Preoperative assessment of the ambulatory patient

Preoperative Assessment of the Ambulatory Patient JANET CASSIDY, MS, REX A. MARLEY, MS, CRNA,

RN RRT

Whenever the human body is subjected to anesthesia and an invasive surgical procedure, the potential for complications exists. A goal ofperioperative care is to minimize that risk while providing the safest care available for the patient. Initial steps toward accomplishing this goal include (1) conducting a thorough preoperative assessment of the patient’s medical, surgical, and anesthetic history; (2) performing a physical examination; and (3) procuring and interpreting the results of necessary diagnostic procedures and laboratory evaluations. The increased use of ambulatory surgical services, coupled with changes in health care economics, dictates reform in patient evaluation before surgery. The evaluative process must be cost-eflective and efficient without compromising reliability. This article familiarizes and updates the perianesthesia nurse on management issues for the surgical patient. 0 1996

by American

Society

of PeriAnesthesia

UALITY surgical care encompasses more than performing noninvasive and surgical procedures to treat various maladies of the human body. An important feature of patient care is a timely and thorough preoperative assessment to identify factors that increase the risk from anesthesia and surgery. Preoperative assessment is mandatory for all patients who will undergo anesthesia to help identify the anesthetic risk and the suitability of the patient relative to the pro-

Q

Janet Cassidy, MS, RN, is an Independent Nurse Researcher and a Preadmission Nurse in Patient Care Services, and Rex A. Marley, MS, CRNA, RRT, is a StaffNurse Anesthetist in the Department ofAnesthesia at Poudre Valley Hospital, Fort Collins, CO. Address correspondence to Janet Cassidy, MS, RN, Patient Care Services, Poudre Valley Hospital, 1024 Lemay Ave, Fort Collins, CO 80524. 0 1996 by American Society of PeriAnesthesia Nurses. 0883-9433/96/l 105-0008$03.00/0

334

Journal

Nurses.

posed surgery.‘-4 Significant findings enable the health care team to make adjustments in patient care to afford the safest approach to surgery and anesthesia. Based on findings obtained from a patient’s history and physical examination, subsequent individualized assessments might include obtaining diagnostic tests, consulting with a specialist for additional evaluation, and instituting various treatment modalities. Delaying surgery may be necessary if insufficient time exists to properly prepare the patient. Each ambulatory facility is responsible for establishing policies that delineate requirements for the history, physical examination, and what, if any, preoperative diagnostic tests and laboratory evaluations are to be conducted.’ The comprehensiveness of this preoperative assessment depends on the needs of the individual patient, the surgical procedure, and the type of anesthesia (Table 1).5

of PeriAnesrhesia

Nursing,

Vol 11, No 5 (October),

1996: pp 334-343

PREOPERATIVE

ASSESSMENT

335

Considering the current restructuring of medical care financial resources, preoperative assessment must focus on reducing patient care costs while maintaining quality care. This is a challenge, particularly in the ambulatory setting, where more complicated and prolonged surgical procedures are being performed routinely on sicker (American Society of Anesthesiologists’ Physical Status Classification III or IV) patients. There is a paucity of information targeted to the perianesthesia nurse that deals with contemporary preoperative assessment and the associated approaches to containing spiraling health care costs without sacrificing quality patient care. PREOPERATIVE

ASSESSMENT

CLINIC

As the number of patients receiving ambulatory surgical care increases, and as more complex surgical procedures become available, it is apparent that a formalized approach to patient assessment is necessary, especially in the older and more medically compromised surgical candidate.6 Specific medical conditions necessitate a timely evaluation before surgery because there is a higher likelihood that additional workup may be required (Table 2).7 Cooperation and communication between the surgeon, primary care physician, anesthesia provider, and preoperative assessment nurse can enhance and streamline the

Table

To To

optimize minimize by assessing anesthesia

anesthetic To minimize day

satisfaction, morbidity

factors that or that might technique surgical

delays

affect the risk of alter the planned

assess procedure

To

evaluate determining

appropriateness of the patient for the ambulatory facility

on the

the

investigations To formulate To communicate effectively surgeon, To ensure

and consultations are a plan of patient care patient management

between care providers primary care provider). efficient and cost-effective

Everett

and

Kallar.’

Early

Medical conditions daily activity

inhibiting

Medical

Preoperative

the

Evaluation

necessitating

conditions

ability

to engage

continual

in normal

assistance

monitoring at home within the past 6 mo Admission within the past 2 mo for acute episodes exacerbation of chronic condition

or or

Medication use (eg, anticoagulants or monamine oxidase inhibitors) that might require schedule or dosage modification Cardiocirculatory History of angina,

coronary

artery

disease,

infarction, symptomatic dysrhythmias Poorly controlled hypertension (diastolic systolic > 160 mm History of congestive

Hg) heart

myocardial > 110 mm Hg,

failure

Respiratory Asthma or COPD requiring chronic medication or acute exacerbation and progression of these diseases within the past 6 mo History

of major

airway

surgery

or unusual

airway

anatomy or upper and/or lower airway tumor obstruction History of chronic respiratory distress requiring ventilatory assistance or monitoring Endocrinologic Non-diet-controlled

diabetes

hypoglycemic agents) Adrenal disorders or active

(insulin thyroid

or home

or oral disease

Neuromuscular History of seizure disorder or other disease (eg, multiple sclerosis) History Hepatic

of myopathy

Temporomandibular Cervical or thoracic Oncological

or other

significant

muscle

joint disorder spine injury

process

with

CNS

disorders

with

compromise

restricted

significant

mobility

physiological

residual or compromise Gastrointestinal Massive obesity Hiatal hernia Symptomatic

patient’s health status, which specific preoperative

evaluation from

and

Requiring

General

Chemotherapy Other oncological

of surgery

To

Data

and comfort and mortality

or cancellations

2. Conditions

Active hepatobiliary disease or compromise Musculoskeletal Kyphosis and/or scoliosis causing functional

1. Goals of Preoperative Assessment for Ambulatory Surgery patient care, perioperative

Table

(>140%

ideal

gastroesophageal

body

weight)

reflux

thus required

Abbreviations: COPD, chronic obstructive ease; CNS, central nervous system. Modified

and reprinted

with

pulmonary

dis-

permission.’

issues (eg,

anesthetist,

patient

screening and management of these patients. A referral mechanism should be instituted by which complex cases are directed to the patient’s primary care physician or to an internal medicine specialist.

CASSIDY

336

Physical Layout and Commuzication

Support

Each ambulatory facility ideally should provide a unit designed specifically for preoperative assessment and care. The preoperative assessment clinic should include, or be in close proximity to, secretarial support, laboratory facilities, blood bank (eg, autologous blood donation), radiographic facilities, and a private room for patient assessment. It should be conveniently located so that anesthesia personnel can be summoned to consulr and make recommendations regarding patients with more complex conditions. Appointment times are arranged by the preoperative assessment clinic secretary to enable the patient and support members to visit this unit before surgery. When the patient arrives for the preoperative visit, secretarial staff can gather from the patient any needed information for the hospital’s registration department and facilitate patient flow through the preoperative clinic. Various personnel (eg, anesthesia provider, primary care physician, registered nurse, nurse practitioner, or physician’s assistant) may be responsible for performing the preoperative assessment.’ The individual responsible for preoperative assessment visits with the patient to obtain a history, perform a physical examination, adjust orders for diagnostic testing or specialized consultation as defined by each institution, carry out preoperative surgical preparation orders, provide education to the patient regarding the nursing and anesthesia care they will receive, respond to questions or concerns expressed by the patient, and communicate to nursing and anesthesia staff significant health considerations. This communication can be made by recording information on the patient’s chart or by introducing data into the surgical schedule via computer. The performance and documentation of the patient’s history and results of physical examination and diagnostic tests are completed before surgery.’ A licensed independent practitioner with appropriate clinical privileges* makes the final determination of pa-

* A licensed, independent practitioner is any individual who is permitted by law and by the organization to provide patient care services, without direction or supervision, within the scope of the individual’s license and in accordance with individuully granted clinical privilegex2

AND

MARLEY

tient suitability for surgery based on the patient assessment.l Timing of Preoperative Assessment An advantage of the preoperative assessment clinic is the opportunity to screen patients before the day of surgery, thus assuring that requisite care is provided. Patient evaluation should take place sufficiently in advance of the scheduled surgery to integrate an appropriate evaluation, necessary testing, access to consultative services, and thorough patient education to properly prepare the patient for surgery. Proper timing of the interview, especially for the high-risk patient, minimizes surgical delays and cancellations.6Xs,9 Last-minute discovery of information about the patient-such as presence of gastric reflux, insulin-dependent diabetes mellitus, asthma, and suspected difficult airway management (Table 2)often results in changes to the plan of care, subsequently creating delays in operating room schedules. In turn, these delays result in additional health care costs.” The otherwise healthy individual who does not have the opportunity to visit the clinic (eg, inconvenient, schedule conflicts, hastily scheduled surgical date) may be evaluated on the day of surgery. The risk of this late evaluation time lies in the potential for surgical cancellation if additional workup is required. The patient interview and physical examination should be obtained within 30 days before surgery.’ All patients, regardless of when they were initially screened, undergo a final evaluation immediately before induction of anesthesia.’ PATIENT

INTERVIEW, EDUCATION, PHYSICAL EXAMINATION

AND

The initial interaction between the patient and preanesthesia assessment personnel typically occurs in the preoperative assessment clinic in the form of an information interview and physical examination. The objective of obtaining a preoperative history is to gather sufficient information to familiarize medical personnel involved with the patient’s perioperative care with pertinent factors that may affect the anesthetic, nursing, or surgical management. The patient history is obtained by several means, which might include a questionnaire that is completed by the patient or responsible individual, dialogue with the pa-

PREOPERATIVE Table

3. Objectives

To assure that the goals (see Table 1) To provide preoperative

ASSESSMENT of the Preoperative of preoperative education

facility

(ie, to reduce

familiarity) To evaluate

the patient’s

social

ambulatory To motivate

surgery the patient

to comply

strategies (eg, smoking cardiovascular fitness) Data from

Everett

assessment

with

stress

are met and family

the ambulatory and increase

situation with

cessation,

and Kallar’

Interview

to the patient

(see Table 5) To obtain informed consent To acquaint the patient and family surgical

337

with

respect

preventive

to

care

improving

and Roizen.”

tient (in person or via telephone), chart review, consultation with the patient’s primary care provider, and retrieval of information from other institutions where the patient has been treated. When evaluating the patient, three questions should be addressed: (1) Is the patient in optimal condition for surgery? (2) Could, or should, there be improvements in the patient’s mental or physical status before surgery? (3) Does the patient have any health problems or use any medications that could unexpectedly increase perioperative risk?’ L Interview The patient interview is structured to accomplish certain goals (Table 3).‘,r2 Interviewing and educating the patient has been found to reduce the patient’s anxiety leve1’3-i5 as well as increase patient satisfaction.16 The interview process can be conducted by anesthesia personnel; however, a perioperative nurse trained specifically for preadmission assessment is beneficial to overlap the assessment and education duties from both the anesthesia and the nursing perspectives. A format for transmission of information to all relevant parties is necessary and should encompass personnel working in the preoperative preparation area, anesthesia department, operating room, postanesthesia care unit, and postoperative ambulatory setting. Options for communication tools would include the assessment instrument, adding information to the operating room schedule printouts, and verbal reports. Specific and necessary information to be obtained

from the patient interview should be decided by each institution. Although the history can be abtained in person, a more efficient approach is to ask the patient to complete a questionnaire and then conduct a face-to-face interview. Important information to be elicited during the history is detailed in Table 4.5.17 Recent interest in an automated history retrieval system has led to the development of the HealthQuiz II (Michael F. Roizen and the University of Chicago, Chicago, IL), a small handheld device that contains a computer chip and a video screen and uses a decision tree to ask a minimum of 60 health-related questions. (An updated HealthQuiz Prescreen model is now available.) The automated questionnaire consists of a patient-driven computerized medical historytaking program.” The device recommends specific preoperative tests based on information gathered from the patient. Reported advantages of the automated interview is ease of application and increased sensitivity and specificity in determining appropriate tests.” A limitation of this device might be seen in subgroups of patients from divergent socioeconomic backgrounds who do not read English. The cost-effectiveness of this device for diagnostic testing has not been established. l8 One study, which compared the test-ordering patterns of practicing anesthesiologists with the tests recommended by HealthQuiz II, found the total cost of tests deemed appropriate by HealthQuiz II criteria to be 5.5 times more expensive.” Although the personalized approach to the patient interview is preferred, for patients who are unable to visit the hospital setting (eg, live out of town, have difficulty in obtaining transportation), an appointment for a telephone interview can be arranged. This accommodates the transmission of information from and to the patient but would preclude the possibility of obtaining current diagnostic testing or performing a physical examination Education An important step in preparing the patient or responsible individuals (eg, family members, legal guardian) for upcoming surgery includes an educational process during which the staff counsels the patient concerning fundamental perioper-

CASSIDY

338 Table Surgical illness What surgical What

other

procedure surgeries

had? Coexisting medical Do you have condition Do you

are you

4. Components

of the

Review Liver

having?

and hospitalizations

have

you

before?

and amount

of alcohol

Do you Cancer

or drugs

that

Could you be pregnant? Airway problems

Heart

infant

death

syndrome

temporomandibular your mouth, snoring,

you

ever

angina,

pacemaker,

have

had a problem

with

problems

with

your

Pulmonary problems Bronchitis, emphysema, asthma Have you ever had bronchitis, emphysema, or asthma?

in

Do you

your

heart,

blood

such

Have

you

had a recent

snore? Bleeding disorder Do you bleed with Data from

blood Everett

cough

obstructive

sleep

as

a

joint disease, trouble opening or loose or false teeth?

Medications What medications

pressure?

activities?

or

easily

regularly

Kallar’

and Long.”

under

any

lenses?

currently

take

(eg, prednisone) the past year or

(including or received

or occasionally?

Allergies and drug reactions Please fist drugs to which

or do you

any

problems

clotting? and

do you

products

anticoagulants (blood thinners) within the past month? Do you take aspirin or other anti-inflammatory drugs

or cold?

or have

or any other

blood

or contact

dose and schedule)? Have you taken steroids chemotherapy within

a bad reaction and bruise

cell disease

problems? to receiving

circumstances? Do you wear glasses

surgery,

or wheezing pneumonia,

apnea,

have sickle

hemoglobin Do you object

Do you ever use oxygen at home? Upper respiratory tract infection Sleep apnea Do you have

with

Do you have trouble walking one block? Other concerns Do you have any problems with your thyroid

irregular

chest pain, palpitations, heart attack, heart congestive heart failure, or heart murmur? Hypertension, (treated or untreated) Do you

intubation of

adrenal glands? Do you have diabetes?

pain, unstable heartbeat

Have

of difficult symptoms

Exercise tolerance Do you have any physical limitations? Do you get short of breath during normal

disease

Chest

problems?

diagnosis history

Do you have a history previous anesthesia,

have a history of low heart rate or periods of low or absent (apnea)? of sudden

back or neck

Psychiatric Obstetric

Birth and developmental history (pediatrics) Was your child’s delivery premature or at term? Did your child experience any neonatal complications?

Is there any history your family?

or gastritis?

arthritis?

have

per

surgery? of systems

your child (bradycardia) respirations

with your kidneys? hernia, gastric ulcers,

problems) a hiatal hernia,

packs

you use? When did you last use alcohol or drugs? Who is going to be with you and care for you after

Does

with

problems

ever had a problem problems (hiatal

Skeletal problems Do you have

Do you use tobacco, alcohol, or any nonprescription drugs or other chemicals? If you do, do you smoke cigarettes or pipe or chew tobacco? Now or in the past? How many day? How many years have you smoked?

or problems

Seizures Do you have any neurological problems, such as seizures, stroke, severe headaches, or memory loss?

Have you or any of your blood relatives ever had a problem with any type of anesthesia? Social history

Review

ever had any jaundice

heartburn, bowel Do you have reflux,

had anesthesia

is the type

you

Have you Gastrointestinal

feel sick at this time?

What

of systems (cont’d) disease (jaundice, hepatitis)

your liver? Kidney, urinary, or bladder

illness

MARLEY

History

Have

any medical problems other than the for which you are having surgery?

Anesthetic history Have you ever

Patient

AND

Excerpts

reprinted

with

permission.5

you

are allergic

or have

had

PREOPERATIVE Table To promote

ASSESSMENT

5. Patient

interactive

and care providers ‘To encourage patient care To maximize

Objectives

communication

between

participation

and enhance

participation phase

Education

in decision

patient

in continuing

self-care

to cope with

making skills

care during

To increase the patient’s ability health status To increase patient compliance

patients

and

the postoperative

with

his or her

perioperative

care

To provide individualized preoperative instructions Where and when laboratory tests, consultations, diagnostic procedures will be completed Appropriate ingestion Personal

time at which the patient of food and drink considerations

about

should

(eg, comfortable

and cease

clothes

to wear;

no jewelry or makeup; what personal items to bring; leave valuables at home; bring favorite toy, comforter, or book) Postoperative

considerations

and instructions

anticipated recovery course, to deal with complications) Who to contact if the patient’s changes (eg, upper cancellation) To detail the registration

discharge physical

respiratory

tract

how

conditions infection, Table

process

on the day of surgery

time and location of arrival) To review advance directive information in some states To explain

(eg,

instructions,

sults considered to determine the patient’s surgical and anesthetic risk as well as the need for appropriate health care modifications.’ The controversy lies in which tests are necessary and appropriate for specific settings. The rationale for performing “routine” tests has been under intense scrutiny, primarily because of recent and ongoing changes in health care economics. A protocol that delineates the indications for testing should be established by each ambulatory facility and approved by the medical staff. When protocols for the ordering of preoperative laboratory tests are followed, there is a 50% to 60% reduction in the total number of tests performed as well as improvement in the appropriateness of the tests.“3 Based on 1990 dollars, this could result in a savings to the United States health care system of 2.9 to 4.3 billion dollars annually.24 A necessary step in the implementation process for preoperative testing guidelines is the education

the ambulatory

facility

policies

Patient as required

6. Components

of the Physical

Examination

tie, by law

to the patient

and

family

demographics

Age, height, Vital signs

weight

Blood pressure temperature,

(both arms), oxyhemoglobin

resting pulse, saturation

respirations,

Head and neck Data from Organization?’

Joint

Commission and Marley.”

on Accreditation

of Healthcare

ative issues (Table 5).*‘.“’ Reinforcing information to the patient verbally and in writing is important to enhance patient compliance.22 For patient convenience, this process often is accomplished while the patient is at the preoperative assessment clinic.

Physical Examination Data obtained from the physical examination are designed to supplement knowledge of the patient for anesthetic risk evaluation. Visual, tactile, and auscultory patient evaluation should use a comprehensive and systematic approach. Important areas of patient evaluation are described in Table 6. DIAGNOSTIC

TESTING

Appropriate laboratory evaluations and diagnostic procedures should be obtained and the re-

Airway assessment, lesions, cervical cervical masses, Precordium Cardiac

auscultation

Lungs Auscultation muscles Abdomen Distention,

perfusion, infection, Back Deformity, Neurological Baseline peripheral

Jaundice, turgor, Data from

for murmurs

for wheezing,

masses,

Extremities Muscle wasting

Eyes Abnormal Skin

dental conditions, tongue size, spine motion, tracheal deviation, carotid and jugular pulses

rales,

use of accessory

ascites

or weakness,

mental

and gallops

rhonchi,

mobility,

bruising, clubbing, edema, sensation, bruising,

oral

general

distal

cyanosis, cutaneous skin texture

infection

status,

sensorimotor

cranial

nerve

function,

function,

cognition,

walking

movement cyanosis, pallor Roizen”

nutritional

and Long.17

abnormalities,

dehydration,

CASSIDY

340

of the medical staff. Centralizing the test ordering process, such as found in the preoperative assessment clinic, makes standardization and compliance more attainable. Routine Diagnostic

Testing

It has been traditional practice, even within the past decade, to order a battery of routine evaluative tests before a patient undergoes anesthesia and surgery. The routine ordering of preoperative diagnostic tests remains a common practice in many institutions. Until the early 1990s the rationale for obtaining preoperative diagnostic tests was rarely questioned. Tests frequently were ordered for a variety of reasons, but they often were unrelated to findings based specifically on the patient’s history and physical examination. Reasons cited for ordering the standard battery of preoperative tests included the following”5-27: 1. to follow customary practice at an institution, 2. to adhere to institutional or legislative mandates that dictate the tests to be performed, 3. to further evaluate and determine the progress of a known disease because pre-existing medical conditions pose a greater risk for intraoperative and postoperative complications, 4. to detect asymptomatic yet modifiable conditions that could alter anesthetic and surgical care, 5. to detect asymptomatic but unmodifiable conditions that could alter anesthetic and surgical risk, to screen for conditions unrelated to the planned surgery, to acquire baseline results that may be useful in the perioperative period, and to protect against medicolegal entanglement. When considering the value of conducting preoperative tests one must consider the following: 1. The diagnostic procedures should be cost-effective (ie, the costs saved from knowing the results exceed the expense of performing the tests).28 2. The diagnostic procedures should have positive benefit-risk ratios (ie, the benefits derived from conducting the tests outweighs the harm that might ensue from false positive results).‘*

AND

MARLEY

3. Test results should be available for interpretation and recuperative intervention before surgery. 4. Test results should yield information that could not be obtained from the history and physical examination.29 5. Abnormal test results in an asymptomatic patient would influence patient care, surgery, or anesthesia management.*’ Without any clinical sign, the likelihood of observing a significant anomaly is minuscule in diagnostic procedures (eg, electrocardiogram,26 chest radiograph,26,30*31or laboratory tests24X26,32). Asymptomatic disease is rarely of clinical concern in perioperative surgical care. In addition, unexpected abnormal findings from preoperative tests tend not to affect upcoming surgery.33 When a battery of routine preoperative tests are conducted, abnormal test results potentially alter patient care only 0.22% to 0.56% of the time.26,32 A consistent conclusion of most studies is that routine preoperative laboratory screening is neither cost-effective nor predictive of postoperative complications.25,34 Limitations to routine preoperative diagnostic testing. It has been estimated that at least 10% of the more than 30 billion dollars spent on laboratory testing annually in the United States goes toward preparing the patient for surgery.7 Although added health care costs are the most apparent limitation to performing the routine battery of preoperative tests, additional factors can negatively impact the patient and care providers. Indiscriminant ordering of tests for diagnostic evaluation increases the likelihood that at least one test will yield abnormal results in the healthy patient. 27 False-positive and even false-negative test results can lead to additional medical evaluation and the potential for increased morbidity to the patient. Abnormal laboratory tests for continuous data are defined in probabilistic terms and assume a normal patient population distribution.26,27The end points of the bell-shaped distribution curve are arbitrarily set at 2.5%, thus 5% of test results in normal patients are reported as abnormal. False-positive test results may lead to additional follow-up tests, which can place the patient at risk of increased morbidity.2s,35 Abnormal test results that are not further investigated,

PREOPERATIVE Table Chest

ASSESSMENT

7. Indications

for Diagnostic

341 Procedures

radiograph

Symptomatic pulmonary Pulmonary

or debilitating asthma, chronic obstructive disease, or cardiovascular disease’,” infection (eg, new or chronic productive cough

or blood-tinged or purulent-appearing sputum” Malignancy in which pulmonary metastasis might surgical therapy’*

laboratory testing should be based appropriately on age, gender, concomitant medical diseases, surgery to be performed, and type of anesthesia.25 A well-conducted preoperative evaluation, conTable

8. Indications

for Laboratory

Testing

alter the

Electrocardiogram Age 2 50 years’

Complete

blood

count

Hematologic disorder’ Vascular procedure’

Presence

of risk of cardiovascular

abuse, Diabetes

hypertension, mellitus (age

Significant

pulmonary

disease

(eg, cocaine

renal disease)5,7,‘2 2 40 years)’ disease5,‘*

Chemotherapy’ Hemoglobin and hematocrit Age < 1 year” Malignancy’* Renal disease” Anticoagulant’* Procedure with

as well as the rationale for not investigating the abnormal tests documented, have increased medicolegal risk for the physician.36 Timing of diagnostic testing. In general, diagnostic test results obtained within the past 4 months are deemed current if the results were normal and if the patient’s current health status indicates no change since the tests were performed.27 However, specific tests require more current data analysis. Serum potassium levels should be determined within 7 days of surgery for patients receiving diuretics or digitalis, and blood glucose levels should be determined on the day of surgery for patients with diabetes that is controlled by medication.‘r Indications for diagnostic testing. A continuing point of controversy relates to agreement on which tests are appropriate for specific patients, surgeries, and conditions. There is disagreement between and within medical specialties as to which tests are appropriate.37 Suggested guidelines, based on results of the patient’s history and physical examination, have been offered for ordering diagnostic procedures (Table 7) or laboratory tests (Table 8). This list will continue to change as consensus is approached and more experience with the procurement of diagnostic tests, as well as more knowledge regarding their efficacy in the perioperative setting, are gained. SUMMARY

Preoperative diagnostic testing without specific indications is neither useful nor cost-effective and no longer can be justified.27 Preoperative

significant

blood

Chronic illnesses (eg, cystic arthritis, severe pulmonary Congenital heart disease5,r2

10s~~~

fibrosis, rheumatoid disease)”

White blood cell count Leukemia” Radiation therapy” CNS disease?* Glucose Diabetes” Steroids’* Creatinine and BUN Cardiovascular Renal disease”

disease

(eg, hypertension)”

Diabetes’* Diuretics” Digoxin” Pregnancy Possibility

of pregnan$‘,”

Serum chemistry Renal disease’,” Adrenal or thyroid Chemotherapy’,”

disease’

Potassium Digoxin Diuretics Aspartate transaminase Hepatic disease”

and alkaline

phosphatase

Exposure to hepatitisI’ Coagulation studies PTiPTT Leukemia” Hepatic disease” Bleeding disorder’* Anticoagulant user’ Platelets and Bleeding Bleeding Urinalysis

Not indicated Abbreviations: urea nitrogen: plastin

time.

Time

disorder” as a routine CNS, central PT, prothrombin

screening nervous time;

test” system; BUN, blood PTT, partial thrombo-

CASSIDY

342

sisting of a thorough patient interview and physical examination, lays the foundation and rationale for determining the need for further diagnostic testing. 26 The preoperative assessment nurse is integral in coordinating the objectives of the surgical, nursing, and anesthesia staffs to create a more streamlined, less-confusing assessment

AND

MARLEY

and educational process for the patient. Although updating current protocols requires a cooperative commitment from all professional specialty staff involved, the efficiency and improved clarity of communication will be a result undoubtedly as appealing to the patient as it is to the professional team.

REFERENCES 1. Accreditation association for ambulatory health care: Anesthesia services. 1996/1997 Accreditation Handbook for Ambulatory Health Care. Skokie, IL, 1996, p 39 2. Joint Commission on Accreditation of Healthcare Organizations: Assessment of patients. 1996 Comprehensive Accreditation Manual for Ambulatory Care. Oakbrook Terrace, IL, 1995, pp 89-122 3. American Association of Nurse Anesthetists: Documenting the standard of care: The anesthesia record. Professional Practice Manual for the Certified Registered Nurse Anesthetist. Park Ridge, IL, 1991, p 1 4. American Society of Anesthesiologists: Basic Standards for Preanesthesia Care. Park Ridge, IL, American Society of Anesthesiologists, 1987 5. Everett LL, Kallar SK: Presurgical evaluation and laboratory testing, in Twersky RS (ed): The Ambulatory Anesthesia Handbook. St. Louis, MO, Mosby-Year Book, 1995, pp 1-34 6. Conway JB, Goldberg J, Chung F: Preadmission anaesthesia consultation clinic. Can J Anaesth 39:1051-1057, 1992 7. Pasternak LR: Screening patients: Strategies and studies, in McGoldrick KE (ed): Ambulatory Anesthesiology: A Problem-Oriented Approach. Baltimore, MD, Williams & Wilkins, 1995, pp 2-19 8. KIeinfeldt AS: Preoperative phone calls reducing cancellation in pediatric day surgery. AORN J 51:1559-1563, 1990 9. MacArthur AJ, MacArthur C, Bevan JC: Preoperative assessment clinic reduces day surgery cancellations. Anesthesiology 75:A1109, 1991 (abstr) 10. Gibby GL, Gravenstein JS, Layon AJ, et al: How often does the preoperative interview change anesthetic management? Anesthesiology 77:A1134, 1992 (abstr) 11. Roizen MF: Preoperative evaluation, in Miller RD (ed): Anesthesia. New York, NY, Churchill Livingstone, 1994, pp 827-882 12. Roizen MF: What is necessary for preoperative patient assessment? ASA Refresher Courses in Anesthesiology 23:189-202, 1995 13. Lichtor JL, Johanson CE, Mhoon D, et al: Preoperative anxiety: Does anxiety level the afternoon before surgery predict anxiety level just before surgery? Anesthesiology 67:595-599, 1987 14. Levesque L, Grenier R, Kerouac S, et al: Evaluation of a presurgical group program given at two different times. Res Nurs Heahh 7:227-236, 1984 15. Ah NS, Khalil ZK: Effect of psychoeducational intervention on anxiety among Egyptian bladder cancer patients. Cancer Nurs 12:236-242, 1989

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RECOMMENDED

READING

Everett LL, Kallar SK: Presurgical evaluation and laboratory testing, in Twersky RS (ed): The Ambulatory Anesthesia Handbook. St. Louis, MO, Mosby-Year Book, 1995, pp l34 Pastemak LR: Screening patients: Strategies and studies, in McGoldrick KE (ed): Ambulatory Anesthesiology: A Problem-Oriented Approach. Baltimore, MD, Williams & Wilkins, 1995, pp 2-19 Roizen MF: Preoperative evaluation, in Miller RD (ed): Anesthesia. New York, NY, Churchill Livingstone, 1994, pp 827-882