1. Perioperative Pre-Admission Testing Patient Flow pat-process-review.pdfpat-process-review.pdf

2. Preoperative evaluation

  • Current AUMC PAT clinic protocols as of May 16, 2016 aumc-pat-protocols.pdfaumc-pat-protocols.pdf
  • Practice advisory for preanesthesia evaluation Selection of patients with timing of interview and physical exam, routine testing recommendations, advanced clinical decision making testing recommendations. [Systematic review, empirical]  (Anesthesiology 2012;116:522-38 asa-preaneseval2012.pdfasa-preaneseval2012.pdf
  • ASA House of Delegates, Standards, and Practice Parameters. Statement on Routine Preoperative Laboratory and Diagnostic Screening. No routine testing or diagnostic screening is necessary for preanesthetic evaluations. Testing must be related to specific clinical indicators that influence the anesthesia plan of care. [Consensus statement] Last revised 2008. asa2008-patguidelines.pdfasa2008-patguidelines.pdf
  • Are We Choosing Wisely? Expert review of the top five items to stop in practice based on consensus of identified organizations. Emphasis on reduction of testing practices. See Appendix I. [Consensus review]  (SAMBA E-Newsletter 2014;29) samba2014.pdfsamba2014.pdf
  • Preop evaluation/perioperative management of coronary artery disease during vascular surgery. No routine stress testing before vascular surgery, use Lee index to risk stratify. Only those with >=3 risk factors or active cardiac conditions should undergo stress testing, and only if vascular surgery can be delayed. Use beta blockers unless patient is 0 risk factor, preferably 30 days preop. [Empirical] (J Vasc Surg 2010;51:242-251) bauer2010.pdfbauer2010.pdf
  • Preop labs for elective low-risk ambulatory surgery. Preop testing is overused for low-risk ambulatory surgery. Neither testing nor abnormal results were associated with postop outcomes. High rates of testing in healthy patients, physician and/or facility preference, and not only patient condition currently dictated use. Surgical society involvement needed to establish preop testing guidelines. [Empirical]  (Ann Surg 2012;256:518-28) benarrochgampel2012.pdfbenarrochgampel2012.pdf
  • Ordering of unnecessary preop laboratory tests. In review of 1000 consecutive patient records, more than half had at least 1 unnecessary test. The percentage of patients with at least 1 unnecessary test can be an endpoint to monitor ordering. Incidence may be reduced if anesthesiologists rather than surgeons order tests/consults. [Empirical]  (Anesth Analg 2011;112:207-12) katz2011.pdfkatz2011.pdf
  • Preop evaluation for ambulatory. In a study of 13,000 patients, well-controlled ASA 3s had outcomes similar to that of ASA 1s and ASA 2s and did not require additional testing. Tests should only be ordered if the results will change the anesthetic or surgical plan or decrease procedure risk. [Summary of Katz study] (ASA Newsletter 2011;75:22-25) richman-glass.pdfrichman-glass.pdf
  • ASA practice guidelines for preop fasting and use of pharmacologic agents to reduce risk of pulmonary aspiration. Selection of patients with timing of fasting recommendations. General consensus is 2-hour fasting for clear liquids for infants and patients 2 years and up, 4-hour fasting for breast milk, 6-hour fasting for infant formula, solids and nonhuman milk. Guidelines for healthy patients undergoing elective surgery. No routine use pharmacologic agent. [Systematic review, empirical] (Anesthesiology 2011;114:495-511) Anesth2011.pdfAnesth2011.pdf

3. Surgery in obese patients

  • Obese patients undergoing ambulatory surgery. Increased risk for perioperative complications among patients with BMI >50kg/m2. Patients with lower BMIs do not have increased risk as long as comorbidities are controlled. [Systematic review, empirical] (Anesth Analg 2013;117:1082-91) joshi2013.pdfjoshi2013.pdf
  • Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Standards and Pathways Manual. Refer to Standard 5. Resources for Optimal Care of the MBS Patient.pdf

4. Documentation referencing ERSA and Surgical Home programs. gupta2015.pdfgupta2015.pdf

5. Hereditary hemorrhagic telangiectasia