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Hospitalists branch into perioperative medicine with preop assessments

Hospitalist Management Advisor, May 1, 2006

Hospitalists at the Cleveland Clinic and other facilities nationwide are fulfilling an important yet largely unmet need that they can provide in their communities to help them build their hospital medicine practices: performing preoperative assessments for surgical patients, says Amir Jaffer, MD, medical director for the IMPACT Center at the Cleveland Clinic and associate section head for hospital medicine.

According to Jaffer, roughly 13,500 patients at his facility received a thorough preoperative assessment from a hospitalist before undergoing noncardiac surgery in 2005.

Note: The IMPACT Center (Internal Medicine Preoperative Assessment, Consultation, and Treatment, www.clevelandclinic.org/gim/impact.htm) examines patients and gathers health data before surgery with the aim of minimizing their risks of developing complications as a result of surgery or anesthesia. See a sample protocol on p. 5 of the PDF of this issue.

The goal of the preoperative assessments is not only to clear patients for surgery, but also to optimize the health of patients who have medical conditions, Jaffer says. Before the IMPACT Center was founded in 1997, the Cleveland Clinic was forced to cancel surgeries regularly because patients were not cleared or in optimal health, Jaffer says. “Patients were unhappy, surgeons and anesthesiologists were unhappy, and there was lost revenue [because] the operating room was not utilized.”

In the past, surgeons admitted patients a day or two before their surgeries to perform diagnostic testing and assessment in the hospital. Today, primary care physicians (PCP) are more likely to perform preoperative assessments, but for many reasons, the quality of the assessments can be hit-or-miss, according to Jaffer. PCPs may not have the time, skills, or interest to perform the thorough assessments that are necessary.

Tip: The coordination of an outpatient infrastructure is one of the keys to establishing a successful perioperative program. It is important to consider which mechanism(s) your facility will use to schedule appointments, examine patients, and communicate with them and their PCPs on an outpatient basis.

The current need for good preoperative assessments of surgery patients is so great that it’s almost difficult to imagine that a hospital medicine service could fail in launching such a program, Jaffer says. Last year, the IMPACT Center (coupled with a satellite center for eye surgery) billed $5 million for the Cleveland Clinic—double the $2.5 million it billed in 2003.

“The biggest problem our program faces is meeting the surgical demand,” Jaffer adds. To avoid the pitfall of having to turn down consults due to a lack of staffing, hospitals and hospitalist programs must attempt to accurately predict the potential growth of their preop programs.

A recent study of 510 patients conducted by Jaffer and his colleagues and published in the October 2005 Journal of Clinical Outcomes Management found that patients who had preoperative assessments experienced a far lower rate (2.7%) of postoperative pulmonary complications than is typically reported for surgical patients. (To read the study’s complete findings, go to www.turner-white.com/jc/abstract.php?PubCode=jcom_oct05_pulmonary.)

Tip: Preop assessments at the IMPACT Center are billed to payers for patients with medical conditions. For about 5% of patients who are healthy and do not have medical conditions, the IMPACT Center bills the surgical service for history and physical.

The 10 S’s

To guide hospital medicine programs in developing their own preoperative assessment clinics or services, Jaffer developed what he calls the 10 S model. The following are 10 considerations for administrators and hospitalists who want to establish a preoperative assessment program at their own institutions:

1. Strategy. The first consideration is identifying your institution’s “type” and deciding which population you want to target for preoperative care, saysJaffer. Identify surgeons who want your services and will champion your cause. At the Cleveland Clinic, anesthesiologists were the leaders requesting the services of the IMPACT Center. They wanted to focus on anesthesia issues and did not feel equipped to handle patients’ complex medical conditions before surgery. The IMPACT Center now screens patients for many types of surgery, including

  • neurosurgery
  • orthopedics
  • colorectal surgery
  • vascular surgery

    At the Cleveland Clinic and other programs, orthopedic surgeons have been at the leading edge of requesting preoperative services from hospitalists.

    2. Space. Secondly, you will need office space for evaluating patients. Jaffer recommends negotiating for free space from the hospital when possible.

    Another inexpensive alternative is to set up shop at a preadmission testing clinic that is already oriented toward providing preoperative services.

    3. Staffing model. The IMPACT Center has a staff of four administrative personnel, two nurses, and five hospitalists. Jaffer says that if he wanted to run a leaner operation, he could probably get by with two administrative staff members. He estimates that one hospitalist is needed to see about 14 patients per day and .5 nurses is needed for each hospitalist. Some programs make use of physician extenders (e.g., physician assistants) and residents in their preoperative clinics. In terms of scheduling, Cleveland Clinic hospitalists work at the IMPACT Center for two weeks at a time. During the course of a year, the 24 hospitalists at the Cleveland Clinic will work at the preop clinic for a total of about eight to 12 weeks. Jaffer says the rotations in the preop clinic give hospitalists time to decompress and may help prevent burnout.

    4. Salary. Once you determine the number of staff needed, you can then project the budget for salaries, which, of course, are influenced by the geographic area in which you are providing services, Jaffer says.

    5. Structure. The IMPACT Center offers preoperative assessments every day from 8 a.m. to 3:30 p.m., with an hour off for lunch. Patient appointments last for half an hour. For new programs, Jaffer recommends that hospitalists designate certain hours during the week when they will conduct preoperative assessments. It is important to accommodate surgeons, especially at the beginning, he stresses. If you turn down too many requests for preoperative assessments on patients because of an overbooked schedule or a lack of staff, surgeons may stop requesting your services, Jaffer adds.

    6. Skill set. Before undertaking a perioperative program, ensure that hospitalists are comfortable with their perioperative medicine skills. Hospitalists just out of residency programs “are not always up to speed in the nuances of perioperative medicine,” Jaffer says. Others may shy away from providing outpatient services because they’re more comfortable with the inpatient setting.

    7. Screening tools. According to Jaffer, it would be a waste of time for a hospitalist to conduct a preoperative assessment on a healthy 30-year-old who is scheduled for toe surgery. As a result, it is important to screen all patients. The anesthesia department at the Cleveland Clinic has developed an online preoperative health questionnaire called the HealthQuest that rates patients’ risk profiles on a scale of one to four based on medical history. Patients with scores of three or four are usually referred to the Cleveland Clinic. Some vendors market screening programs based on this module, but a hospital medicine program could develop its own questionnaire for screening purposes.

    8. Standardization. An important role for hospitalists is to help standardize their facility’s perioperative care by ensuring that all practitioners involved in a patient’s care are on the same page regarding cardiopulmonary risk assessment, perioperative beta blockers, anticoagulation therapy, diabetes management, etc. Jaffer says hospitalists’ involvement in preoperative assessments of patients provides a perfect opportunity for them to communicate with surgeons and anesthesiologists about the standardization of care before, during, and after surgery.

    9. Services. About one in five patients who undergoes preoperative assessment is recommended as a candidate for postoperative services with a hospitalist, Jaffer says.

    As a result, the IMPACT Center hospitalist who rotates on the inpatient medical consult service and is aided by the internal medicine residents provides postoperative follow-ups. Patients are recommended for postoperative follow-up if they are at high risk for cardiac or pulmonary complications, delirium, or confusion; require perioperative anticoagulation management; or have other medical issues. In addition to preop services for elective surgery, a hospital medicine program can offer preop services for more emergent procedures (e.g., hip fractures, etc.) for which patients may come through the emergency department, Jaffer says.

    10. Systems issues. Part of a preoperative program launch plan entails outlining for administrators the benefits of providing such assessments to the system as a whole. According to Jaffer, preoperative assessments by hospitalists can result in

  • reduced lengths of stay
  • fewer routine lab tests
  • fewer surgery cancellations on the day of surgery
  • shorter times from hospital admission to surgery
  • improved outcomes n

    Hospitalist program needs outpatient orientation to make preoperative clinic a success

    One challenge for a hospital medicine program in setting up a preoperative clinic is putting in place an outpatient infrastructure for scheduling appointments, examining patients, and communicating with them on an outpatient basis, says Jeffrey Dichter, MD, FACP, founder of the hospitalist program at Ball Memorial Hospital in Muncie, IN. A hospital medicine program typically does not have that outpatient infrastructure, he says.

    Scheduling is a particularly key function for a preoperative clinic. The preoperative clinic at the 350-bed Ball Memorial assesses about 250 patients per year, says Dichter.

    The program got its start when orthopedic surgeons began requesting that hospitalists perform preoperative assessments of their patients who were scheduled for joint-replacement surgery.

    Currently, the clinic schedules two to three assessments per week but could handle up to three patients daily Monday through Friday, according to Dichter. The hospitalists see patients at the specialty practice’s offices.

    Whenever possible, the practice tries to assign a patient in the preoperative clinic to the same hospitalist that will care for him or her postsurgery to establish familiarity, Dichter adds. The hospitalists at Ball Memorial also strive to fulfill their commitment to begin a patient’s preop assessment within 15 minutes of a patient’s arrival.

    To ensure success, a preoperative clinic must also be diligent in following up on tests ordered during the preoperative assessment. This step is critical enough to warrant establishing a standardized procedure, Dichter says. “This is not an insignificant amount of work or devotion of resources.”

    Dichter recommends dedicating one staff member to the outpatient portion of the practice. He or she doesn’t have to be a full-time employee, but should be one who is accountable. Dictations, which should be done in a timely manner and sent to the anesthesiologist when complete, are another consideration.

    There are also special communication challenges in operating a preoperative assessment clinic, Dichter says. Primary care physicians and referring physicians must be informed regularly of their patients’ preoperative assessments.

    Specialty consultants should be told why they are being asked to assess a preop clinic patient. Lastly, patients must be educated about why it is necessary to undergo a preop assessment, Dichter says.

    Sample protocol for evaluating patients preoperatively

    In preoperatively evaluating patients, hospitalists at the Cleveland Clinic’s IMPACT Center use the following guidelines:

    1. General

  • A standardized typewritten unified preoperative assessment form that is available in the electronic record of the patient and printed the day before surgery so it is available as a hardcopy for the anesthesiologists and the surgeons. The form highlights detailed history of present illness; past medical and surgical history; review of systems; medications; allergies; physical exam; impression of the patient’s risk for the planned surgery; and succinct, legible, and evidence-based recommendations.
  • Subacute bacterial endocarditis prophylaxis when indicated.
  • Laboratory evaluation for all patients older than 50 using institutional guidelines.
  • Electrocardiogram in all patients with known cardiac disease, new chest pain, shortness of breath, or significant coronary artery disease risk factors.
  • Discontinue (D/C) herbals medications about two weeks before surgery.
  • D/C nonsteroidal anti-inflammatory drugs for five to seven days before surgery.
  • D/C acetylsalicylic acid and aspirin for 10 days before surgery if deemed safe.
  • D/C Clopidogrel for five days before surgery if deemed safe.
  • Hold ACE inhibitors and diuretics the morning of surgery.

    2. Cardiac

  • Functional class assessment (grades 1 to IV)
  • Noninvasive cardiac testing according to American College of Cardiology/American Heart Association guidelines in patients
  • Pacemaker checks on all patients with permanent pacemakers or automatic implantable cardioverter defibrillators
  • Echocardiograms for suspected aortic stenosis

    3. Pulmonary

  • Screening peak flow evaluation at the discretion of the physician for patients who show chronic lung disease, wheezing, or crackles upon lung examination; previous irradiation; or resection to the chest or signs of active respiratory tract infection
  • Spirometry (forced expiratory volume [FEV], forced vital capacity, and flow-volume loops) if indicated in patients with FEV less than 1L or known severe restrictive lung disease
  • Reassessment of patients suboptimally prepared for surgery at initial visit with reversible conditions (e.g., active wheezing, acute or chronic dyspnea)

    4. Neurologic

  • Carotid ultrasound for patients with new (or previously uncharacterized) carotid bruits with referral in selected case for a consultation on endarterectomy for those with stenosis greater than 80%
  • Consult for a history of malignant hyperthermia

    5. Hematologic

  • Stop warfarin five days before elective surgery and recheck on the international normalized ratio on the morning of surgery
  • Use bridging anticoagulation with heparin products in patients with a high risk of thromboembolism
  • Perform coagulation tests in patients with a known hemorrhagic diathesis, known family history, or long-term warfarin therapy

    6. Endocrine

  • Prophylactic use of perioperative intravenous glucocorticoids in patients at risk for adrenal suppression (prolonged corticosteroid treatment within the past year or known adrenal insufficiency)
  • Screening blood glucose (and glycosylated hemoglobin in selected cases) in all diabetics with preoperative optimization of glycemia as appropriate
  • Thyroid function tests in patients suspected of clinical hypo- or hyperthyroidism preoperatively


  • Cervical radiographs (with flexion views) in selected patients with rheumatoid arthritis (e.g., prolonged or deforming disease and anticipated general anesthesia)