Implementation and evaluation of guidelines for preoperative testing in a tertiary hospital

Preoperative investigations for elective surgical patients in a resource limited setting: Systematic review

Background

Preoperative investigation for surgical patients is important to check for conditions that may affect surgical outcome. It helps the anesthetist and surgeon to plan perioperative anesthesia and surgical management appropriately. However, 60-70% of laboratory tests before surgery are not really required. This review was conducted to develop evidence-based recommendations on preoperative investigations for patients waiting for surgery in a resource limited setting.

Methods

After formulating the key questions, scope, and eligibility criteria for the articles to be included, advanced search strategy of electronic sources from data bases and websites was conducted. Duplication of literatures was avoided by endnote. Screening of literatures was conducted with proper appraisal. This review was reported in accordance with the preferred reporting items for systematic reviews and meta-analysis (PRISMA) 2020 statement.

Results

A total of 553 articles were identified from data bases and websites using an electronic search. 75 articles were removed for duplication and 223 studies were excluded after reviewing titles and abstracts. At the screening stage, 82 articles were retrieved and evaluated for eligibility. Finally, 46 studies met the eligibility criteria and were included in this systematic review.

Conclusion

and recommendation: Selective laboratory ordering reduces the number and cost of investigations. Preoperative tests should be guided by the patient's clinical history, co-morbidities, and physical examination. Patients with signs or symptoms of certain types of disease should be evaluated with appropriate testing. Therefore, adherence to recommendations of guidelines on preoperative investigation is important for good surgical outcome and patient satisfaction.

Positive Impact of Clinical Audit on Appropriateness of Laboratory Investigations for Glucose-6-Phosphate Dehydrogenase-Deficient Patients in the Emergency Department

OBJECTIVES

The authors aim to assess the use of investigations for patients with acute hemolytic anemia due to glucose-6-phosphate dehydrogenase (G6PD) deficiency and to ensure guidelines application during practice to reduce the misuse of hospital resources in the emergency department (ED).

METHODS

A cross-sectional study was conducted at a pediatric tertiary hospital on children presenting to the ED with an acute hemolytic crisis due to G6PD deficiency. Initial investigations were collected from patients' records and compared to local hematology unit guidelines. After a period of basic training and guideline dissemination to the residents, a re-audit was conducted. Percentages of the requested investigations in each audit were calculated and compared using Chi-square test.

RESULTS

Fifty-three acute hemolytic anemia patients were included in the initial audit and 58 patients in the re-audit. In the initial audit, the most commonly requested nonindicated investigations were the Coombs test and liver enzymes. The requested nonindicated chemistry labs dropped from 74% in the initial audit to 14% in the re-audit (p < 0.001), and Coombs test from 81% to 12% (p < 0.001).

CONCLUSIONS

A large proportion of requested investigations for children presenting with G6PD acute hemolytic crisis are nonindicated. Education of medical staff about the guidelines and their continuous assessments through audits were effective at reducing unnecessary diagnostic tests.

Role of a digital tool in preoperative lung resection surgery assessment

The assessment of patients likely to undergo lung resection surgery is a multidisciplinary approach involving pulmonologists, surgeons and anaesthesiologists. In thoracic surgery, medical operability is also a calculation of postoperative lung function. A mobile application – PreParAPP MSD – to calculate postoperative lung function has been developed with the endorsement of the Italian Society of Anaesthesia, Analgesia and Intensive Care and with the unconditional support of MSD Italia. Thanks to a simple graphic interface, the calculation becomes fast and intuitive, while the possibility of storing and sharing data in an analytical and computerised way with other clinicians might help with the full assessment of patients without forcing them to undergo several medical examinations. These simple calculated parameters are performed by a minority of clinicians, generally anaesthesiologists. In our facility, there is a team involved in the perioperative evaluation of lung resection surgery (13 pulmonologists, 9 surgeons and 5 anaesthesiologists). In order to evaluate the possible Awareness towards postoperative lung function calculation better, we organised an internal survey with 27 clinicians who are members of such a team before and after the introduction of the PreParAPP MSD. It was found that after the introduction of PreParAPP MSD, the percentage of clinicians involved in postoperative lung function calculation rose from 18% to 70%. The implementation of a digital tool may help to improve guideline adherence, in accordance with other experiences in which such tools represented the start for various quality improvement purposes throughout the medical field.

Decreasing Resource Utilization without Compromising Care through Minimizing Preoperative Laboratories

Approximately 18 billion dollars is spent annually on preoperative testing. The purpose of this study was to determine whether implementation of an algorithm aimed at minimizing pre-operative tests resulted in decreased costs without compromising care. We performed a pre–post trial comparing January 2016 to April 2016 with May 2016 to July 2017. In May 2016, an algorithm was instituted in which laboratories were canceled based on an algorithm that incorporated patient and procedural factors. Total number of laboratories canceled before orthopedic, urologic, or general surgical procedures was documented. Case cancellations during this time were recorded. There were 22,175 laboratories during the study time frame. There was a significant decrease of 2.4 per cent in expected laboratories in the post-intervention group. There was an overall cost savings of $33,032.00. The per cent of patients who were seen in preoperative testing clinic and still needed medical optimization decreased after algorithm implementation (3.3% vs 2.1% P < 0.01). No cases were canceled because of lack of laboratory information. An algorithm for selective preoperative laboratory testing provides overall cost savings. Decreasing the number of unnecessary laboratories ordered reduced case cancellations. Instituting an algorithm for preoperative laboratory testing is cost-effective without compromising care.

How to rationalize preoperative tests? A method to implement local guidelines successfully

BACKGROUND

Preoperative screening includes clinical examination and tests. Systematic prescription leads to excessive tests. We conducted an observational retrospective study to assess the success of implementing a protocol-guided prescription procedure for preoperative tests (PTs). We compared the number of PTs prescribed for scheduled surgery before and after the implementation of local guidelines with a specific method.

METHODS

Local guidelines for prescribing PTs based on the French Society of Anaesthesia's recommendations were developed, validated by the anaesthesia team and actively implemented. The implementation procedure was complex and based on the application of sociologic concepts to facilitate PT prescriptions in accordance with the protocol. All PTs (except for children and emergency surgeries) prescribed over a one-week observation period were analysed before and after protocol implementation, respectively in 2011 and 2013.

RESULTS

Two hundred and ninety-two patient files were analysed: 157 in 2011 and 135 in 2013. Ninety-one percent of the prescriptions were in accordance with the recommendations in 2013. Excessive prescribing decreased significantly after the implementation of recommendations (7.1% versus 20.7%, P<0.0001), enabling us to reduce excess costs.

CONCLUSION

We observed excellent adherence to the prescription protocol for PTs. The method used to implement the protocol was successful. A future evaluation should be undertaken to confirm these results over the long-term.

Quality improvement in preoperative assessment by implementation of an electronic decision support tool

OBJECTIVES

To evaluate the impact of the electronic decision support (eDS) tool 'PReOPerative evaluation' (PROP) on guideline adherence in preoperative assessment in statutory health care in Salzburg, Austria.

MATERIALS AND METHODS

The evaluation was designed as a non-randomized controlled trial with a historical control group (CG). In 2007, we consecutively recruited 1363 patients admitted for elective surgery, and evaluated the preoperative assessment. In 2008, PROP was implemented and available online. In 2009 we recruited 1148 patients preoperatively assessed using PROP (294 outpatients, 854 hospital sector). Our analysis includes full blood count, liver function tests, coagulation parameters, electrolytes, ECG, and chest x-ray.

RESULTS

The number of tests/patient without indication was 3.39 in the CG vs 0.60 in the intervention group (IG) (p<0.001). 97.8% (CG) vs 31.5% (IG) received at least one unnecessary test. However, we also observed an increase in recommended tests not performed/patient (0.05±0.27 (CG) vs 0.55±1.00 (IG), p<0.001). 4.2% (CG) vs 30.1% (IG) missed at least one necessary test. The guideline adherence (correctly tested/not tested) improved distinctively for all tests (1.6% (CG) vs 49.3% (IG), p<0.001).

DISCUSSION

PROP reduced the number of unnecessary tests/patient by 2.79 which implied a reduction of patients' burden, and a relevant cut in unnecessary costs. However, the advantage in specificity caused an increase in the number of patients incorrectly not tested. Further research is required regarding the impact of PROP on perioperative outcomes.

Data collection variation in preoperative assessment: a literature review

This study is a systematic literature review to identify data collected in the preoperative assessment. The PubMed and CINAHL databases were searched for articles published from 1997 to 2007. From the included articles, data items that were described as part of the preoperative assessment were extracted. Identified data items were categorized into 13 categories originating from SNOMED CT. Forty-one relevant articles were found. Preoperative assessment was equally performed in outpatient clinics and in-hospitals. The assessment was performed between the day of surgery and 30 days before surgery by anesthesiologists (51%) and/or nurses (39%) and/or other professionals (34%). The included articles described 541 data items. The two largest categories of data were "past history of clinical finding" and "physical examination procedure," with 212 and 75 data items. Only 6 data items "age," "diabetes," "ECG," "cardiovascular diseases," "hypertension," and "cigarette smoking and other use of tobacco" were stated in 50% or more of the articles. This study revealed a high diversity of data being collected during the preoperative assessment. Because of the diversity of patients, one undisputed preoperative assessment data set is hard to define. However, to solve the problem of data exchangeability, professionals should at least use a common core data set.

Selective ordering of preoperative investigations by anesthesiologists reduces the number and cost of tests

PURPOSE

Preoperative investigations are frequently ordered according to care maps or protocols. We hypothesized that selective ordering of investigations by anesthesiology staff would reduce the number and cost of testing.

METHODS

Prospective descriptive double cohort study carried out over 17 weeks in a tertiary care preadmission clinic. In Group 1, testing followed usual practice (based on standing preoperative orders) while in Group 2 testing was initiated only on the order of an attending anesthesiologist or anesthesiology resident. Postoperative complications were categorized and confirmed by an internist blinded to group assignment. Fisher's exact test, Chi-square and Student's t test were used to compare the groups as appropriate. Statistical significance was inferred at P < 0.05.

RESULTS

Data were obtained from 507 patients in Group 1 and 431 patients in Group 2. Demographics and ASA risk score were similar in both groups. The mean number of tests ordered did not differ between groups. The mean cost of investigations was reduced from 124 dollars in Group 1 to 95 dollars in Group 2 (P < 0.05). If data for patients assessed by staff anesthesiologists only were considered, the mean cost of testing was reduced to 73 dollars. The number and cost of tests ordered by anesthesia residents were similar to that in Group 1. More complications were noted in Group 2, but these did not appear to be related to the altered test ordering practice.

CONCLUSION

Selective test ordering by staff anesthesiologists reduces the number and cost of preoperative investigations. Educational efforts should be directed towards improving resident and staff preoperative test ordering practices.

EFFECTIVE STRATEGY TO GUIDE PATHOLOGY TEST ORDERING IN SURGICAL PATIENTS

BACKGROUND

Ordering of pathology testing by junior medical staff is often a haphazard process with little regard to the appropriateness of test ordering. The aim of the present study was to reduce ordering of inappropriate pathology tests in surgical patients attending the pre-admission clinic (PAC) through the introduction of a protocol-based test ordering system and to create an environment where such improvement can be sustained.

METHODS

This is a prospective study with a retrospective control group. Three cohorts of patients attending the PAC were included. Group I (n = 700) attended prior to the introduction of the test protocols (April-June 2002) and acted as a control group. Group II (n = 720) attended after the protocol introduction (April-June 2003), and group III (n = 763) attended during the subsequent 3-month period from July to August 2003. The study examined the numbers of patients in each group who were ordered any of eight standard pathology tests. The average number of tests per patient, and cost of tests per patient were also ascertained.

RESULTS

Following the introduction of pathology test protocols, the ordering of all but one of the eight tests was statistically significantly reduced. In particular, ordering of coagulation studies was reduced from 22.5% to 13.8% and electrolytes, urea and creatinine from 65.2% to 48.25% of patients (both P < 0.0001). Average number of tests performed per patient declined from 2.48 to 1.88, representing a savings of 10.33 dollars per patient (a decrease from 42.22 dollars to 31.89 dollars) and a projected annualized cost saving in excess of 26,000 dollars.

CONCLUSIONS

Provided that certain preliminary guidelines are followed, these protocols can reduce pathology test ordering in any pre-admission Service.

The value of process measures in evaluating an evidence-based guideline

BACKGROUND

Linking the process of evidence-based guidelines to outcomes is difficult. We hypothesized that the process of implementing an evidence-based clinical guideline for blunt splenic trauma would reduce resource consumption and improve outcome.

METHODS

Time periods were divided into period 1 (7/1/96-6/30/99) and period 2 (7/1/99-6/30/01). On 7/1/99 our American College of Surgeons-verified level I trauma center instituted an evidence-based approach for managing splenic trauma incorporating hemodynamic normality as the process measure triggering clinical decisions. Outcomes included the number of hemodynamically normal patients treated without operation, patient death, length of stay, and cost.

RESULTS

Two hundred thirty-one patients had blunt splenic injury; 115 patients were seen during period 1 and 116 during period 2. Hemodynamically normal patients undergoing splenectomy decreased during period 2 (P<.05). Median length of stay was 8 days in period 1 and 6 days in period 2 (P<.03). Cost per patient was $34,972 US dollars in period 1 and $24,037 US dollars in period 2 (P<.03). The mortality rate was unchanged.

CONCLUSIONS

Compliance with evidence-based data in the management of blunt splenic injury improved rates of nonoperative management, decreased hospital days, and did not change mortality rates. An evidence-based clinical guideline evaluated with process measures can reduce resource use and improve outcome in a trauma program.