Preoperative screening is more than a form with a checklist of questions to be answered. Surgery center staff may be walking a well-worn path, but the key is asking a familiar question in a way that could elicit a different, better response.
“The physician [conducts] the pre-op. Then. nurses do it on the phone, and then anesthesia also reviews what the doctor and nurse sent over,” says Catherine Ruppe, RN, CASC, associate principal at ECG Management Consultants in Seattle.
The important thing is to ask the same question, but in a different way. For example, a nurse could call a patient for screening and say, “OK, Mrs. Smith, I received your health history, and I’d like to review that with you,” Ruppe says. “The nurse could ask this question this way and get a better answer.”
Sometimes, patients are under less stress when answering questions by phone rather than at an in-person visit, and so they might elaborate on a particular answer. These are some tips for improving the preoperative screening process:
• Cover the most common health issues. Physicians can screen patients weeks before surgery and have them make changes that could improve their health before their procedures.
Two of the most common risks that can be mitigated when patients make lifestyle changes presurgery are smoking and diabetes.
“With smoking, it’s not uncommon for doctors to ask that the patient not smoke for at least two weeks,” says Charles Dinerstein, MD, MBA, FACS, director of medicine for the American Council on Science and Health in New York City. “There is good evidence to show that current smoking inhibits wound healing. [Patients] can get a nicotine patch.”
For total joint surgery, surgeons often recommend patients abstain from smoking for a month prior to the procedure, Ruppe notes. Diabetes needs to be well-controlled in the perioperative period — before, during, and after surgery, Dinerstein says. Anesthesiologists might be the gatekeeper, setting a cutoff for a patient’s blood glucose level.
“If the patient’s lab results come back wonky, then the physician will contact the primary care provider and see if there’s an issue we need to be aware of and get pre-op clearance,” Ruppe says.
Preoperative screening is a way for physicians and surgery centers to identify underlying risks that might not have been noticed, Dinerstein says. “We make sure diabetes, cardiovascular condition, and hypertension are all addressed preoperatively,” he explains. “You can say, ‘You have a small degree of hypertension, and I want you to see your internal medicine doctor and get that addressed.’”
• Look closely at the risk obesity poses. When the first screening indicates a patient is obese, the surgeon will decide whether it is better to proceed with the procedure or ask the patient to lose weight first, Ruppe says.
“If it’s a procedure they can wait on, they will suggest some exercises and say, ‘Go back and see your primary care provider, and when you’ve lost 25 to 50 pounds, I’ll be happy to help you,’” she adds.
There is a well-established preoperative management approach by orthopedic surgeons, who want the weight to come down before knee surgery, Dinerstein says.
Bariatric surgeons also might make this request as an insurance hurdle to show how much patients really want this procedure. Established bariatric programs have a long preoperative evaluation, he adds.
Some surgery centers have an upper limit for patients’ weight, Ruppe says. “They might stop at 35 or 40 or 45 body mass index,” she adds. “Once a patient is larger than that, the equipment might not handle them, and it’s hard on the staff.”
• Go over pre-op instructions clearly and repeatedly. “The doctor goes over things in the office about what patients should expect and gives general instructions that nurses can reiterate to patients,” Ruppe says.
The pre-op assessment emphasizes the instructions of patients not bringing in valuables, not wearing jewelry, and not eating or drinking since the evening before, she adds. “Nurses tell patients what medications they can and cannot take before surgery,” Ruppe says.
It is a good idea to let them know why these instructions are important, such as explaining that if they have a full stomach, they might feel nauseous and vomit.
• Address sleep apnea risk. Physicians should screen for sleep apnea, both diagnosed and undiagnosed.
For instance, patients need to be asked about their sleep patterns, snoring, and drifting to sleep while driving. If they are overweight and have any sleep issues, sleep apnea could be a problem, Dinerstein says.
“It’s easy to screen them and refer them to someone who can address it,” he adds. “There are three or four questions you can put into the patient care flow to pick up those patients.”
• Screen for COVID-19. Most surgery centers have instituted strict screening protocols for COVID-19. Staff take patients’ temperatures before even entering a facility.
Additionally, staff could ask patients about recent travel, symptoms, and fever in a preoperative phone call. Screening for COVID-19 can occur close to surgery time because handling the process two weeks early may not be as helpful.
For instance, a patient may test negative at one visit, then test positive one week later. Similarly, but much worse, a patient could undergo a COVID-19 test, the results return negative three days later, and the patient starts exhibiting symptoms the day after that.