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The anesthesiologist is the specialist most knowledgeable in evaluating and managing operative medical complexities as they relate to anesthesia and surgery. "The assessment of, consultation for and preparation of patients for anesthesia," is part of the American Board of Anesthesiology's definition of the practice of anesthesiology. *
As changes in the health care system decrease reimbursement and the length of stay in the hospital, more
The preoperative evaluation is often the first encounter a patient has with anesthesia and health system- or hospital-based services. Examination facilities, personalized services, and organizational efficiency during the evaluation often influence a patient's perception of the quality of health care at an institution. As previously mentioned, our group has found that the rapidity with which a physician sees the patient is the most important factor in determining patient satisfaction with the preoperative process (Foss JF et al, personal communication).
The establishment of a centralized anesthesia preoperative evaluation clinic (APEC) or what I call a "Preoperative And Preprocedure Assessment Clinic" (PPAC)[25] [26] [284] [285] [286] [287] [288] [289] [290] can be a positive investment for the anesthesia group and the hospital, as it becomes a recognized center for decreasing perioperative costs, improving the efficiency of clinical services, implementing clinical pathways that educate and increase market share, and increasing patient and surgeon satisfaction with perioperative and periprocedure services.
The goal of the APEC, or PPAC (I have used these terms interchangeably, although I now prefer PPAC), is to provide a comprehensive anesthesia service for physicians and their presurgical and preprocedure patients. One centralized location provides all anesthesia consultations, physical examinations, laboratory and electrocardiographic services, educational resources, and hospital registrations and insurance authorizations. Modifying the existing clinical practice to provide cost-effective preoperative evaluation can be approached by a variety of methods, educational tools, and uses of data ( Table 25-21 ).
Certain advantages do accrue when a PPAC is established, but implementation may require stages of change and growth. (I advocate taking incremental steps up the organizational ladder to efficiency: improvement of preoperative testing, implementation of education about perioperative care, and then implementation of education about expectations on pain therapy.) Instituting such a clinic requires a commitment from more than the anesthesia department. Without the support of surgical services and without administrative, financial, and emotional commitment, the PPAC will not realize its full potential and may even incur extra costs rather than savings. However, with such commitment, the health system will increase the quality of care and will decrease costs. Nevertheless, logical as it is, such commitment will not come easily.
The development of the PPAC represents a collaboration between hospital administration and the departments of anesthesia, surgery, gynecology, and nursing. Table 25-22 lists the operational goals for a PPAC.
A timeline for the development of a PPAC should be defined for hospital administration in a business plan. The plan should clearly describe not only reasonable and sustainable goals but also the financial, political, and emotional support necessary for success of the PPAC. The plan should also include analysis of the existing method of providing preoperative evaluation, recommended changes, developmental strategies, descriptions of PPAC management and organizational imperatives, and evaluation of financial risk.
The development of a PPAC begins with a departmental commitment to improve the current system. Even the simplest of changes can enhance the quality of patient care. For example, having a patient complete an anesthesia medical questionnaire in the surgeon's office and then having that information transmitted to the anesthesiologist for review several days before surgery would greatly increase the anesthesiologist's awareness of the patient's medical status.
I advise regularly sending (every 3 months) NPO guidelines, a letter about the clinic and its policies, and a set of forms reminding them of its functioning ( Fig. 25-20 , Fig. 25-21 and Fig. 25-22 , and Table 25-20 ; also see Fig. 25-2a and Fig. 25-2b ) to all surgeons and proceduralists. The information could then be made available to the surgeon, OR, and anesthesiologists the day before the anticipated surgery. This practice could reduce the delays and cancellations that occur when unexpected medical problems are present or unresolved at the scheduled time of surgery.
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