|Year : 2017 | Volume
| Issue : 1 | Page : 20-23
Does implementation of preanesthesia assessment clinics improve surgical patients care in Nigeria?
Saidu Yusuf Yakubu
Department of Anaesthesia, A.B.U. Teaching Hospital, Shika Zaria, Nigeria
|Date of Web Publication||13-Sep-2017|
Saidu Yusuf Yakubu
Department of Anaesthesia, A.B.U. Teaching Hospital, Shika Zaria
Source of Support: None, Conflict of Interest: None
Introduction: Preanesthesia assessment of patients is a major component of the perioperative care of surgical patients. The benefits of outpatient preoperative assessment clinics (PAC) were recognized over 67 years ago. However, these clinics are not used in Nigeria as part of surgical care. Search of the literature did not reveal any hospital in Nigeria that operates PAC, and therefore, its implementation in this country is still in process. This may not be unconnected with scarce financial, material, and human resources. Materials and Methods: This study was a questionnaire survey of the views of anesthetists, surgeons, and hospital administrators in some Nigerian Federal Teaching Hospitals on the usefulness and limitations of PAC. Structured questionnaires were sent to surgeons, anesthetists and Chairmen, Medical Advisory Committees in the selected Hospitalsand the results were analyzed. Results: Respondents indicated the benefits of preanesthesia assessment clinics as decrease in the incidence of surgery delays and cancelations, shorter lengths of hospital stay, improvement in the logistics of preoperative preparation, improved patient knowledge of anesthesia, and preoperative care as well as the role of the anesthetist in surgical care. Limiting factors to successful preanesthesia clinics were lack of cooperation from anesthetists and surgeons, other medical specialists, lack of supporting staff, finance, and appropriate office space. Conclusions: Preanesthesia assessment clinic increases the overall efficiency of the period of stay of the surgical patient in the hospital. Its benefits outweigh its disadvantages, and its successful implementation requires effort, time, money, and close collaboration with hospital administrators.
Keywords: Assessment, care, implementation, preanesthesia, surgical patients
|How to cite this article:|
Yakubu SY. Does implementation of preanesthesia assessment clinics improve surgical patients care in Nigeria?. Arch Med Surg 2017;2:20-3
|How to cite this URL:|
Yakubu SY. Does implementation of preanesthesia assessment clinics improve surgical patients care in Nigeria?. Arch Med Surg [serial online] 2017 [cited 2019 Mar 23];2:20-3. Available from: http://www.archms.org/text.asp?2017/2/1/20/214555
| Introduction|| |
Preanesthesia assessment is the process of clinical evaluation that precedes the delivery of anesthesia care for surgery and nonsurgical procedures. It includes an interview and examination of the patient, a review of previous medical, surgical, and anesthesia problems, a detailed account of the current medication use and reviewing the results of laboratory investigations. It can be carried out either days or minutes before surgery and on outpatient or inpatient basis.
The benefits of outpatient preoperative assessment clinics (PAC) were recognized almost 67 years ago. However, these clinics are not used in Nigeria as part of surgical care. Search of the literature did not reveal any hospital in Nigeria that operates PAC, and therefore, its implementation in this country is still in process. This may not be unconnected with scarce financial, material, and human resources.
Routinely, elective surgical patients are admitted to the hospital few days or the day before surgery and have anesthetic assessment and preoperative preparation done as inpatients. This trend has changed in many developed countries of the world. Despite the fact that PACs have not become universal even in the EU and the USA, there is a shift toward that direction because of its cost-effectiveness. The biggest disadvantage of inpatient preanesthesia assessment as is obtainable in Teaching Hospitals in Nigeria is its lack of efficiency. Preanesthesia clinics help in the reduction of day of surgery delays and cancelations by ensuring that patients are fully optimized before their surgery. It has been demonstrated that hospital efficiency is enhanced by early preoperative evaluation.
A multitude of factors play a role in the implementation of a preanesthesia assessment clinic. Besides financing and the cooperation of the various professional groups involved in surgical patient care, underlying factors such as perceived benefits and disadvantages, financial rewarding system, and organizational structure are also related to successful implementation.
This study seeks to determine the benefits and limitations of the implementation of preanesthesia assessment clinics in Nigeria.
| Materials and Methods|| |
The study was a questionnaire survey of the views of anesthetists, surgeons, and hospital administrators in some Nigerian Federal Teaching Hospitals on the usefulness and limitations of PAC. Approval of the Hospital Ethics committee was obtained before the study. Over a 3 months period, structured questionnaires were sent to surgeons, anesthetists, and Chairmen, Medical Advisory Committees in the selected Hospitals and the results were analyzed. Data obtained was presented as percentages and absolute numbers.
| Results|| |
Eighty questionnaires were sent out, and 60 were returned. [Table 1] shows that 58 out of 60 respondents said yes that the clinic improve the logistics of preoperative preparation. Fifty-six respondents believe that there will be a decrease in the incidence of surgery delays and cancelations. Another 56 of those interviewed said that PAC enriches the profession of the anesthetist. Shorter lengths of hospital stay were mentioned by 43 respondents.
Lack of appropriate office space was seen as a limiting factor to 57 of those interviewed. Fifty-five respondents indicated lack of supporting staff as a limiting factor to the successful implementation of preanesthesia clinics [Table 2]. Lack of cooperation from surgeons was cited by 49 persons. Anesthetists were seen as a hindrance to PAC in 48 instances, and lack of finance was stated by 40 respondents as a limitation to the PAC.
|Table 2: Limiting factors to the implementation of preoperative assessment clinics|
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| Discussion|| |
The study was able to determine some of the benefits and limiting factors to the successful implementation of preanesthesia assessment clinics.
Lemmens et al. in their study on the effect of national guidelines on the implementation of outpatient preoperative evaluation (OPE) clinics in Dutch hospitals found that the percentage of Dutch hospitals with an OPE clinic increased from 50% in 2000 to 74% in 2004, and the percentage of hospitals with a complete OPE clinic increased from 20% to 52%. In all hospitals without OPE clinic, the implementation of such a clinic was on the agenda and negotiations had started between the professional groups.
The development and implementation of modern and efficient PACs in the USA, Canada, Australia, and Europe  occurred in the 1990s. A modern PAC is been implemented in South Africa.
In this study, majority of the respondents say that PAC will improve the logistics of preoperative preparation. In a related study by Lemmens et al., more than 80% of those interviewed mentioned improved logistics in the preoperative pathway as a benefit of PAC. A large number of them stated that there will be a decrease in the incidence of day of surgery delays and cancellations when PAC is successfully operated. A similar study by Fischer reported a decrease in the rate of surgery cancelation from 1.96% in the year before implementation of the anesthesia preoperative evaluation clinic to 0.21% in the year following its implementation at the Stanford University Hospital. This is an indication that there are positive perception and usage of PACs in the developed world. Preoperative assessment increases efficiency and improves patient satisfaction by decreasing the number of “on the day of surgery” cancelations, and streamlining investigations., Furthermore, increasing patient satisfaction through efficient practice is an appropriate objective of a health-care system. A high cancelation rate for elective surgical procedures makes it difficult to accomplish this.
Several studies demonstrated that the reduction in the number of surgeries canceled and in the number of preoperative investigations was the main outcome of the outpatient preanesthesia evaluation. Patients will not derive any benefit from unnecessary investigations.
In a study by Roizen et al., in which they examined the adverse effects of preoperative chest X-rays (CXRs) on 606 patients, 386 CXRs were ordered without justifiable indications, and of which the discovery of only one abnormality (an elevated hemidiaphragm) could have led to improved care. Similarly, the discovery of lung shadows on three of these “routine” CXRs led to further invasive testing, including a thoracotomy, with no discovery of abnormality but at the risk of immense morbidity to the three patients, including the occurrence of a pneumothorax.
In a previous study, the implementation of an anesthetist-directed preanesthesia evaluation center at a government-funded Veterans Affairs Hospital resulted in a decrease in the cancelation rate of outpatient surgery from 26% to 6.6% during the first 6 months of its establishment.
Nearly 72% of participants mentioned short length of hospital stay as a benefit of PAC. This is what is obtainable in the USA. It was found that a PAC can shorten hospital stay by allowing patients to undergo day case or ambulatory surgery. Meeting a patient's needs for information before surgery has been shown to produce patients who are ready to leave the hospital early. Wijeysundera et al. retrospectively evaluated patients aged 40 years and older who underwent major vascular, intra-abdominal, urologic, thoracic, and orthopedic operations in Ontario, Canada, between April 1994 and March 2004 using population-based, linked, administrative databases, they found that based on the approximately 32,000 Ontario patients who underwent eligible procedures in 2003, routine anesthesia consultation might have prevented the equivalent of 11,200 days of inpatient hospitalization. They went on to conclude that the reduction in patient days of hospitalization could permit hospitals to reduce costs for inpatient care, to schedule more surgical procedures, or to use the hospital beds for other nonsurgical patients.
In this study, only 25% of respondents agreed that PAC will reduce preoperative testing. This is in variance with what is obtainable in the USA and EU. This may not be unrelated to the fact that most of our patients here come to the hospital when their disease is well advanced and therefore need thorough investigations for proper diagnosis. This is the same reason why the ordering of CXRs is high in this environment. PAC results in a reduction in excessive preoperative testing. It has been estimated that 60%–75% of preoperative tests ordered are medically unnecessary and they only add to the cost and delay the procedure and add to patients inconvenience and discomfort., PACs can provide many advantages if run under ideal conditions. Patients can be seen days or weeks before the surgery. Cancelations, preoperative delay, hospital stay, intensive care time, and laboratory testing can be reduced. It has been suggested that PACs directed by anesthetists are more cost-effective, in part due to cost-efficient practices in preoperative testing.
Only 45% of those interviewed agreed that PAC will reduce preoperative consultations in this environment. In the study by Lemmens et al. in Dutch hospitals, 79% of respondents said that there will be decrease in specialists consultations. Again, this is because patients in this environment come to the hospital with advanced disease and therefore needs properly evaluation by specialists to reduce the incidence of morbidity and mortality. A PAC can reduce the use of costly subspecialty consults without affecting patient outcome. The implementation of more stringent consultation algorithms through a high volume, tertiary care PAC led to a significantly reduced rate of preoperative cardiology consultations.
This study found that the most limiting factor for the implementation of PAC was lack of appropriate office space (95%). This was in variance with the findings of a similar study by Lemmens et al. where they found 20%.
Lack of supporting staff was mentioned by most respondents as a limitation. In the study by Lemmens et al., the most important reasons for having a partial instead of complete OPE clinic was shortage of manpower (69%). A significant number mentioned lack of cooperation from anesthetists and surgeons as a limitation to the implementation of PAC. This may not be unrelated to the fact that in most hospitals anesthetists are short staffed and since there will be no increase in salary with the running of PAC the willingness to set up one may not be there. Again, there is need for advocacy discussions between anesthetists and surgeons so that the surgeons that are worried that PAC may delay their cases will be reassured. In this environment, some surgeons perceive anesthetic nurses as more cooperative than physician anesthetists when it comes to taking their cases. This is partly because the physicians try as much as possible to practice evidenced-based medicine.
The importance of motivation and cooperation of the professionals involved was also found in a study on implementation of an in-training-assessment program in anesthesia  and in more general studies on implementation processes in medical settings. More than half of those interviewed mentioned lack of finance as a limiting factor to PAC. Lack of finance is a frequently reported problem with respect to implementation of innovations in healthcare.
| Conclusions|| |
Preanesthesia assessment clinic increases the overall efficiency of the period of stay of the surgical patient in the hospital. Its benefits outweigh its limiting factors, and its successful implementation requires effort, time, money, and close collaboration with hospital administrators.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice advisory for preanesthesia evaluation: A report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2002;96:485-96.
Lew E, Pavlin DJ, Amundsen L. Outpatient preanaesthesia evaluation clinics. Singapore Med J 2004;45:509-16.
Lee JA. The anaesthetic out-patient clinic. Anaesthesia 1949;4:169-74.
Okorosobo T. Healthcare financing in Nigeria. Niger J Health Plan Manage 1998;3:1-10.
Ferschl MB, Tung A, Sweitzer B, Huo D, Glick DB. Preoperative clinic visits reduce operating room cancellations and delays. Anesthesiology 2005;103:855-9.
Lemmens LC, Kerkkamp HE, van Klei WA, Klazinga NS, Rutten CL, van Linge RH, et al.
Implementation of outpatient preoperative evaluation clinics: Facilitating and limiting factors. Br J Anaesth 2008;100:645-51.
Lemmens LC, van Klei WA, Klazinga NS, Rutten CL, van Linge RH, Moons KG, et al.
The effect of national guidelines on the implementation of outpatient preoperative evaluation clinics in Dutch hospitals. Eur J Anaesthesiol 2006;23:962-70.
Fischer SP. Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology 1996;85:196-206.
Boothe P, Finegan BA. Changing the admission process for elective surgery: An economic analysis. Can J Anaesth 1995;42(5 Pt 1):391-4.
Kerridge R, Lee A, Latchford E, Beehan SJ, Hillman KM. The perioperative system: A new approach to managing elective surgery. Anaesth Intensive Care 1995;23:591-6.
van Klei WA, Moons KG, Rutten CL, Schuurhuis A, Knape JT, Kalkman CJ, et al.
The effect of outpatient preoperative evaluation of hospital inpatients on cancellation of surgery and length of hospital stay. Anesth Analg 2002;94:644-9.
Ravindra P, Fitzgerald E. Surgical preoperative assessment: What to do and why. Stud Br Med J 2012;20:d7816.
The Association of Anaesthetists of Great Britain and Ireland (AAGBI). The Anaesthesia Team. 3rd
ed. London: AAGBI; 2010.
Ivarsson B, Larsson S, Sjöberg T. Postponed or cancelled heart operations from the patient's perspective. J Nurs Manag 2004;12:28-36.
Roizen MF, Kaplan EB, Schreider BD, Lichtor LJ, Orkin FK. The relative roles of the history and physical examination and laboratory testing in preoperative evaluation for outpatient surgery: The 'Starling' curve for preoperative laboratory testing. Anesthesiol Clin North America 1987;5:15-34.
Pollard JB, Zboray AL, Mazze RI. Economic benefits attributed to opening a preoperative evaluation clinic for outpatients. Anesth Analg 1996;83:407-10.
Shuldham C. A review of the impact of pre-operative education on recovery from surgery. Int J Nurs Stud 1999;36:171-7.
Wijeysundera DN, Austin PC, Beattie WS, Hux JE, Laupacis A. A population-based study of anesthesia consultation before major noncardiac surgery. Arch Intern Med 2009;169:595-602.
Kumar A, Srivastava U. Role of routine laboratory investigations in preoperative evaluation. J Anaesthesiol Clin Pharmacol 2011;27:174-9.
] [Full text]
Halaszynski TM, Juda R, Silverman DG. Optimizing postoperative outcomes with efficient preoperative assessment and management. Crit Care Med 2004;32 4 Suppl: S76-86.
Starsnic MA, Guarnieri DM, Norris MC. Efficacy and financial benefit of an anesthesiologist-directed university preadmission evaluation center. J Clin Anesth 1997;9:299-305.
Tsen LC, Segal S, Pothier M, Hartley LH, Bader AM. The effect of alterations in a preoperative assessment clinic on reducing the number and improving the yield of cardiology consultations. Anesth Analg 2002;95:1563-8.
Ringsted C, Østergaard D, van der Vleuten CP. Implementation of a formal in-training assessment programme in anaesthesiology and preliminary results of acceptability. Acta Anaesthesiol Scand 2003;47:1196-203.
Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: Systematic review and recommendations. Milbank Q 2004;82:581-629.
Fitzgerald L, Ferlie E, Wood M, Hawkins C. Interlocking interactions, the diffusion of innovations in health care. Hum Relat 2002;55:1429-49.
[Table 1], [Table 2]