Pre-operative Anaesthesia visit: Problems and Prospects in a University Teaching Hospital in Enugu, South East Nigeria
- *Corresponding Author:
- Dr A.O. Amucheazi
Department of Anaesthesia, College of medicine, University of Nigeria, Enugu campus.
E-mail: [email protected]
Date of Received :19/12/2010
Date of Accepted :7/1/2011
Available Online :7/1/2011
Background: PreâÂÂÂÂanaesthetic evaluation is a basic component of safe anaesthetic practice and ends with the establishment of an anaesthetic plan of action for individual patients.
Objectives: The aim of the present study was to assess the difficulties encountered by the anaesthetist during such visits and suggest ways they can be overcome
Subjects and Methods: The ‘activity book’ of anaesthetic resident doctors in the hospital was reviewed retrospectively for documented problems they encountered during the pre-operative visit. The problems listed were then subjected to analysis using the SPSS 17.
Result: The commonest problem was the unavailability of the patient for review 73.1% followed by very busy schedule (7.4%) and unfit patients (6.9%)
Conclusion: Anaesthetists still do encounter problems during the pre-operative visit. Exposing such problems creates the necessary awareness for improvement of patient care.
Anaesthetist; pre-operative visit; problems
Morbidity and mortality during surgery result both from the surgical procedure and the patient‟s preoperative physical status. The preoperative anaesthetic visit is aimed primarily at detecting and assessing the patient‟s health status, as well as optimising the patient‟s condition. Furthermore, it affords the anaesthetist the opportunity to review relevant investigations, provide information to the patient, explain the importance of adequate preoperative fasting, and decide the most appropriate anaesthetic technique for each patient. This visit is fundamental and mandatory. Therefore, in the absence of preoperative assessment, administering anaesthesia may be precarious. This study was carried out in our centre to identify what problems preclude proper pre-operative anaesthetic assessment.
Materials and Methods
The resident doctors in the Department of Anaesthesia, University of Nigeria Teaching Hospital, Ituku-Ozalla keep a daily activity book on behalf of the department which contains amongst other things, problems they encountered in the course of the day‟s job. The information was collected from September 2007 to June 2010. The data thus recorded was reviewed retrospectively for documented problems they encountered during the pre-operative visit. The problems listed were analysed descriptively using SPSS version 17.
During the pre-operative visits, the anaesthetists that reviewed patients were confronted with certain problems that eventually led to cancellation of cases. There were 435 patients in this category. The commonest problem was that patients were not available for review (not found in the ward or yet to be admitted) 318 (73.1%). Of these, more than 70% were due to the fact that the patients were day cases so were not admitted; and even on the morning of surgery, presented late to the anaesthetist for review. These patients reported logistics problems, transport delay, delay at records etc. This is distantly followed by patients who have been booked but could not procure anaesthetic/surgical materials for financial reasons 35 (8.05%) and problems from the anaesthetists on call being busy with emergencies so not having sufficient time to review the patients for surgery 32 ( 7.36%).
Other problems include; inability to find the patients folder 15 (3.45%); late presentation of lists 9 (2.07%); patient failing to turn up for surgery or refusing surgery while on admission 6 (1.37%) respectively (See the table and the figure below).
|Not in bed||318 (73.1)|
|Patient not ready||35 (8.1)|
|Busy anaesthetist||32 (7.4)|
|Case note withdrawn||15 (3.5)|
|Late presentation of lists||9 (2.1)|
|Patient refusal||6 (1.3)|
|Patient failing to turn up for surgery||6 (1.3)|
|Power outage||4 (0.9)|
|No operation list||2 (0.4)|
|Case postponement by surgeons||2 (0.4)|
|Robbery attack||1 (0.2)|
|Emergency solved by nature||1 (0.2)|
|Locking of ward door||1 (0.2)|
|Elective case converted to emergency||1 (0.2)|
|Patient not clerked||1 (0.2)|
|Patient died||1 (0.2)|
Table : Problems Associated with Pre-Operative Assessment of Patients
From our study, the major problem that anaesthetists encounter during the pre-operative visit, is not finding patients on their bed at the time of review. This negates the purpose of preoperative assessment which is to ensure that every patient is in the optimal state for anaesthesia and surgery as well as to formulate an anaesthetic plan suitable, and adapted for each individual patient. It is noteworthy that more than 70% of these patients who were not in bed were for ambulatory surgeries. This problem can be averted by proper planning and counselling of patients for day case procedures. The establishment of preoperative anaesthesia clinic could be one of such measures.
The purpose of pre-operative assessment is to ensure that every patient is in the optimal state for anaesthesia and surgery as well as to formulate an anaesthetic plan suitable, and adapted for each individual patient. Preoperative assessment, however, follows laid down guidelines for preoperative consultation. Once overlooked in clinical practice may result in morbidity and mortality. During a survey by Lau et al. (2001) more than 96% of patients undergoing surgical procedures requiring anaesthetic service were assessed preoperatively.
Depending on hospital‟s practice, the preoperative assessment can be performed at the anaesthesia clinic, in the ward prior to the day of surgery, or by a telephone interview/health questionnaire or even on the day of surgery.
The traditional practice has been that of anaesthetic assessment the evening before the procedure. This is the practice in our institution, but is now diminishing in certain hospitals due to inadequate time for preparation. Also pre operative assessment performed just prior to the scheduled surgery for patients admitted on the same day of operation, presenting with complex medical conditions, does not allow sufficient time for review of tests or reassessment after medical treatment had been instituted.
These days the emphasis is on performing the pre-operative assessment in the anaesthetic clinic. This practice has been shown to be of tremendous effect on optimisation of patient‟s condition, minimise surgical delays and cancellations on the day of operations for various reasons including unfit patients, or those who did not observe the pre-operative fasting guidelines etc. The anaesthesia clinic has been described as a cost effective, method of meeting patient care objectives. However, there is no prototype though it reduces expensive inpatient admissions.
Another disadvantage of assessment in a preoperative anaesthetic clinic is that the anaesthetist reviewing may not be the person responsible for intra-operative anaesthetic management. This may not be a problem in our centre because the anaesthetist that reviews though will not be the same to provide the service usually follows laid down guidelines on preoperative assessment. With adequate communication i.e. proper documentation, telephone call where necessary and efficient hospital procedures, continuous patient care can be provided. Efficiency will be increased with improved teamwork when clinical guidelines for patient assessment are practised. The preoperative anaesthetic clinic enhances patient awareness of the role of the anaesthetist as a perioperative physician, in both a professional and a public sense.
This study had some weakness. It did not answer the question as to whether the pre‐anaesthetic assessment improves patients outcome or perioperative care. Furthermore information on the total number of cases that did not present with problems was not seen in the records, thus it may be difficult to highlight the enormity of the problem. Though it has been shown by the Australian Incident Monitoring Study that inadequate preoperative assessment and management were associated with a six fold increase in mortality.
The anaesthetist should strive to review all patients pre-operatively. Barriers to this must be overcome by the right facilities. The creation of anaesthesia clinic should be encouraged for day cases and combined with the traditional practice of inpatient review the evening prior to surgery. Furthermore, day care patients should be counselled adequately to report on time.
- Forrest JB, Rehder K, Cahalan MK and Goldsmith CH. Multicenter study of general anesthesia. III. Predictors of severe perioperative adverse outcomes. Anesthesiology 1992; 76: 3–15.
- Smetana GW. Preoperative pulmonary evaluation. N Engl J Med 1999; 340: 937-944.
- Kluger MT, Tham EJ, Coleman NA, Runciman WB and Bullock MF. Inadequate pre-operative evaluation and preparation: a review of 197 reports from the Australian Incident Monitoring Study. Anaesthesia 2000; 55: 1173–1178.
- Hong Kong College of Anaesthesiologists-Professional guidelines; 1996; 13.
- Lau L, Hung CT, Chan CK, Chow B, Chui PT, Ho B et al. Anaesthetic clinical indicators in public hospitals providing anaesthetic care in Hong Kong: Prospective study. HKMJ 2001; 7:251-260.
- Millar M. Pre-operative assessment clinics - the last word. Anaesthesia 2001; 56:372-373.
- Roizen MF, Foss JF and Fischer SP. Preoperative evaluation. In: Miller MD (Ed). Anaesthesia 5th ed. New York: Churchill Livingstone; 2000:824-883.
- Conway JB, Goldberg J and Chung F. Preadmission anaesthesia consultation clinic. Can J Anaesth 1992; 39:1051-1057.
- Finegan BA. Pre-admission and Outpatient Consultation Clinics. Can J Anaesth 1992; 39: 1009-1011.
- Down MP, Wong DT and McGuire GP. The anaesthesia consult clinic: does it matter which anaesthetist sees the patient? Can J Anaesth 1998; 45:802-808.
- Cosgrove JF. Anaesthetic pre-assessment clinics. Anaesthesia 2000; 55:405-406.