Pre-op Trip to Anesthesia Evaluation Clinic Lowers Surgical Cancellations

As streamlined as hospital throughput may be, unanticipated surgical cancellations still have a significant effect on an institution’s bottom line. Yet, as a University of Texas Health Science Center analysis has revealed, such missteps can be prevented with a preoperative visit to an anesthesia evaluation clinic.

“The perioperative surgical home has initially put a lot of emphasis on the patient experience and the quality of experience we provide for patients who are scheduled for surgery,” noted Davide Cattano, MD, PhD, associate professor of anesthesiology and medical director of the Preoperative Anesthesia Clinic at Memorial Hermann Hospital, Texas Medical Center, in Houston. “However, it’s our understanding that the work of the anesthesia preoperative evaluation clinic is fully integrated into the perioperative surgical home.”

As Dr. Cattano described, previous research demonstrated that the anesthesia preoperative evaluation clinic improves patient risk stratification, patient optimization and utilization of health care resources by reducing surgical cancellation rates (Anesthesiology 1996;85:196-206 and Int Anesthesiol Clin2009;47:151-160). The purpose of his team’s quality review, he added, was to understand the influence of the clinic on surgical cancellations among patients who received an in-clinic assessment, a phone assessment or no assessment.

Reasons for Cancellation

To that end, Dr. Cattano and his colleagues examined cancelled surgical procedures among 37,997 adult patients who underwent elective surgery at their institution between May 2008 and June 2014. The causes of cancellation were grouped into seven categories (Table). The evaluation’s main objective was to determine both overall and cause-specific cancellation rates in each assessment group.

Table. Categories of Reasons for Cancellation Reason for Cancellation Examples Patient-related reasons Patient ate/drank; failed to cease medications Misadventure Respiratory tract infection; car accident Clinical deterioration of the patient’s condition between preoperative evaluation and surgery A condition that was present worsened following preoperative evaluation Clinical disagreement The anesthesiologist or surgeon on day of surgery disagrees with the preoperative evaluation of fitness for surgery Undetermined causes Reason for cancellation unclear from medical records; medical records could not be found System error Lab results not checked; surgeon cancellation due to scheduling conflict Financial reasons Insurance clearance not obtained to proceed

“All our day-surgery patients are screened through our preoperative clinic,” Dr. Cattano said. “Depending on scheduling, we invite them to either come to a one-on-one assessment or have a phone assessment with a nurse. If the schedule is too late or the patient doesn’t have the opportunity to talk to us, they sometimes show up on the day of surgery with no assessment.” According to the institution’s most recent data, 45% of patients visit the clinic, 45% are assessed by phone and 10% have no assessment.

As Dr. Cattano reported at the 2015 annual meeting of the American Society of Anesthesiologists (abstract A2110), the overall cancellation rate was 3.5%, including 1.9% among patients seen in the preoperative evaluation clinic, 2.8% of those assessed by phone and 8.2% of those who were not assessed.

Despite their overall similarity, in-clinic assessment proved superior to phone assessment in reducing cancellations with respect to patient- and system error–related causes.

“Although we were encouraged by the fact that we were able to dramatically decrease our cancellation rate over the six years to an average of 3.5%, there’s more to the story,” Dr. Cattano told Anesthesiology News. “Over that time, we actually saw our cancellation rate fall from 4.5% to the point where it’s now less than 1.5%. So in an academic setting in a large, Level 1 trauma center, we’re essentially matching that of a freestanding surgical center.”

Despite these promising results, the study also revealed areas for improvement, including financial issues and understanding the parameters of clinical deterioration. Studies focusing on these areas of cancellations will ultimately help improve the delivery of preoperative care and reduction of surgical cancellations.

Session moderator Aalok V. Agarwala, MD, MBA, offered some suggestions to help address the financial factors that may be causing cancellations. “Assuming that the financial issues resulting in cancellations are primarily about insurance, it seems like something that should perhaps be managed during the surgical booking process from the surgeon’s office,” said the assistant division chief of General Surgery and associate director for Quality and Safety at Massachusetts General Hospital, in Boston. “It should be the responsibility of the office to make sure the patient is cleared before the day of surgery.”

“This is something we’ve been discussing with administration, because it’s an important issue,” Dr. Cattano replied. “I think that from the moment you’re scheduled for surgery, there should be a process to manage insurance.”