EXECUTIVE SUMMARY
Preoperative assessments are critical to patient safety and reducing liability risks. Some assessments are inadequate and fail to identify risks that could be avoided.
• Nurses may be more effective in conducting assessments than physicians.
• Do not rely solely on online questionnaires.
• Train nurses and physician assistants to probe deeper when patient answers are insufficient.
The preoperative assessment of patients is intended to uncover any potential health issues that could complicate surgery and threaten patient safety. Sometimes, the assessment can turn into a routine list of questions the patient answers without much thought. This can lead to complications and potential liability.
An effective pre-op assessment requires clinicians to carefully listen to a patient’s responses and probe more when necessary.
Although many surgeries are conducted daily across the world without incident, undetected disease, known diseases, chronic illness, and other risk factors may increase the risk of surgical complications, notes Kim Hathaway, MSN, RN, CPHRM, CPHQ, healthcare quality and risk management consultant with The Doctors Company, a medical malpractice insurer in Napa, CA.
A pre-op assessment is a standard element for accreditation and regulatory agencies. Many professional associations provide guidelines for conducting the assessment. Also, it is the key data point to determine the safest location for a surgical procedure, Hathaway says.
Potential surgical candidates with known conditions — ranging from minor upper respiratory illness or a cold to chronic conditions such as diabetes or heart disease — increase the risk of complications, she says. The procedure and length of anesthesia time must be evaluated in the context of the individual’s health. The pre-op assessment evaluates whether conditions are controlled, thus lowering their risk, or out of control, which increases the risk of complications.
The surgeon’s history and physical (H&P) should focus on whether the patient can undergo the surgery, Hathaway says. Patients with underlying comorbidities may be referred for clearance or surgical optimization by a specialist.
When a surgery is planned and elective, there is time to optimize the patients’ health status. “Generally, an H&P is conducted within 30 days of the procedure and submitted to the hospital for review by the surgical team, including the anesthesia provider. The anesthesia provider will often call the patient several days out and ask additional questions related to anesthesia to verify information and provide pre-op education,” Hathaway says. “Included in that discussion are family members’ reaction to anesthetic agents that may be hereditary to the patient, withholding food and liquids, what meds to take, the timing of the meds, and whether they should bring their meds to take immediately postoperatively.”
Specific Risks
The anesthesia provider also will record an initial score based on the ASA Physical Status Classification System, and will assess the patient again on the day of surgery. This score is helpful to suggest the setting of hospital vs. outpatient, Hathaway explains.
“The very young and very old patients have different risk factors, including frailty, than a healthy adult. Understanding normal anatomy and age-specific variations or anomalies may be detected in the physical exam and provide vital information for the surgical team,” she says. “Assessing the length and shape of the neck and tongue helps the anesthesia provider know if there will be any challenges related to intubation.”
Smoking is an independent risk factor for complications related to breathing and wound healing. It also may contribute to cardiac and other vascular events, Hathaway notes. The pre-op assessment performed several weeks before surgery can provide time for the patient to quit smoking, decreasing the risk by lowering blood pressure.
Patients with diabetes should undergo a hemoglobin A1c test. A high hemoglobin A1c may be grounds to reschedule an elective procedure, she says.
“A second assessment is also done, and is a regulatory standard, on the day of surgery just prior to induction. Nurses and the anesthesia provider will take vitals and ask questions to determine if there have been any changes, and will answer any remaining questions the patient may not have had an opportunity to ask,” she says. “The surgeon also will review the record again and ask if anything has changed. If there is a left/right surgery, it is an opportunity to review that all records have the correct procedure, patient, side, and site.”
When surgery is urgent or emergent, a good assessment can assist the surgeon and anesthesia provider in formulating the best plan for the patient despite the fact they did not have a longer preoperative period to “tune up” the patient with pre-existing conditions or risk factors, Hathaway explains. It is especially critical because often there is no history with that patient and no time to obtain records from prior care, she says.
Research Shows Assessments Vital
The authors of a paper published by the American Society of Anesthesiologists found that adequate preoperative assessment and evaluation and communication are among the most common contributing factors to preventable adverse events. (That study is available online at: https://monitor.pubs.asahq.org/article.aspx?articleid=2446504.)
Similarly, The Doctors Company Anesthesia Closed Claims Study revealed inadequate H&P often led to improper management of patients under anesthesia. These complications were caused by comorbidities present before the patient was taken to surgery. (The study is available online at: https://www.thedoctors.com/the-doctors-advocate/fourth-quarter-2019/making-further-advancements-in-anesthesia-care-safety/?utm_source=PR&utm_medium=referral&utm_campaign=PR_External&utm_content=Anesthesia_Study.)
“We found in our study that 67% of the patients had at least one comorbidity. Obesity as a risk factor impacted patients’ care in almost three times as many cases as other anesthesia cases,” Hathaway says. “Obstructive sleep apnea common in obese patients was six times more likely to impact the outcome. Hypertension was three times more likely to impact patient’s surgical results. The conditions were unrelated to the purpose of surgery, but ultimately, they were the cause of the patient harm.”
It appears many patients were unhealthy before surgery. A good preoperative assessment may have provided clues to where trouble may arise., she says.
These patients suffered high-severity injuries in 62% of cases compared with 16% of high-severity injuries in all other anesthesiology cases (excluding tooth damage cases).
H&P Guidance Available
The assessment is a focused, quality H&P, which includes review and analysis of all the information available that would apply to the procedure and the patient. There is substantial guidance from surgical, anesthesia, and other specialty organizations that describe the elements of a good assessment, Hathaway notes.
H&P is foundational to all healthcare professions, she says. “The key is to follow those recommendations and to assure the results are available in a timely manner for the healthcare team to evaluate the risks for each individual and construct the perioperative plan that is the safest. If there are cardiac issues, there are specific guidelines to optimize the patient’s condition. If they have diabetes, lung disease, or neurological disorders, the specialty will usually be consulted prior to surgery to minimize the risk, and perhaps follow the patient post-surgery,” she says. “There are tools that help to stratify the risk of patients. The ACS NSQIP [American College of Surgeons National Surgical Quality Improvement Program] Surgical Risk Calculator helps the physician evaluate the risk of complications or even death based on patient factors and type of surgery.”
Still, pre-op assessments can fall short. The Doctors Company Anesthesia Closed Claims Studies revealed that “production pressures often limited testing and input from attending or referral physicians. These pressures also limited anesthesia professionals’ opportunities to recommend safer locations for anesthesia care (e.g., hospital operating room vs. ambulatory surgery, GI, or cardiac labs) or to prepare for complications that might occur as a result of multiple comorbidities or complicated health histories.”
Patient assessments were closely linked to allegations related to failure, delay, or wrong diagnoses, Hathaway says. The physical examination (PE) always has been an integral part of medical practice. But new technologies, widespread use of electronic health records, and changes in medical school curricula are contributing to its rapid decline, she says.
“It is paramount that at the time there is a determination to proceed with an elective procedure, the proper attention must be given to the length and depth of the pre-op assessment. The surgeon’s H&P is one factor, but the optimization of the patient’s physical state is paramount to a successful outcome,” Hathaway explains. “Understanding the patient’s exercise ability, to walk without getting winded, or functional capacity is inversely related to complications. Therefore, it is extremely important to tune up a patient’s health status, particularly when comorbidities are present.”
Hathaway points out the questionnaires provide preliminary data that must be validated at several levels. It is not a standalone document or data point. A questionnaire is given in the surgeon’s office, and the hospital or surgery center also will require a health history questionnaire at admission. This typically is the first document used to capture data for a physician’s H&P, and it always should be clarified and reviewed with the patient, she says.
“This H&P examination is a regulatory requirement. If it is not done or not present, it needs to be completed and on the medical record before the patient can go to the OR suite,” she explains. “Everyone involved in the case usually reviews that document and the patient’s self-reported history, asks clarifying questions, and then adds or amends the medical record to include any missed information. It is vital that discrepancies be communicated and clarified among the surgeon, anesthesia provider, and nurses who care for the patient.”
Probe Deep for Useful Answers
The pre-op assessment should be completed at the surgery center or hospital rather than relying on the information supplied by the physician’s office, says Catherine Ruppe, RN, associate principal with ECG Consultants in Seattle.
“We got the history and physical that the physician’s office sent to us, but also did our own, side by side,” Ruppe says. “We talked to every patient ahead of surgery and would ask thorough questions, head to toe. Sometimes, we would find that the surgeon would do a cursory assessment and not delve into the details, whereas I found that the nursing staff was good about digging deeper.”
For instance, a patient may reply to a question about blood pressure by saying he or she has no hypertension issues. But then the nurse can follow up by noting the patient is taking three different blood pressure medications, and seek clarification, Ruppe says.
“The doctor may ask that question, and when the patient says no, the doctor might just move on,” Ruppe says. “We’d like to think everyone is doing a thorough job every time, but we did see a difference in how nurses approached that task. That proved critical in getting meaningful pre-op assessments.”
At her surgery centers, nurses focused specifically on family history issues that could suggest a risk of malignant hypothermia, which would require moving the surgery to a hospital setting or altering the anesthetic plan, Ruppe says.
Ruppe notes she worked closely with the surgery centers’ risk manager. Any patient safety incidents prompted an incident report, and they would review the significant incident reports together. Often, the risk manager’s first question was about the pre-op assessment.
“We always wanted to know if we missed anything. Was there anything that could have been detected in the pre-op assessment that could have flagged this particular issue?” Ruppe says. “That was not always the case, but she was always very interested in taking a look at the pre-op assessment as a primary way of seeing if this issue could have been avoided.”
The ability to conduct a good pre-op assessment comes with time and experience, Ruppe says. The key is to listen carefully to what the patient is telling you and putting that together with what you are seeing with the patient, or what you have reason to suspect might be true despite what the patient is saying or not, she says.
Nurses must engage with the patient in a meaningful way rather than just asking rote questions and recording their answers, she says. That does not always happen when physician offices ask patients to go online and complete the same health questionnaire a nurse would give, Ruppe says.
The online questionnaire is efficient, saving time over asking patients to complete the survey on site. But it is only a starting point for the pre-op assessment, she says.
“We found that if we relied on just the patient and not having the nurse review and ask some of the questions again, the online answers were not enough. You forget things that didn’t seem significant to you until someone probes more, like a family history that didn’t seem pertinent until the nurse asks,” Ruppe says. “A few minutes on the front end can save a whole lot of misery on the back end.”
Train to Listen
Nurses should be regularly trained on the importance of a thorough pre-op assessment, Ruppe says. She notes that physician assistants (PAs) conduct assessments in some practices, so they should be trained, too.
“We worked with the PAs of an orthopedic practice we worked with regularly. By training them to listen with kind of a different ear, their assessments were much better, much more thorough,” she explains.
Risk is relative, and the mortality risk will differ substantially among various procedures, notes Charles Dinerstein, MD, MBA, FACS, FSVS, medical director at the American Council on Science and Health in New York City, and a former vascular surgeon.
For example, the 1-5% mortality risk associated with vascular surgery is far too high for the 1% or so risk associated with cosmetic surgery or orthopedic surgery, he says.
“That said, you try and identify the salient risks that can be modified. Being massively overweight carries risks but cannot effectively be managed in a short time frame. Smoking can, and many physicians require smoking cessation for six weeks before elective treatment,” Dinerstein says. “The other classic problems would include stable management of chronic conditions such as hypertension or diabetes. You do not want to operate on a patient whose blood sugars are out of reasonable control. You also want to identify real but unidentified risks — the greatest being cardiovascular disease, especially coronary disease — because the stress of surgery may result in a perioperative myocardial infarction, which carries a greater mortality risk.”
Preoperative assessment also is a time tradeoff, Dinerstein says. In his experience, referring a patient for cardiac evaluation meant delaying surgery by four to six weeks. While that may be reasonable for some elective surgery, some urgent surgery cannot be delayed that long.
“The ultimate risk manager is frequently the anesthesiologist who completes a preoperative assessment and may delay surgery by not providing anesthesia services until they are satisfied it is safe. What is ‘safe’ can sometimes be gray,” he says. “Preoperative assessment is a fertile area for medical malpractice hindsight. Many surgeons request preoperative clearance from primary care physicians or specialists hoping to both deflect possible responsibility and provide, in a fee-for-service world, a form of thank-you for referring the patient.”
There is a lot of pushback from primary care physicians who have to perform many clearances, Dinerstein says. These physicians often complain they are not clearing the patient for surgery, only reviewing their current medical status.
There also has been a push to standardize these assessments with preoperative evaluation programs, Dinerstein says. These programs were developed, in part, as a cost-saving measure because of routine testing that had no value.
“The poster child here is the chest X-ray, which rarely provides any information to assess risk or improve care,” Dinerstein says. “The same holds for cardiac evaluation in patients without risk factors.”
Preoperative assessments should be designed to provide a comprehensive view of the patient’s health history and status, detect any unknown conditions, and help create the best treatment plan for their procedure, says Jennifer Kim, product manager at Casetabs, a company based in Irvine, CA, that provides technology for surgery coordination. Further, the assessments should be easy for patients to complete, and efficient for clinicians to review and share among care teams to provide the highest quality of care.
The transition to online questionnaires improves efficiency at some hospitals and surgery centers. If carried out properly, they can improve patient safety, Kim says.
“The COVID-19 pandemic is forcing these health systems to practice new protocols to minimize risk of exposure, including how information is obtained from patients in advance of a procedure,” Kim says. “This is good news, as taking the preadmission process online enables patients to complete histories at a time that is convenient for them, which yields more thorough and accurate histories.”
Furthermore, in a post-COVID world, it is critical to ensure the patient experience is not overlooked, Kim says. Physicians must recognize preassessment as not just a routine process but as actual medical care, putting the patient at the center of the entire continuum of care.
“Engaging patients meaningfully and streamlining the process for staff through a more thoughtful preassessment experience ensures the best patient outcomes, as well as higher completion rates, shorter stays, and fewer cancellations,” Kim says.
Less comprehensive assessments can lead to major adverse reactions for the patient, including morbidity, mortality, or hospital admissions, Kim explains. All factors of the patient experience should be considered throughout the patient’s stay to deliver the highest quality of care, and not just in the operating room.
“Older patients, for example, can be at fall risk at the facility,” she says. “As health systems adopt more digital health solutions in a post-COVID world, it’s critical now more than ever than that assessments are not only comprehensive in capturing all potential risk factors, but are simple for patients to complete and clinicians to access.”
Some physicians may view certain procedures as low risk, and therefore conduct less thorough assessments, Kim notes. When this happens, it is easy to miss underlying and undetected conditions.
Risk managers can encourage better assessments by recognizing and communicating that assessments are not just a process, but are equivalent to actual medical care and set the stage for a patient’s overall care experience, Kim says.
“Engaging patients meaningfully at a time when they are not rushed and have all necessary information on hand minimizes the chance of risk factors being overlooked — factors which could have major implications on the patient’s outcome,” she says.
SOURCES
- Charles Dinerstein, MD, MBA, FACS, FSVS, Medical Director, American Council on Science and Health, New York City. Phone: (212) 362-7044. Email: [email protected].
- Kim Hathaway, MSN, RN, CPHRM, CPHQ, Healthcare Quality and Risk Management Consultant, The Doctors Company, Napa, CA. Phone: (800) 421-2368.
- Jennifer Kim, Product Manager, Casetabs, Irvine, CA. Phone: (323) 922-5551.
- Catherine Ruppe, RN, Associate Principal, ECG Consultants, Seattle. Phone: (206) 689-2200. Email: [email protected].
Preoperative assessments are critical to patient safety and reducing liability risks. Some assessments are inadequate and fail to identify risks that could be avoided.
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