Frequently Asked Questions About the
Preoperative Anesthesiology Clinic (PAC)

(File last saved: 11/4/04 )

PAC Home

Navigate to the page links below:

What is the Purpose of the Preoperative Anesthesiology Clinic?

The PAC mission is to be responsible for preparing the patient for anesthesia. This includes:

1. Evaluating each patient to identify problems which may be of a particular concern when performing an anesthetic.
2. Alerting the O.R. with regard to specific patient problems which may best be managed by particular anesthesiologists.
3. Acting as a resource for surgical services to consult when unsure of the appropriate evaluation for certain types of patients.
4. Educating patients about issues such as: NPO requirements, medications to be taken on the morning of surgery, and differences in anesthesia options.

On the other hand, however, the PAC cannot (with current resources and mandate) be responsible for:

How Do I Contact the Preoperative Anesthesiology Clinic?

[top] | PAC Home

What is the Purpose of Preoperative Assessment?

1. Documenting the condition(s) for which the procedure is needed.
2. Identifying other conditions in a timely fashion (at least 2 to 3 days before surgery) which can be improved to reduce the patient's surgical and anesthetic perioperative morbidity or mortality.
3. Obtaining consultations, when necessary, with appropriate medical services to optimize the patient's health. These consultations should ideally not be done in a "last second" fashion.
4. Allowing time for the Anesthesia Team to anticipate potential problems and to modify the anesthetic technique, the medications, and/or monitoring.
5. Educating and informing the patient about the surgical - anesthetic process, risks, and alternatives.
6. Reducing economic loss or inconvenience to patients, physicians, nursing and hospital staff by avoiding delays and cancellations.

[top] | PAC Home

What is Necessary from the Surgery/Primary Care Clinics for a Work-up?

First of all, the Surgery Clinic is responsible for explaining the surgical procedure to the patient. The Clinic should also explain the ABSOLUTE necessity of an escort home for Outpatients (who have ANY sedation, G/A, Bier block or other regional anesthesia), as well as the usual need for a caretaker overnight post-op (except for minor procedures in healthy patients when approved ahead of time). The Clinics should NEVER promise that a procedure will be done at a certain time on the day of surgery since schedules always change up to the last day before surgery. Any such unfulfilled promise is a recipe for patient dissatisfaction!

For a patient to be properly evaluated in the Anesthesiology Preoperative Clinic, the following basic information should be assembled and available to the PAC at the time of the visit:

1. The proposed procedure and the surgeon's name.
2. Whether the procedure is planned as FDS or OP , and the requested/suggested type of anesthesia (either local + sedation & monitoring: "Monitored Anesthesia Care"--also called "MAC," or regional/general anesthesia)
3. The planned date of the procedure.
4. The patient's complete chart, which includes: the old records, a medical history , an adequate review of systems , a physical exam , and available test results. The cancellation rate is, and will continue to be, increased for patients coming to the APC without a chart and/or without an H&P. Without adequate information, it is impossible to do a complete evaluation.
5. An adequate History and Review of Systems. Significant positives in the assessment should be explored, e.g.: it is not very helpful to state only that the patient has "heart disease." What kind of disease? The nature, extent, and treatment of each problem have different implications for preparing the patient for anesthesia and surgery.
   Inadequate evaluation of the cardiovascular system is the main cause of procedure delays or cancellations.
   The history, which includes medications currently taken, allergies to medications, and a pertinent review of systems continues to be the most important aspect of the preoperative assessment. This cannot be overemphasized! Omissions in the medical history continue to be an important cause of delays and cancellations.
6. The patient's vital signs (especially BP) are recorded.
7. The work-up is signed legibly by the person who performed it. Preferably, the evaluator's name is printed next to the signature. If we cannot read the signature, we won't know who to call with questions.
8. When possible, the pertinent laboratory data, the ECG, and the CXR (when appropriate) should accompany the patient to the PAC. Having immediate access to these tests will speed the evaluation process. This, we realize, is not always possible. (However, see next below)
9. If test results are not available to the PAC, each surgical clinic must have a mechanism to follow-up on abnormal tests before the day of surgery.

IMPORTANT! If patients are first seen in the PAC the day before surgery (or even worse - late in the day before surgery) it will be difficult to arrange medical consultation or obtain outside records. Please bear this in mind when surgery clinic staff arrange for the pre-surgical visit or transfer of records! Last minute evaluation of patients with significant medical problems greatly increases the likelihood of postponement and patient dissatisfaction. For these patients, an evaluation at least 3 days before surgery will greatly reduce delays and smooth the preoperative process. (Please note that there is a specific "Phone Triage" form available to be used at the time of the phone call to patient's to schedule the surgery clinic preop visit. Call us for details.)

Another important point to remember is that the patient's primary care physician or specialist is an excellent source of medical information needed in the preoperative evaluation. A patient's cardiologist or pulmonologist should always be notified of a patient's impending procedure. In addition to finding important medical information, it is important for professional courtesy, (as well as for future referrals) that the patient's primary physician and/or specialists know that the patient is scheduled for surgery.

[Top] | PAC Home

Why do Surgeries get Postponed?

In studying the problem of avoidable preoperative cancellations or postponements, it is clear that certain factors appear again and again:

1. Last minute attempts to evaluate patients with complex medical problems.
2. Lack of generally accepted clinical guidelines for adequate preoperative assessment .This produces inconsistencies, misunderstandings, and (at times) unnecessary arguments between surgeons, anesthesiologists, and internists. That is what these guidelines seek to avoid.
3. Misunderstanding about what constitutes the important aspects of preoperative assessment.
4. Missing or unavailable old records at the time of the anesthesia work-up process.
5. Missing or incomplete portions of the preoperative history or physical exam (e.g. no recorded blood pressure).
6. Lack of follow-up of ordered tests, prior to day of surgery.

Obviously, all cancellations can not be avoided. Some patients will have a change in their medical condition on the day of surgery which can not be foreseen. Most problems, however, are the result of a lack of adequate preparation and can be prevented with a little initiative. For example, in the work-up of CHEST PAIN, the following simple questions will usually resolve the issue of how to proceed:

1. How long have these episodes been going on?
2. What kind of pain: sharp, heaviness or pressure, stabbing?
3. How severe is it? (scale of 1-10)
4. How long does it last? Seconds, minutes, hours?
5. Location(s) of pain? Radiation of pain to other areas? arm, jaw, back?
6. What brings it on and what makes it worse: Activity or at rest? Food affect? Position? Deep breath, moving, anxiety? Can patient walk 2 blocks at a normal pace? Climb 1 flight of stairs? What makes it better: rest, antacid, NTG (how many per day)?
7. Associated symptoms: SOB, sweating, palpitations? Other: nocturnal dyspnea, orthopnea, edema, dizziness.
8. Has the patient seen a doctor about this? Any work-up or tests? When? How can we get these records?
9. Does primary physician or cardiologist know that patient is having surgery?

[top] | PAC Home

When does a work-up or laboratory testing become "outdated?" There is, of course, no absolute answer in the strict medical sense. In a way, it becomes outdated the day after the preoperative visit. However, JCAHO requires a H&P within 30 days of the procedure. For testing, see our current recommendations: "Basic testing Issues", "Suggested Preoperative Tests", and "Specific Disease Testing." The other question is: "when is another comprehensive H&P necessary?" Rather than give a fixed time limit to this, it makes more sense to say that patients need an evaluation directed toward the involved organ systems in a time frame commensurate with the severity and stability of the disease. For some patients with complex medical problems (especially cardiovascular ones), this may mean a week or less. For some patients who are perfectly healthy, this means up to 30 days. An "Update" note is required by CMS and JCAHO for any H&P that is more than 7 days old. However, every patient needs to be briefly reevaluated on the day of surgery. This ensures that a previously stable condition has not changed, and that a new condition has not suddenly appeared.

[Top] | PAC Home

We are often asked to comment on which patients are not appropriate candidates for outpatient surgery. These criteria are continuously evolving. Below is a table of those patients usually regarded as "poor" candidates for OP status. You must consult with us at the Anesthesiology Preoperative Clinic if you wish to book these patients as outpatients.

[Top]

PAC Home