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Preoperative Investigations

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John Campbell ST3 Anaesthetics 12th November 2009 Problems of Pre-op Investigations Cost of investigations Time/ Delays Stretches other resources eg.labs Unlikely to ... – PowerPoint PPT presentation

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Title: Preoperative Investigations


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
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6
But...
  • Based on level 4 evidence
  • Use patients ASA grade
  • Use grade of surgical procedure
  • Simple format is 32 tables
  • Vague

7
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

8
Results Demographics
9
Results Demographics
10
Patient Age
11
Age by Specialty
12
Results ASA
13
ASAcomorbidity
  • Hypertension
  • Smoker (ASA 1 or 2)
  • Asthma/ COPD
  • Hypothyroidism
  • Ischaemic heart disease

14
NICE Guidelines
15
NICE Guidelines
  • Without children!

16
NICE Guidelines
17
By specialty ENT
18
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

19
By specialty General
20
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

21
By specialty Gynae
22
Gynaecology
  • Average age 49.2 years
  • Mostly appropriate (following NICE)
  • Trend of FBP and Blood group
  • Staffed by SHO-level dedicated to ward

23
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

24
Other tests
  • Lung function tests
  • ABG
  • Urinalysis
  • Sickle cell test
  • Pregnancy test
  • Does not include blood product matching

25
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?

26
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

27
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 96485-96.
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