PREOPERATIVE EVALUATION

It is ironic that, as our interest, expertise, and knowledge concerning preoperative evaluation (see Chapter 25 ) is increasing, our ability to meet and talk with patients directly appears to be decreasing. The emphasis on ambulatory surgery (see later; also see Chapter 68 ) and same-day admissions, regardless of type of surgery, often makes preoperative personal contact with patients, whether in urban or rural settings, difficult. Despite such challenges (as well as those relating to staffing, patient scheduling, and payment), preoperative clinics appear to be increasingly prevalent.^[13] They perform the functions of data acquisition, data screening (followed by physician consultation in an unknown percentage of cases), and patient education. Patients are seen, histories and physical examinations are reviewed, appropriate (and only appropriate) laboratory tests are ordered, and additional consultations, if indicated, are requested.^{[14] [15]} Explanations of the anesthetic and surgical plans and of the options available for postoperative pain relief decrease patients' anxiety and give them a modicum of control over their own destiny.^[15] Evaluation of comorbid conditions is not only directed toward "getting the patient ready for surgery" but also—and more importantly—focuses on the long-term prognosis of specific diseases and may enhance the patient's health status (e.g., initiate β-adrenergic blocker therapy for those at risk for complications of coronary artery disease). Diagnostic, therapeutic, and consultative

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A primary issue is the staffing of these preoperative clinics. The use of advanced practice nurses appears to be common. A question that arises is whether it is ideal, desirable, and, most importantly, necessary and economically feasible for all patients to talk to an anesthesiologist during the preoperative evaluation. Screening of patient data using various algorithms can determine those whose medical status warrants direct physician consultation. Additionally, even if a patient does talk with an anesthesiologist, it is increasingly likely that it will not be the one who will be directly involved with his or her intraoperative care. This makes review and discussion of the anesthetic plan with the patient on the day of surgery, although occasionally time-consuming and inefficient, mandatory.

Undoubtedly, new options for familiarizing patients about anesthesia and surgery will emerge in the ensuing years. These might, and in some cases already do, include greater family involvement in anesthesia care, especially in the case of pediatric patients, and supplemental videotapes, in-hospital on-demand television, and departmental or hospital-based Web sites accessible from the patient's home. ^[16] These sites will likely become interactive and a source for data input directly by the patient.