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Preoperative Investigations

Preoperative Investigations. John Campbell ST3 Anaesthetics 12 th November 2009. Problems of Pre-op Investigations. Cost of investigations Time/ Delays Stretches other resources eg.labs Unlikely to change management Who looks at results? False positives Liability. Our audit.

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Preoperative Investigations

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  1. Preoperative Investigations John Campbell ST3 Anaesthetics 12th November 2009

  2. Problems of Pre-op Investigations • Cost of investigations • Time/ Delays • Stretches other resources eg.labs • Unlikely to change management • Who looks at results? • False positives • Liability

  3. Our audit • Objective = To demonstrate rationale and consistency in our preoperative investigations. • Standard = NICE Guidelines: The use of routine preoperative tests for elective surgery.

  4. NICE Guidelines • Published June 2003 • Originally to be reviewed 2007 and updated 2009 • Now to be reviewed ±updated June 2010 • “Recommendations to help guide the appropriate use of routine preoperative tests before elective surgery” • Children and adults • Aimed at Secondary care

  5. But... • Based on level 4 evidence • Use patient’s ASA grade • Use grade of surgical procedure • “Simple” format is 32 tables • Vague

  6. Methods • 12 days randomly selected • Feb-April 2009 • Patients’ notes reviewed • Exclusions: Emergency/ Day case/ Maternity • ASA as noted by anaesthetist • Labs/ Radiology system checked • Data of patient/procedure/tests

  7. Results: Demographics

  8. Results: Demographics

  9. Patient Age

  10. Age by Specialty

  11. Results: ASA

  12. ASA:comorbidity • Hypertension • Smoker (ASA 1 or 2…) • Asthma/ COPD • Hypothyroidism • Ischaemic heart disease

  13. NICE Guidelines

  14. NICE Guidelines • Without children!

  15. NICE Guidelines

  16. By specialty: ENT

  17. ENT • Many children; Average age 27.7 years • Lower ASA grade • Fewer tests • However, highest proportion of recommended tests not performed • Patients clerked by SHO-level between other duties

  18. By specialty: General

  19. General Surgery • Older patients • Higher ASA • Few recommended tests not performed • High number of unnecesary tests performed (esp. coag screen) • Staffed by FY1s following tradition • Possible variation between consultants

  20. By specialty: Gynae

  21. Gynaecology • Average age 49.2 years • Mostly appropriate (following NICE) • Trend of FBP and Blood group • Staffed by SHO-level dedicated to ward

  22. Overall Trends • Few CXRs performed: reassuring • ECG was most common test recommended but not performed • Trends by specialty may relate to staff clerking patients • Many tests “to be considered” as per NICE: were given benefit of doubt

  23. Other tests • Lung function tests • ABG • Urinalysis • Sickle cell test • Pregnancy test • Does not include blood product matching

  24. Issues • Who performs/ requests investigations? • What guidance is followed? • Is NICE guidance an appropriate standard? • Will a pre-assessment clinic rationalise and standardise our investigations?

  25. Summary • No clear guidance followed • Trends in investigations depending on specialty of patient • Trends may relate to staff clerking patients • Introduction of pre-assessment clinic may standardise investigations

  26. References • National Institute for Health and Clinical Excellence. Preoperative tests: the use of preoperative tests for elective surgery. Available at: guidance.nice.org.uk/CG3. Accessed July 4, 2009. • Roizen M. More preoperative assessment by physicians and less by laboratory tests. New England Journal of Medicine 2000; 342: 204-5. • Practice Advisory for Preanesthesia Evaluation: a report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2002; 96:485-96.

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