficult decisions (and available to all anesthesiologists). ASA, the Society for Ambulatory Anesthesia, and the Society for Perioperative Assessment and Quality Improvement provide many resources to guide decision-making (spaqi.org/web/index.php).
For higher-risk procedures on more complicated patients, preoperative testing and specialist physician evaluation make sense. Should that severe aortic stenosis be corrected before a carotid endarterectomy, or at the same time? Does the risk of worsening liver failure in the moderate cirrhotic patient outweigh the need to fix the large ventral hernia? How about the end-stage COPD patient who has quality of life-limiting joint pain? What can we do to optimize her chance of a good outcome for a hip replacement? There are more subtle questions that arise occasionally, too, but anesthesiologists are best suited to make decisions about perioperative risk to the whole patient. We should “practice at the top of our licenses,” to borrow a current trendy phrase.
If your system or group requires “clearance” for low- and moderate-risk procedures, ask yourself why. What does a generic checkbox note add to your own evaluation and discussion with your patient and surgeon, as an expert in perioperative medicine? It is past time to eliminate this low-yield expenditure of health care time and money and inconvenience to our patients.
Rather than sending a request for clearance, ask a specific management question or concern. It can be written or typed into a convenient form and faxed by your staff to a consultant physician after your medical assessment. The answer should provide insight not already readily available to the anesthesiologist or surgeon and guide discussion with the patient. As leaders of the health care team, anesthesiologists must guide outpatient center policies to optimize high-value practices with minimal waste. There is still ample opportunity to decrease this waste (N Engl J Med 2022;1293-5).