EXECUTIVE SUMMARY

Surgery centers can improve their preoperative screening process, which can lead to safer and more efficient outcomes.

  • A nurse discovered a patient had presented with undiagnosed malignant hyperthermia by digging into the details of the patient’s allergies and family history.
  • Surgeons, nurses, and anesthesiologists should work together to develop screening guidelines.
  • One technique is to ask questions that keep the big picture in mind.

Preoperative screening is routine. Occasionally, a physician or nurse might save a life by asking the right questions in ways that cause patients to go deeper in their answers.

Take the case of an ear-nose-throat (ENT) nurse, whose years of experience gave her the confidence to follow her instincts during a preoperative screening visit with a patient.

“She walked in and said, ‘We are going to cancel this next case,’” recalls Catherine Ruppe, RN, CASC, associate principal at ECG Management Consultants in Seattle.

The nurse had asked the patient questions about allergies, and the woman said something about an allergy to lidocaine. This triggered the nurse’s suspicion. She asked if the patient was related to anyone who reacted negatively to anesthesia. The patient first said, ‘No,’ but she changed her mind as the nurse continued to ask questions.

“She asked the same question 10 different ways, kept going, and ferreted out the answer that the patient had an aunt or uncle who died during surgery,” Ruppe says.

The nurse suspected malignant hyperthermia, even though that is rare, and she told the patient she would need to be tested for the condition before undergoing surgery. Later, the patient called the surgery center to report she did test positive for the condition.

“The patient said, ‘I was pretty mad that you canceled that surgery that day, but you may have saved my life,’” Ruppe says. “Probably 80% or 90% of people would have missed this. Whatever it was that the patient said, it made the nurse’s antenna go up.”

The better a surgery center’s preoperative assessment of patients, the better their chances of experiencing positive outcomes and avoiding risks. “Nobody likes surprises,” Ruppe says. “It’s better to be very thorough on the front end.”

There are several ways surgery centers can improve the preoperative assessment process and reduce post-surgery risk. For example, centers could collect data that is surgeon-specific. “Surgeons have the training and background to know the relative risk of procedures. What would be more valuable to them is to know their own statistics,” says Charles Dinerstein, MD, MBA, FACS, director of medicine for the American Council on Science and Health in New York City.

Data on morbidity in terms of infections and post-op problems is a worthwhile track, Dinerstein offers. For instance, organizations could track physician-level data about the number of infections that occur within 30 days after surgery. Surgery centers that are part of healthcare systems might have access to that level of data through their health system’s registries.

Another tactic is to ask questions while keeping the overall picture in mind. “If you ask a simple question, you will get a simple answer,” Ruppe says. “You have to look at the overall picture and use all the information you receive, including a review of body systems from the surgeon’s office.”

Nurses are good at conducting a thorough review of systems and eliciting better answers, according to Ruppe. “Nurses usually develop a routine and go over everything.” If a patient responds to a question about blood pressure problems by saying that is no longer is a problem, then the nurse might point out the patient is on several blood pressure medications. Nurses also might ask patients about prior surgeries and family history to learn more about potential problems with anesthesia.

“Ask whether the patient or any blood relatives ever had a problem with anesthesia,” Ruppe suggests. “If the patient says their cousin had a big problem, and the doctors said he shouldn’t have surgery anymore, then that answer should lead to more questions.”

Sometimes, nurses might examine anesthesia records from the hospital, even with same-day surgery candidates. The risk is small for malignant hyperthermia, but the consequences are huge.

One of the best methods for improving the preoperative screening process is to direct physicians, nurses, and anesthesiologists to develop guidelines for optimal screening, Dinerstein suggests.

“Spend a few hours to figure out what people need,” he says. “Give everyone dinner, moderate a discussion, and walk them through the guidelines that will give them an opportunity to talk with one another without the stress of ‘I have a case to do.’ It pays dividends that way.” Then, they can put these suggestions into guidelines with which everyone agrees, thereby improving the surgery center’s flow. The guidelines should include an assessment of patients’ medical issues, as well as the American Society of Anesthesiologists (ASA) physical status classification system priorities.

Anesthesiologists study patients’ diseases and, using the ASA classification system, they categorize patients according to level one (a normal, non-smoking, healthy patient) to level five (a patient who might not survive without surgery) and level six (a brain-dead patient). (Learn more about this system here.)

The ASA classification can help predict perioperative risks. If the anesthesiologist, in conjunction with the surgeon, classifies the patient an ASA 1, then the patient may not need any extra presurgery interventions. If the patient is an ASA 2, then the surgeon might ask the patient to quit smoking for a couple of weeks before surgery and for several weeks after. Perhaps the surgeon would ask the patient to take other actions to reduce his or her risk of postoperative complications. This collaborative approach to developing preoperative screening guidelines is much more efficient and helpful than the surgeon making the decision to go ahead with a patient’s procedure, only for the anesthesiologist to intervene, Dinerstein observes.

“There’s nothing worse than scheduling a patient, going in for preoperative testing three days before, and, in the end, the anesthesiologist says the diabetes is not under control. The case comes off the schedule with nothing in its place,” Dinerstein explains. “The surgeon who is booking the case should have a clear set of ideas of what is going to be required.”