Same-day Admission Research Articles

A Strategy to Improve Quality of Outpatient Education for Residents and Medical Students on a Vascular Surgery Service

In the current era of same-day admissions and decreased length of hospitalization for major vascular operations, education of residents and medical students in the outpatient setting has become an increasingly challenging problem. We developed a strategy to provide improved outpatient experience for advanced vascular surgery residents (VSRs), general surgery residents (GSRs), and medical students (MSs) on a vascular surgery service. A survey of program directors and VSRs at accredited vascular surgery fellowships in the United States and Canada was undertaken to determine the manner in which outpatient education was accomplished and the amount of time devoted to pre- and postoperative patient evaluation. The survey revealed that VSRs, GSRs, and MSs spent 1 or more days in clinic at approximately half of accredited vascular surgery programs. There were no appreciable differences in time spent in clinic for different levels of trainees. VSRs preoperatively evaluated at least half of their patients at approximately two-thirds of the programs, while at the other third of the programs they preoperatively evaluated one-quarter or less of their patients before surgery. GSRs preoperatively evaluated at least half of their patients at 50% of programs, according to program directors, and at 69% of programs, according to VSRs. Because of recent changes in health care delivery and the effect of these changes on resident training, outpatient education of VSRs, GSRs, and MSs will require increased attention on the part of vascular surgeons involved with their education. increasing time demands and decreasing reimbursements for vascular surgeons as a result of managed health care may make this goal increasingly difficult to accomplish. Improved strategies and extra efforts are necessary to ensure that trainees obtain sufficient experience to evaluate vascular patients pre- and postoperatively and maintain high quality of care for vascular surgery patients.

Dysphagia lusoria: A case study

Dysphagia lusoria is described in the literature as difficulty swallowing because of a “jest of nature.” The “jest of nature” is a birth defect encompassing any aortic root vascular anomaly that causes esophageal dysphagia. Persons with dysphagia lusoria can be categorized according to their specific subclavian anomaly (ie, depending on the presence of an aneurysm, occlusive disease, or esophageal compression). All patients with this anomaly have an aberrant subclavian artery in a transposed position that courses posterior to the esophagus. The operative approach to repair this condition has been controversial. An extrathoracic approach is documented as superior to a repair involving thoracotomy because there is decreased rate of complications that may be associated with a thoracotomy and greater visibility of the subclavian and carotid artery. This case study describes a 25-year-old woman with dysphagia lusoria related to an aberrant right subclavian artery. The report includes a literature review and describes the perioperative approach and nursing care. The use of the preadmission and same-day admission services are supported as is an extrathoracic surgical approach. At follow-up this patient reported no symptoms of dysphagia and showed no evidence of esophageal compression confirming that persons with symptomatic dysphagia lusoria can be managed with positive long-term results. (J Vasc Nurs 2001;19:14-9)

Short Stay Carotid Surgery for Veterans: An Emerging Standard

We have taken the short stay approach to carotid artery surgery to our VA setting over the past 5 to 6 years. Retrospectively, we reviewed the efficacy and safety of that approach in 201 consecutive carotid operations over the recent 4-year period (January 1, 1996–December 31, 1999). In 1996 we had already begun the transition to an algorithm to (1) utilize carotid color flow Doppler duplex exams for diagnosis, (2) same-day admission (SDA), (3) intensive care unit (ICU) only when deemed medically necessary, and (4) next-day discharge. Results of this approach have been a decrease in the utilization of diagnostic arteriograms and utilization of the ICU from 100% previous to the onset of this approach to 17 and 22%, respectively. SDA increased from 24 to 89%. Mean LOS decreased from 5.13 ± 0.9 to 1.97 ± 0.4 days. The percentage of patients completing the algorithm went from 15 to 72%. Stroke and/or death varied from 0 to 3.7% each year and was only 2.4% over the 4-year period. In conclusion, this approach to short stay carotid surgery in the veteran population has proven both efficacious and safe with results similar to those in university and community practices.

Carotid stenting

Carotid endarterectomy (CEA) is one of the most frequently performed surgeries in the United States. To offer patients a less invasive means to achieve the same goal, we investigated carotid angioplasty with stenting (CAS) as an alternative to CEA. A total of 528 patients underwent CAS; 604 vessels/hemispheres were treated. The mean age was 69 ± 10 years; 172 patients (33%) were women. Of the patients treated, 91 (15%) presented with post-CEA restenosis. Contralateral carotid occlusion was present in 61 patients (10%). CAS was performed by using a coaxial system with a 7F, 90-cm sheath, predilatation, stent placement, and stent dilatation. Patients were pretreated with antiplatelet therapy. Same-day admissions and 23-hour discharges were typical. The technical success rate was 98.6%. The 30-day mortality rate was 1.6% (3 [0.6%] neurological, 5 [1 %] systemic). There were 6 (1 %) major strokes (4 [0.6%] related to intervention), and 29 minor strokes (4.8%). Of the 29 minor strokes, 11 (38%) resulted in complete recovery. On an annualized basis, the incidence of minor stroke declined: 7.1% (1994 to 1995), 5.8% (1995 to 1996), 5.3% (1996 to 1997), 3.2% (1997 to 1998), and 3.1% (1998 to 1999). Restenosis of ≤50% was identified in 5.3% of cases. We conclude that CAS is an effective treatment for carotid stenosis. The complication rate compares favorably with endarterectomy. Carotid endarterectomy (CEA) is one of the most frequently performed surgeries in the United States. To offer patients a less invasive means to achieve the same goal, we investigated carotid angioplasty with stenting (CAS) as an alternative to CEA. A total of 528 patients underwent CAS; 604 vessels/hemispheres were treated. The mean age was 69 ± 10 years; 172 patients (33%) were women. Of the patients treated, 91 (15%) presented with post-CEA restenosis. Contralateral carotid occlusion was present in 61 patients (10%). CAS was performed by using a coaxial system with a 7F, 90-cm sheath, predilatation, stent placement, and stent dilatation. Patients were pretreated with antiplatelet therapy. Same-day admissions and 23-hour discharges were typical. The technical success rate was 98.6%. The 30-day mortality rate was 1.6% (3 [0.6%] neurological, 5 [1 %] systemic). There were 6 (1 %) major strokes (4 [0.6%] related to intervention), and 29 minor strokes (4.8%). Of the 29 minor strokes, 11 (38%) resulted in complete recovery. On an annualized basis, the incidence of minor stroke declined: 7.1% (1994 to 1995), 5.8% (1995 to 1996), 5.3% (1996 to 1997), 3.2% (1997 to 1998), and 3.1% (1998 to 1999). Restenosis of ≤50% was identified in 5.3% of cases. We conclude that CAS is an effective treatment for carotid stenosis. The complication rate compares favorably with endarterectomy.

Ultra fast track in elective congenital cardiac surgery

Background. Changes in healthcare delivery have affected the practice of congenital cardiac surgery. We recently developed a strategy of limited sternotomy, early extubation, and very early discharge, and reviewed the perioperative course of 198 pediatric patients undergoing elective cardiovascular surgical procedures, to assess the efficacy and safety of this approach.Methods. One hundred ninety-eight patients aged 0 to 18 years (median 3.2 years) underwent 201 elective cardiovascular surgical procedures over a 1-year period. All patients were admitted on the day of surgery. Patients were divided into six diagnostic groups: group 1, complex left-to-right shunts (n = 14, 7.0%); group 2, simple left-to-right shunts (n = 83, 41.3%); group 3, right-to-left shunts with pulmonary obstruction (n = 33, 16.4%); group 4, isolated, nonvalvular obstructive lesions (n = 30, 14.9%); group 5, isolated valvular anomalies (n = 20, 10.0%); and group 6, miscellaneous (n = 21, 10.4%).Results. After 201 procedures, 175 patients (87.1%) were extubated in the operating room and 188 (93.6%) within 4 hours from operation. Four patients (2.0%) were extubated more than 24 hours from completion of the procedure, and 2 (1.0%) died while on respiratory support (never weaned). Five patients (2.6%) failed early extubation (<4 hours). Early discharge was achieved for the vast majority of patients. Overall median length of stay (LOS, including day of surgery as day 1) was 2.0 days, with a median LOS of 3.0 days for those patients requiring circulatory arrest duration exceeding 20 minutes. Of 195 patients, 43 (24.6%), 121 (74.0%), and 159 (81.5%) were discharged, respectively, at < 24, < 48, < 72 hours from admission. Longest and shortest mean postoperative LOS were in group 6 (9.9 ± 14.5 days) and group 2 (1.6 = 0.7 days), respectively. Six patients (2.9%) died, and 11 (5.5%) suffered in-hospital complications. Thirty patients (15.4%) were either treated as outpatients (n = 11, 5.7%) or readmitted (n = 19, 9.7%) within 30 days from the time of surgery. Only 8 of 195 patients (4.1%) were readmitted with true surgical complications requiring invasive therapeutic procedures.Conclusions. Selected patients with a broad spectrum of congenital heart disease may enjoy same-day admission, limited sternotomy, immediate extubation, and very early discharge with excellent outcomes and acceptable morbidity.

The effect of anesthetic patient education on preoperative patient anxiety

Background and Objectives. Preoperative time spent with patients has been abbreviated with the advent of same-day admission requirements and outpatient surgery. This study was conducted to evaluate the effects that materials mailed to the home relating to anesthetic-focused patient education may have on preoperative patient anxiety. Methods. Patients scheduled for a total hip arthroplasty or for a total knee arthroplasty were screened via telephone for inclusion in a prospective, randomized study. Patients were asked about their access to a video cassette recorder/player (VCR) and their limitations regarding hearing or vision. Subjects were randomly assigned to either the intervention group and received two pamphlets and a video describing general and regional anesthesia or to the usual care group. All subjects were mailed a preoperative demographic questionnaire and a State Trait Anxiety Inventory (STAI), as developed by CD Spielberger (1). Questionnaires were completed at least 96 hours prior to admission and again preoperative on the day of surgery. Results. Of 236 patients screened, 26 had no access to a VCR, 6 were hearing or visually impaired, and 4 declined participation. Of 200 subjects randomized, 134 completed both sets of questionnaires and thus form the basis of this report. A statistically significant difference between the subjects who received the video and pamphlets and the usual care subjects was detected with respect to change in STAI-assessed anxiety from baseline to immediately prior to surgery ( P = .035). The intervention subjects experienced a smaller mean increase in anxiety. Forty-nine percent of the usual care subjects expressed interest in having additional information. Conclusions. Increase in preoperative anxiety is diminished when additional anesthesia information in printed and video format is made available. Useful information can be provided to patients to view or read prior to surgery.

In Process Citation

Soaring health care costs are also forcing surgeons and anaesthesiologists to introduce practice patterns that allow more efficient use of expensive hospital resources. Because perioperative ward expenditures account for approximately one-third of the hospital costs incurred for surgical inpatients, with personnel costs being a major component, interventions that decrease the length of stay can result in considerable savings without affecting the quality of care. Interventious that can reduce the length of stay are outpatient preoperative evaluation and same-day admission, improvement of OR efficiency and sufficient cost-effective facilities for qualified postoperative care.

One-Day Admission for Lung Lobectomy: An Incidental Result of a Clinical Pathway

Background. Most complications after lung lobectomy are related to pain, narcotic analgesia, and inactivity. When the operation is performed with the goal of minimizing postoperative pain, and when rapid restoration of activity and patient independence can be achieved, most postoperative complications can be obviated and early discharge can be attained.Methods. Since March 1996, we have performed 10 consecutive elective major lung resections (8 lobectomies and 2 bilobectomies) for neoplastic (n = 8) and benign inflammatory (n = 2) lesions. Of the 10 patients, 4 were men and 6 were women ranging in age from 58 to 77 years (mean age, 66 years). Extensive preoperative patient and family education was provided in the surgeon’s office. Same-day admission was followed by an oblique muscle-sparing minithoracotomy to access the chest cavity. A meticulous operation, with special attention to minimizing air leak and postoperative discomfort, was performed. Intercostal nerve cryolysis was used as the main method of analgesia.Results. All patients underwent the planned operation through a minithoracotomy and were extubated in the operating room. All patients exhibited normal ipsilateral shoulder girdle mobility in the recovery room and none required intravenous narcotics after leaving this unit. All patients were out of bed the day of the operation. The chest tube was removed the night of the operation in 2 patients, the morning after the operation in 6 patients, and on the second postoperative day in 1 patient. One patient who was discharged with a Heimlich valve had this device removed in the office 4 days after the operation. After the chest tubes were removed, there were no instances of pneumothorax. All 10 patients were able to ambulate independently on the first postoperative day. Eight patients were discharged home the morning after the operation and 2 on the second postoperative day. None of the patients have required readmission related to their operation or have exhibited evidence of postthoracotomy pain syndrome.Conclusions. We have developed a clinical pathway based on patient education, meticulous minimally invasive operation, cryoanalgesia, and quick resumption of physical activity. Our preliminary experience with this approach has shown minimal morbidity, rapid restoration to preoperative status, and, for most patients, a 1-day hospital stay after major lung resection.

How safe is hospital-in-the-home care?

To describe the rate of negative, unexpected and adverse events associated with hospital-in-the-home (HIH) care in an established unit, and to validate indicators of safety for HIH care. Prospective descriptive survey. 231 patients, who would otherwise have required hospitalisation, accepted for acute home-based care by the HIH unit at Frankston Hospital, a 350-bed hospital serving a population of 240,000 on the south-eastern boundary of Melbourne. The following indicators of safety: patient telephone calls to the on-call service; unscheduled staff callout to patients' homes; return to hospital during an HIH admission; and return to hospital after discharge. 190 acute admissions were examined. Planned same-day admissions were uneventful and excluded from the analysis. The therapies provided were intravenous therapy (mainly antibiotics), anticoagulation, and wound care. Unplanned patient telephone calls were received in 6.3% of admissions; 5.8% of acute admissions required an unscheduled staff home attendance; 4.2% of episodes resulted in a return to hospital, of which 2.6% required continued care in hospital; 2.2% of episodes resulted in a return to hospital within 14 days of discharge for a related problem. The rate of iatrogenic adverse events was 3.5%. HIH care is very safe. This study may help define safety standards for HIH care so that future studies can compare them with those of traditional inpatient care.

Study on Effect of Methods of Preoperative Education in Women

The authors' repeated measures experimental study at a 359-bed community medical center located in California compared the effect of preadmission structured education with postadmission unstructured education on the outcomes of patient satisfaction, postoperative recovery, and return to functional status. Power analysis for a large effect size was used to determine the sample size of 50 adult females scheduled for open abdominal surgery. The authors used valid and reliable tools to measure the dependent variables and their findings suggest that same-day admission surgical patients who receive preadmission structured education have improved clinical outcomes, are more satisfied, are more likely to meet the targeted discharge date, and return to prior functional status sooner.

Use of outpatient preoperative evaluation to decrease length of stay for vascular surgery.

Interventions that decrease perioperative length of stay can result in considerable cost-savings. This study assesses the impact of same-day admission using outpatient preoperative evaluation on the lengths of stay and hospital costs for patients who underwent carotid end-arterectomy (CEA) or lower extremity revascularization (LER). Patient characteristics and length of stay were compared for two 1-yr periods before and after outpatient preoperative evaluation had been implemented. There were no significant differences before and after the initiation of outpatient preoperative evaluation in the CEA and LER groups in mean age and ASA physical status distributions. The average preoperative length of stay decreased significantly from 7.0 to 1.9 days in the CEA group and from 9.0 to 2.8 days in the LER group. This reduction in the length of stay was associated with a cost-savings of $900 per patient and did not have an adverse effect on patient outcome. We conclude that outpatient preoperative evaluation clinics reduce the cost and length of stay in vascular surgery patients. We found that outpatient preoperative evaluation and same-day admission were associated with a decrease of 4.5 days in the preoperative length of stay for carotid endarterectomy and lower-extremity revascularization. This was not accompanied by increased mortality and led to hospital cost-savings of approximately $900 per patient.

Do clinical pathways for major vascular surgery improve outcomes and reduce cost?

This study was performed to determine whether the implementation of clinical pathways for patients who undergo major vascular procedures in a community hospital would shorten the length of stay and reduce charges when compared with Medicare standards. Length of stay, hospital costs, and morbidity, mortality, and readmission rates for the four most common vascular diagnosis-related group (DRG) categories at our institution were compared with Medicare standards. The four categories were DRG 005 (extracranial vascular procedures), DRG 110 (aortic and renal procedures), DRG 478 (leg bypass with comorbidity), and DRG 479 (leg bypass without comorbidity). Between May 1, 1994, and June 30, 1996, 112 patients underwent carotid endarterectomy, 42 patients underwent aortic or renal procedures, and 130 patients underwent lower extremity bypass procedures (68% with comorbidity). Only Medicare patients were included because exact cost/reimbursement data were available. No admissions were excluded. The average length of stay was 1.2 days for DRG 005, 6.9 days for DRG 110, and 3.2 and 2.1 days for DRGs 478 and 479, respectively. The average cost savings when compared with the Medicare reimbursement was $4338 for DRG 005, $7161 for DRG 110, $4108 for DRG 478, and $2313 for DRG 479. Readmission was necessary for 9% of peripheral bypass patients. Ten percent of patients in DRG 005 and 86% of patients in DRG 110 needed intensive care, whereas only 2% of patients who underwent complicated bypass procedures did. Ninety percent of carotid endarterectomy patients and 23% of leg bypass patients were discharged on the first postoperative day. There were two postoperative strokes (2%) after carotid surgery. Thirty-three percent of aortic/renal patients had complications that led to care outside the clinical pathway. Twenty-five percent of leg bypass patients required home care to treat open foot wounds. Total inpatient cost savings were $1,256,000 when compared with Medicare reimbursement. Clinical pathways significantly improve the length of stay and decrease inpatient charges for major vascular surgical procedures while maintaining high standards of care. Factors that favorably affected the length of stay and hospital charges were outpatient arteriography, same-day admission, early ambulation, physical therapy, home care, use of the intensive care unit on a selective basis, and early discharge. Factors that adversely affected these outcomes were emergency admission, inpatient arteriography, thrombolytic therapy, complications, and the need for dialysis or anticoagulation.

Changes in bed resources and admission patterns in acute public hospitals in Victoria, 1987-1995.

To describe changes in admission patterns, bed resources and hospital use in acute public hospitals and their relationship with early readmissions and interhospital transfers in Victoria between 1987 and 1995. Descriptive study of longitudinal trends using data from the Victorian inpatient Minimum Database and the Acute Health Services Branch of the Department of Human Services, Victoria. State of Victoria. Acute public hospital beds and hospital separations per 1000 population; separation type (same-day or longer); mean length of stay; interhospital transfers; and readmissions to the same hospital within 28 days. Between 1987-88 and 1994-95, public hospital beds in Victoria decreased from 3.2 to 2.8/1000 population, and mean length of hospital stay decreased from 6.4 to 4.2 days. There was a significant direct correlation between number of beds/1000 and length of stay (r = 0.90; 95% confidence interval [CI], 0.52-0.98). Bed occupancy remained constant at 80%. Over the same period, same-day admissions increased from 22% to 42% of hospital separations, interhospital transfers increased from 2.7% to 4% of separations, and readmissions to the same hospital within 28 days for any reason increased from 12.4% to 15% of separations (21% increase). Beds/1000 were inversely correlated with interhospital transfers (r = -0.83; 95% CI, -0.31 to -0.97), while readmission rates were inversely correlated with beds/1000 (r = -0.89; 95% CI, -0.98 to -0.50) and length of hospital stay (r = -0.95; 95% CI, -0.99 to -0.74). There were significant changes in the patterns of use of public hospitals between 1987 and 1995, possibly reflecting technological advances and changes in clinical practice, as well as policy to improve efficiency. Early readmission rates may be a useful proxy measure of potentially avoidable adverse outcomes.

Efficacy and financial benefit of an anesthesiologist-directed university preadmission evaluation center

Study Objective: To study the effectiveness of an anesthesiologist-directed preadmission evaluation center (PEC) in our institution. Design: I: Preoperative test costs were measured on two sets of patients undergoing same-day surgery, II: Rate of cancellation was measured on all patients undergoing same-day surgery in a subsequent one-year time period. Setting: The PEC, short procedure unit, and same-day admission unit of a university hospital. Patients: I: 3,062 male and female patients undergoing same-day surgery between January 1, 1992, and August 31, 1992. II: 9,454 male and female patients undergoing same-day surgery between July 1, 1993, and June 30, 1994. Interventions: Age, ASA physical status, type of surgery performed, and tests ordered were recorded in two groups of same-day surgical patients. Group S had testing primarily ordered by surgeons, augmented by the anesthesiologists in the PEC. Group A had testing primarily ordered by the anesthesiologists in the PEC, but surgeons could still order tests they felt necessary. On the day of surgery, the attending anesthesiologist recorded any additional testing that was required or would have altered intraoperative management. In a follow-up study, cancellations of same-day surgical patients were recorded for a one-year period. Measurements and Main Results: I: With the exception of complete blood counts with differentials, significantly fewer tests were ordered in Group A than Group S. These changes produced an average cost savings of $20.89 per patient. There were no recorded cancellations or apparent alterations in intraoperative management attributable to inadequate testing. II: Of the 9,454 same-day procedures from 7/1/93 to 6/31/94, 66 were cancelled on the day of the procedure. None of the patients seen in the PEC were cancelled due to causes possibly preventable by a PEC, unlike the cases of 4 patients who had not been evaluated in the PEC and were cancelled. Conclusion: A PEC, in which the anesthesiologist primarily orders preoperative tests and approves patients' readiness for surgery, is both an efficient and cost-effective system.

Practitioner or provider: Are they mutually exclusive?

Practitioner or provider: Are they mutually exclusive?

Advances in anesthesia for cardiac surgery: an overview for the 1990s.

Anesthetic care for patients undergoing cardiac surgery has changed dramatically in the past 10 years. Examples of such change include same-day admissions, "fast-track" protocols, selective use of pulmonary artery catheters, transesophageal echocardiography, and the introduction of new drugs such as phosphodiesterase inhibitors and antifibrinolytic agents. Under pressure from our peers and those funding health care, we are making major efforts to reduce costs and the length of hospitalization while maintaining high quality of care.

Same-day admissions and other cost-saving strategies for elective aortoiliac surgery.

We retrospectively analyzed whether same-day admissions and other resource utilization methods for patients undergoing elective infrarenal aortoiliac surgery (AoIS) were safe and cost-effective. Morbidity and mortality rates and costs were compared between 71 patients admitted before the day of surgery (group I) and 57 patients admitted the day of surgery (group II) who underwent elective AoIS between July 1, 1992, and December 31, 1995. After January 1, 1994, a concerted effort was made to decrease hospital costs by performing out-patient preoperative assessment, admitting patients the morning of surgery, and planning early discharge through implementation of clinical pathways. Patients were excluded (total, 33; 20%) from analysis if they were admitted before the day of surgery for intravenous hydration (5), optimizing cardiac function (4), or prolonged preoperative antibiotics (2), or if they required emergency surgery (10) or were transferred from another service or hospital (12). After exclusion, there were no significant differences (p > 0.05) between groups I and II in terms of age, sex, race, diabetes, hypertension, pulmonary disease, cardiac disease, renal insufficiency, type of incision (midline or retroperitoneal), indication for surgery (aneurysm or occlusive disease), or inflow site (aorta or common iliac artery). There were no significant differences between groups I and II in terms of mortality rate (0%); cardiac (1.4% [1/71] vs 0%), pulmonary (9.9% [7/71] vs 5.3% [3/57]), or renal (1.4% [1/71] vs 0%) complications; or readmission rates within 30 days (5.6% [4/71] vs 5.2% [3/57]), respectively (p > 0.05). There were significant decreases in length of hospital stay (mean, 6.4 vs 11.2 days; p < 0.0001) and hospital cost per patient ($34,198 vs $45,694; p = 0.001) for group II compared to group I, respectively. The majority of patients who require elective infrarenal aortoiliac surgery can be admitted the day of surgery and undergo early discharge with significant hospital cost savings and without apparent increase in morbidity or mortality rates.

Reply

Assistant Professor of Anesthesia, Stanford University School of Medicine, Medical Director, Anesthesia, Preoperative Evaluation Clinic, Stanford University Hospital, Stanford, California 94305–5115.In Reply:-Several authors have addressed, in correspondence to Anesthesiology and in personal communications to the author, issues of support, concerns, and questions regarding my recent article. [1]The primary focus of this article was to communicate the imperative need at Stanford University Hospital to change the manner and focus of the anesthesia preoperative system, and to report the results of two cost-effective outcome studies.National health care has entered an era of rapid change, transformation, and evolution. The competitiveness and complexity of these changes place an increasing emphasis on the importance of leadership and strategic decision making. As discussed in the 1994 Rovenstine lecture [2]by the then-editor of this Journal, the anesthesiologist's role is changing, with increased recognition that anesthesiologists are the perioperative medicine specialists.Kempen's correspondence raises several valid concerns and questions regarding the architectural design and evolution of the Anesthesia Preoperative Evaluation Clinic (APEC). As would be expected, the implementation of an APEC is an active process that involves some degree of risk and uncertainty. Innovation and progress requires a program of action to solve problems and to create opportunities. Some questions do not have clear answers or outcomes. However, it is only through a systematic approach that we can begin to evaluate what is functional and that which can be discarded. The process of developing an APEC requires an awareness that not everyone will agree or encourage this endeavor. Norman Vincent Peale put it simply, “If you put off everything till you're sure of it, you'll get nothing done.” The APEC at Stanford University Hospital has become successful in redefining the anesthesiologist's leadership and position as the preoperative medicine specialist.In response to Hannenberg, I agree that delegating certain aspects of the preoperative patient evaluation to the registered nurse practitioner (RNP) may infringe on an area of practice previously relegated only to the expertise of the anesthesiologist. A decade ago, when patients were admitted to the hospital a day before elective surgeries, the assigned anesthesiologist would preoperatively evaluate their patients and establish a personal rapport in a relaxed manner.The dramatic shift to outpatients and same-day admissions has required a change in our practice, to accommodate large volumes of patients (currently 45–50 patients per day at Stanford) and facilitate the anesthesiologists' focus on intraoperative care. Ideally, I would prefer that several anesthesiologists attend the APEC full time, but, current resource allocation does not allow this diversion from operating room to APEC. The RNPs at Stanford are not nurse anesthetists, and their specific clinical duties are under the direct, on-site supervision of the attending anesthesiologist in the APEC. The RNPs evaluate patients for unstable medical conditions and present concerns to the anesthesia medical director. The assigned anesthesia team, on the day of surgery, evaluates and reconfirms their patient's status in the anesthesia holding area before entering the operating room. This establishes a personal rapport with the anesthesiologist who will be directly responsible for the patient's management.Lee and Hillman report a preanesthesia clinic service in Australia with comparable and contrasting development from Stanford's APEC. The conceptual goals appear similar: to provide efficient quality services, increase productivity, and decrease cost. I agree that further studies are needed to define the APEC's role in patient-care outcomes.Silverman discusses the expanding role of the anesthesiologist in today's practice and the increased visibility the APEC can provide. I concur with Silverman that, to expand our specialty into the future, anesthesiology must evolve beyond the traditional operating room/procedure role.Recently at Stanford, the Department of Medicine proposed structuring a preoperative screening clinic staffed by an internist, pulmonologist, and cardiologist for evaluation of presurgical patients. The surgical leadership responded in a concise and congruent manner. They indicated that the anesthesiologists at Stanford are the primary preoperative and operating room medicine experts and that their patients would continue to attend the APEC for presurgical assessment.Positive changes can occur and certain advantages can accrue to the anesthesiologist and department of anesthesia when an APEC is established.Stephen P. Fischer, M.D., Assistant Professor of Anesthesia, Stanford University School of Medicine, Medical Director, Anesthesia, Preoperative Evaluation Clinic, Stanford University Hospital, Stanford, California 94305–5115.(Accepted for publication October 10, 1996.)

Pre-operative oximetry and capnometry: potential respiratory screening tools.

The growing number of patients admitted for outpatient surgery or for same-day admission makes it difficult to obtain thorough pulmonary evaluation. We wanted to evaluate the applicability of pre-operative pulse oximetry and capnography as possible pulmonary screening tools. In this preliminary study, 200 unselected, unmedicated adult patients who were being admitted for surgery were connected to a dual parameter patient monitor (Capnomac Ultima, Datex). A standard adult clip-on finger probe was used for pulse oximetric oxygen saturation. Sidestream capnometry documented the end-tidal carbon dioxide and the capnogram which was recorded for further analysis. In these unmedicated patients, the oxygen saturation ranged from 91 to 99% and was found to be 94% or less in five percent (N = 10) of the cases. The end-tidal carbon dioxide ranged from 21 to 48 mmHg. In five percent of the cases (N = 10) it was found to be 45 mmHg or higher, reflecting elevated arterial CO2. When the shape of the capnogram was rated, it was found normal in 54% of the cases. Slow rising capnogram, indicating mild (N = 84) or moderate (N = 8) airway obstruction was detected in 42% or 4% of the cases respectively. Since pulse oximeter and end-tidal carbon dioxide values are often not measured until after sedation or after induction of anesthesia, patients with pre-operative abnormalities might escape pre-operative detection. In unmedicated patients, routine pre-operative or pre-admission determination of oxygen saturation, end-tidal carbon dioxide and the capnogram may be a valuable screening tool.

Patient characteristics, safety, and benefits of same-day admission for coronary artery bypass grafting

The move toward outpatient and same-day surgery has been phenomenal in the past several years. Efforts in this area have focused on limiting inpatient hospitalization, reducing ancillary services, and decreasing length of stay. Two hundred seventy-six DRG 107 patients who were operated on at our institutions in 1994 and registered in The Society of Thoracic Surgeons National Cardiac Surgery Database were reviewed. There were 185 patients randomly admitted to the hospital on the day of operation and 91 patients admitted 1.78 +/- 1.94 days before. These patients were analyzed according to The Society of Thoracic Surgeons National Cardiac Surgery Database predicted risk group and expected operative mortality modules. Univariate analysis of all risk variables listed in The Society of Thoracic Surgeons National Cardiac Surgery Database were used to identify the difference between 176 elective procedure patients in the same-day admission group and 67 elective procedure patients in the non-same-day admission group. The same-day admission group had lower expected operative mortality (1.3% versus 2.9%), fewer female patients (17% versus 29%), younger age (62 versus 67 years), and fewer patients in the higher predicted risk group. Univariate analysis showed only age and ejection fraction variables were significantly different between the two elective groups. Comorbidities predictive of elective non-same-day admission revealed that age and New York Heart Association class IV were significant predictors. The length of stay was shorter and the total charges were less in the same-day admission group. There was no increase in preoperative, intraoperative, or postoperative complications in the same-day admission patients. Same-day admission was safe and cost-effective and could be carried out as a routine admission for several selected groups of patients.