Anesthesia Preoperative Medicine Clinic: Beyond Surgery Cancellations

Abstract

We read with great interest the article of Dr. Ferschl et al. 1titled “Preoperative Clinic Visits Reduce Operating Room Cancellations and Delays,” in which the authors reported a decrease in same-day surgery cancellation rate from 16.2% to 8.4% using an anesthesia preoperative medicine clinic (APMC). The value of an APMC, besides the physical and psychological preparation for surgery, was clearly demonstrated by their study. We applaud their excellent work and would like to present our own data to support their conclusion: An evaluation in the APMC can significantly reduce case cancellations and delays on the day of surgery.In 1998, Kaiser Permanente Baldwin Park Medical Center (Baldwin Park, California) was built to provide a full spectrum of medical and surgical service to a large and diversified population 225,000. We set up an AMPC lead by board-certified anesthesiologists from the beginning, in which all patients were evaluated 1–30 days before their scheduled surgery. Our objectives were (1) to complete preoperative anesthesia evaluation at one time in one hospital visit, (2) to reduce same day surgery cancellations, (3) to minimize operative room delays, and (4) to improve patient’s safety and patient’s satisfaction. As of the end of September 2005, we had a total of 66,424 scheduled surgical procedures (46,959 ambulatory surgeries and 19,465 inpatient surgeries). With respect to the 66,424 scheduled surgeries, we had a total of 1462 same-day case cancellations due to various reasons, with a surgery cancellation rate of 2.2% (medically related, administrative related, and patient related), the lowest same-day cancellation rate reported so far in the literature. We attribute our low same-day surgery cancellation to our successful implementation of APMC.Despite the various benefits of APMC, such as decreased perioperative morbidity and mortality,2–4the value of a full-service APMC for all preoperative patients is increasingly under scrutiny because of the cost of APMCs.5There are growing number of facilities and ambulatory surgical centers replacing APMCs with “cost-effective” alternatives such as phone preanesthesia evaluations, reviews of health surveys, and computer-assisted information gathering.6It is also increasingly common that preoperative anesthesia evaluation is conducted in preoperative holding hours even minutes before scheduled surgery and anesthesia. The study of Dr. Ferschl et al. clearly raises questions about the practice and calls for more studies to evaluate the safety, efficiency, cost, and patient and staff satisfaction of this practice.Operating room efficiency is a major determinant of hospital cost. Reengineering the perioperative process, rather than focusing on operating room turnover time, has recently shown promising result for improving overall operating room productivity.7It was estimated that the cost of operating room time was between $1,430 and $1,700/h plus the variable setup cost of the individual case.8–10However, the negative impact of case cancellations goes far beyond its financial consequence to the hospital; it also impacts patients, family members, and society.10Furthermore, frequent case cancellations can decrease both patient and staff satisfaction. In a health industry that is more frequently pay-for-performance oriented, quality, efficiency, and patient satisfaction are increasingly used as indicators for consumers as well as insurers for selecting healthcare providers. In the cost-driven environment, only hospitals that deliver high-quality care and high patient satisfaction at an affordable price can maintain their financial viability. The study of Dr. Ferschl et al. , along with others, clearly demonstrates that streamlining the perioperative practice, including APMCs, can be more rewarding.We will share our full APMC experience, in addition to our decreased surgery cancellation rate, in our following report.*Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California. chunyuan.x.qiu@kp.orgThe authors thank Rosie Rivera, R.H.I.T. (System Administrator, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California), for her effort in collecting perioperative data.