Daily Operations and Procedures of the PPAC

The daily operations of the PPAC will vary according to patient volume, severity of the patient's medical conditions, availability of the facility, and employee resources. However, we are able to suggest a general operational structure that represents several PPACs currently in existence.

A PPAC facility can serve 40 to 60 patients a day. The full-time PPAC requires availability of assessment from 8 AM to 6 PM Monday through Friday. The average time needed from check-in to discharge of ASA I patients is 40 minutes; of ASA II patients, 60 minutes; and of ASA III or IV patients, 80 minutes. Approximately one third of that time is spent with a clinician. If fewer than 25 patients are seen daily, a half-day clinic may be appropriate. In this instance, physicians might rotate to the OR after 5-hour stints, because work in the PPAC is intense.

To allow patients to be evaluated in a timely and efficient manner, the PPAC appointment schedule and scheduling system is made available to the surgical specialty clinics. The surgeon's specific OR reservation can be linked to the requirement that a patient must also have a PPAC appointment. This practice not only facilitates anesthesia appointments but also encourages the delivery of patient-centered care.

Previously, most patients ("drop-ins") would come to the PPAC in large numbers in the mid-afternoon and would consequently experience long waits for anesthesia evaluation. Although this situation has been greatly improved by scheduling of appointments, some flexibility regarding "drop-ins" helps accommodate patients requiring urgent surgical decisions and patients from outside the hospital area.

After registration, the patient is processed through hospital/health system admissions, utilization review, and financial services, located in the PPAC. These processes are coordinated with the patient's completion of a preoperative questionnaire^[291] (see Fig. 25-2a and Fig. 25-2b ) that seeks information about pertinent medical history, previous surgeries, and medications. These processing services and completion of the questionnaire are scheduled with the goal of maximizing efficient use of physician time. The patient's medical history record is available at the time of the PPAC appointment because the medical records department has received, by electronic communication and 24 to 72 hours earlier, a list of the patient's scheduled appointments for that day.

The anesthesia evaluator interviews and examines the patient and obtains (via facsimile, secure e-mail, internet available secure databases, or phone) whatever outside medical information is needed to complete the assessment. At one site (the University of Chicago), all this information is directly entered into a patient database. Appropriate laboratory, diagnostic, and ECG requirements are determined and obtained on-site in the PPAC. The centralization of services is a significant convenience for patients, who no longer need to visit several hospital sites to complete preoperative requirements. ECGs are evaluated before the patient leaves the PPAC. All laboratory tests are reviewed at the end of the clinic day.

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A perioperative educator (usually a nurse) provides individualized education for the patient and family in the preoperative teaching center located in the PPAC. Preoperative education increases the patient's understanding of what to expect regarding postoperative pain therapy and, by decreasing anxiety and fear, achieves its goal of increasing patient comfort. Additionally, preoperative patient education reduces pain and the length of stay in the phase II recovery area and inpatient facilities, and sets the expectations regarding recovery and the needs of the patient on discharge from the hospital. The educational program is organized with the help of the specific surgical service and the office of hospital/health system planning in order to provide patients with videotapes and descriptions of expectations and plans.

Previously, each surgical service had a nurse educator who provided perioperative education for patients. The PPAC program reduced use of this hospital resource significantly and currently coordinates all education through the centralized PPAC location. The preoperative teaching center has a variety of anatomic models, brochures, charts, prostheses, specific videotapes made for this process, and other items to help patients understand their proposed anesthetic, surgical, and perioperative management. Some items can even focus on preventive long-term care (such as cessation of smoking, exercise programs, control of blood pressure, and medications). The anesthesia perioperative database program generates pharmacy orders as well as written instructions for the patient and significant others (see later). These instructions specify where to go, when to be there, which medications to take, and what to expect in the perioperative period.

The staff telephones patients on the afternoon or evening before surgery to confirm arrival time, to reinforce instructions, and to answer any questions. This contact by telephone helps to avoid delays and cancellations on the day of surgery.