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Preoperative Assessment in Private Practical Pointers for Private Practitioners

Victorian Anaesthetic Group. Preoperative Assessment in Private Practical Pointers for Private Practitioners. Dr Adam Molnar MBBS FANZCA Victorian Anaesthetic Group. Conflict of Interest. Family member owns MediTrust I have no financial interest in the product

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Preoperative Assessment in Private Practical Pointers for Private Practitioners

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  1. Victorian Anaesthetic Group Preoperative Assessment in PrivatePractical Pointers for Private Practitioners Dr Adam Molnar MBBS FANZCA Victorian Anaesthetic Group

  2. Conflict of Interest • Family member owns MediTrust • I have no financial interest in the product • I act as a medical consultant to MediTrust • I have never received a payment in the past from MediTrust • I will not receive a payment in the future from MediTrust • I pay a commercial rate to use the product

  3. My Practice • Full time private practice • Victorian Anaesthetic Group • Inner Melbourne • Major orthopaedic, colorectal, reconstructive plastic, gynaecology and endoscopy. • IT interest

  4. Private Practice in Australia • Around 2 million anaesthetics are given privately in Australia per year • 4% increase in procedures per year • Increasing complexity of cases • Increasing age of patients • Little or no current research on preoperative assessment in private

  5. Preoperative Evaluation • Cardiac –Fleischer LA et al. ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am CollCardiol 2007 • Respiratory-Bapoje SR et al. Preoperative evaluation of the patient with pulmonary disease. Chest 2007 • Diabetes • OSA • Airway

  6. The Problem • Approaching 100% same day admission • Staggered admission • Increasing pressure to provide more information • Compared to public there is a decrease waiting period • Surgeons notify anaesthetists late regarding particular cases • Patient information is on multiple systems which do not interface

  7. Preoperative Assessment Establish Rapport ✔ History ✔ Examination ✔ Investigations ✔ Anaesthetic Plan ✔ Informed Consent ✔ Anaesthetic

  8. Australian Incident Monitoring Study • Kluger MT et al Inadequate preoperative evaluation and preparation: A review of 197 reports from AIMS. Anaesthesia 2000 • 3.1% of adverse events • Preventable in 57% of cases • 23 major cases of morbidity. 7 deaths • 10% of patients had not been seen • 29% poor airway assessment

  9. Victorian Consultative Council on Anaesthetic Mortality and Morbidity • Continually emphasis the contribution of poor preoperative assessment to morbidity and mortality • “These included failure to identify patient information details, poor medical status evaluation, inadequate airway assessment, and failure to adequately assess the cardiovascular system.” • 15%anaesthetic related mortality • 12%anaesthetic related morbidity

  10. Preoperative Assessment in Private

  11. Preoperative AssessmentTechniques • Rely on surgeon assessment and investigation • In room consultations • Perioperative physicians • Phone consultations • Hospital Pre-anaesthetic Clinics • Online solutions

  12. Preoperative Assessment in Rooms

  13. Preoperative Assessment in Rooms

  14. In Rooms Consultation • Probably the gold standard • Costly • Difficult to see all patients – need to screen • May see patients too late

  15. In Rooms Consultation

  16. In Room Consultation

  17. Perioperative Physician • Renal or general physician • Patient referred by the surgeon • Complete 24/7 cover • Advantages- organise appropriate investigations, optimise medical conditions, send summary to anaesthetist prior to surgery, provide cover. • Disadvantages-lack understanding of the operative process, no anaesthetic discussion, inadequate pain control.

  18. Phone consultations • Patients like them • Advantages- History, anaesthetic discussion, screen patients prior to seeing in rooms • Disadvantage – Inefficient, examination and investigation problems, late referrals

  19. Hospital Pre-anaesthetic Clinic • Set up by hospitals • Run by nursing staff • Advantages- History, screen patients prior to seeing in rooms • Disadvantages- Late referrals, no examination or investigations, no anaesthetic discussion

  20. On-line assessment • Increase use of internet, smart phones and tablets • Capture patient at time of surgical booking • Anaesthetist introduced • Specific anaesthetic information • Provides specific informed financial consent • Health survey • Screen for in room consultation

  21. Day of Surgery Admission • Appropriate facilities • Access to rapid investigations • Access to ICU/HDU beds • Willingness to cancel

  22. Preoperative Assessment • Challenging • Anaesthetists need to be prepared to adapt • Anaesthetists must maintain their high professional standards • Anaesthetists must be involved in the process of change

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