Management of a Preoperative Care Center by an Attending Anesthesiologist Is Associated with a Reduction in Day-of-Surgery Cancellations

Although the use of preoperative clinics has been shown to have several benefits, including reduced same-day cancellations and improved patient satisfaction, the setup of preoperative clinics itself has not been fully examined, nor an optimal model yet established.(1-3) Some clinics across the country are set up so that only anesthesiologists see patients, whereas others are staffed with registered nurses (RNs), who complete phone calls and chart reviews, and still others are structured with nurse practitioners (NPs) and an anesthesiologist “on call” for answering questions and addressing more acute issues.(4)

Determining which of these clinic models is the most effective and efficient can be difficult, because clinic models and staffing can vary depending on a hospital’s location, as well as patient demographics and needs.(1,5) At our institution, the two preoperative clinic locations were staffed for several years with full-time and per diem NPs and RNs, one full-time scheduler, and one per diem clinical care provider (CCP) at each location. In October of 2016, it was decided to staff the clinic with a full-time anesthesiologist in addition to the current providers. The role of the physician was not only to oversee day-to-day clinic workflows and activities, but also to assist in evaluating complicated patients and provide feedback and education for the NPs and RNs, with the goal of improving the anesthetic evaluations overall and reducing the number of anesthesia-related same-day case cancellations.

This change in structure provided a natural experiment to test the hypothesis that a clinic model including anesthesiologist presence and leadership may be associated with a decrease in same-day cancellations and an increase in patient visits, and, ultimately, be more cost effective. The primary objective of this retrospective cohort study was to determine whether staffing the preoperative clinic with an anesthesiologist was associated with a decrease in same-day cancellations. The causes for these cancellations also were examined to determine whether those cancellations that still occurred were due to preventable medical reasons that should have been addressed by the preoperative anesthesia team, or if the reasoning was unrelated to the anesthesia evaluation.

Patients and Methods

The study was a retrospective cohort analysis conducted at University of California, San Diego (UCSD). The preoperative care center (PCC), with two hospital locations, is used to evaluate patients preoperatively. An attending anesthesiologist started to staff PCC full time in October of 2016. Patients in the study were selected from a one-year period “before” (October 2015 to October 2016) and one-year “after” (October 2016 to October 2017) the anesthesiologist started for comparison. The resulting dataset remained de-identified and contained no sensitive patient health information as defined by the UCSD Human Research Protections Program, and, therefore, was exempt from the informed consent requirement and was approved by our Institutional Review Board. All cases included were of adult patients who had surgery in the main operating rooms and all out-of-operating-room anesthesia locations, including endoscopy suites, interventional radiology, cardiac catheterization labs, and electrophysiology labs, at both hospital sites.

Data collected for each patient included occurrence of same-day cancellation, surgical specialty, patient age, American Society of Anesthesiologists (ASA) physical status classification score, patient sex, and date of preoperative care clinic visit. Initially all surgical cancellations were selected from the “before” and “after” periods. However, because this study was intended to review those patients who had come through PCC, and those who cancelled on day of surgery only, additional filters were added (Table 1).

A typical PCC appointment at UCSD occurs within 30 days of surgery. Taking that into account, plus the possibility of patient insurance and medical clearance issues, an extra 30 days were allowed between a PCC appointment and the day of surgery. Thus, any patient listed with a PCC appointment more than 60 days before day of surgery was eliminated from the final data. As a result, 420 from the “before” period were considered ineligible, and 972 patients from the “after” period were considered ineligible.

Clinic Structure and Setup

Clinic staff includes full-time and per diem NPs and RNs, one full-time scheduler, and a per diem CCP at each clinic location.

The clinic setup “before” was as follows:

• NPs would evaluate patients, order and follow up on preoperative workup, and contact surgeons with concerns. Each NP typically would evaluate one patient per hour, for a total of eight patients per eight-hour shift.

• The RN’s primary duty was to see patients and fill out patient intake forms, provide patients with chlorhexidine gluconate soap and shower instructions, and communicate with the blood bank regarding lab work.

• The CCP facilitated the RN and NP roles by helping with clinic workflows, obtaining EKGs when requested, and helping the scheduler with phone calls and paperwork.

• PCC schedulers were responsible for communicating with surgery schedulers and ensuring that our schedule was filled appropriately.

Things changed during the “after” period, as follows:

• The NP role changed by increasing the census to 10 to 12 patients per day, with patients booked at half-hour intervals. The responsibility for following up on all preoperative workup was shifted to the RNs and the anesthesia attending.

• The RN patient intake form was eliminated. Rather than seeing all patients, RNs would spend time only with those who needed soap and shower instructions. Their primary responsibility shifted toward patient chart review and follow-up on anything that had been ordered by the NPs, including labs and additional preoperative clearance. An RN checklist (see Appendix A), was developed with input from the RNs and NPs to facilitate this new role. In addition, the RNs also were responsible for calling patients with reminders of medication adjustments and day-of-surgery instructions, as indicated.

• CCP and PCC scheduler roles were largely unchanged.

• The attending anesthesiologist spent time with each NP reviewing current preoperative testing guidelines and protocols and gave regular feedback on the quality of the preoperative evaluations. The NPs also were retrained to pay more attention to factors that would delay or cancel surgery, and taught to focus on patient workup that might alter anesthetic planning. In addition to regular, daily feedback, occasional education workshops were held to provide anesthesia teaching in greater depth.

The final PCC workflow is illustrated in Figure 1. In addition, the attending anesthesiologist oversees the above-listed daily activities, helps to evaluate complicated patients, and also does a final review of charts to ensure there are no last-minute issues with the preoperative evaluation or patient work-up that may have been missed and need to be addressed.

Figure 1. Final PCC workflow and patient movement through the clinic. PCC: preoperative care center; CCP: clinical care partner; CHG, chlorhexidine gluconate; NP: nurse practitioner; RN: registered nurse.

Statistical Analysis

R, a software environment for statistical computing (R version 3.3.2), was used to perform all statistical analyses. The primary outcome of interest was occurrence of a same-day cancellation. A Pearson’s chi-squared test was used to measure differences between categorical variables, respectively. A p value of less than .05 was considered statistically significant. A multivariable logistic regression analysis was performed to assess for the association of attending presence and case cancellations and to control for ASA score, patient age, sex, and surgical service. Odds ratio (OR) and 95% confidence interval (95% CI) were reported.

Results

Over 50,000 cases were obtained from the period between October 2015 and October 2017. An initial review of the data showed that many patients with both a PCC appointment and a day-of-surgery cancellation had a PCC appointment that did not correlate with their surgery date (i.e., the clinic appointment was more than 60 days prior to surgery, or occurred after surgery had been completed). The final case list included 21,815 cases from October 2015 to October 2016 (before attending anesthesiologist staffing of PCC) and 28,517 cases from October 2016 to October 2017 (after attending anesthesiologist staffing of PCC). Table 2 lists the demographics of both cohorts. There were 669 (3.1%) and 752 (2.6%) cases cancelled in the “before” and “after” cohort, respectively (p = .0004) (Table 3). When controlling for ASA class, sex, surgical service, and age, the presence of the anesthesiologist at PCC was associated with reduced case cancellations (OR 0.84, 95% CI 0.70–0.98). Table 4 lists the most common reasons for case cancellations.

Cost Analysis

According to the Bureau of Labor and Statistics, the average salary of an anesthesiologist in the United States, as of May 2017, is $265,990.(6) Assuming a 60-hour work week, this amounts to approximately $90 to $100 per hour, on average.

The cost of an operating room minute depends on the institution, its resources, and caseload.(7) The average cost of an OR minute is $62/minute(8); recently, the average cost of an OR minute in California, specifically, was calculated to be $36 to $37.(9)

Case duration and the cost impact of delays and cancellations can vary between surgical subspecialties. In addition, predicting case durations is difficult, and also can vary between surgeon and institution. One public university hospital in Sao Paola conducted a study including more than 8000 cases from 2011 to 2012, and found an average case duration of 197 minutes (±113 minutes) across 12 surgical subspecialties.(10)

Taking these values as examples and assuming an average case length of 3 to 4 hours (180 to 240 minutes), we can calculate the OR cost of cancellation per case in the United States (Table 5).

There was a reduction in 5 cancellations per 1000 patients seen in PCC in the first year “after”; in other words, there were 35 fewer case cancellations overall in that year. This resulted in a total cost savings of approximately $230,000 to $300,000 after an anesthesiologist began staffing the PCC (Table 6). Subtracting from that the cost of staffing the clinic with an anesthesiologist, you see net savings of approximately $35,000 to $100,000 in that first year (Table 7).

Discussion

This retrospective analysis revealed that the addition of a full-time anesthesiologist in the PCC led to a statistically significant decrease in same-day case cancellation rates, even while accommodating more patients in the PCC. This leads us to conclude that an attending presence not only improves PCC workflows and efficiency, but also is associated with an improvement in the quality of preoperative evaluations and patient optimization.

There are two potential reasons for the improvement. By changing some of the staff roles, there was more emphasis on appropriate patient history and anesthetic optimization by the NP. In addition, consistent education and regular, real-time feedback on the quality of the preoperative evaluations allowed for greater NP learning and understanding of anesthetic management and concerns. Shifting the RN roles to one of chart review largely decreased the redundancies in patient charting and freed up time for the NPs to spend with the patients. Furthermore, having the RNs call patients prior to surgery helped in reiterating preoperative planning and workup for the patients, ensuring that necessary testing was completed and results were reviewed in a timely manner.

Based on the cost analysis, a significant saving occurred in the year after an anesthesiologist began staffing the PCC, which largely offsets the cost of that staffing. In addition to the cost savings generated from reduced cancellations, savings also likely were realized from having more preoperative evaluations completed in advance, thus reducing the time needed on the day of surgery for patient evaluation for both first-case starts and throughout the day.

Having a full-time anesthesiologist can allow for better interdisciplinary coordination and communication preoperatively.

A major limitation to this study is that there is no clear delineation in the reasoning for day-of-surgery cancellations. Many reasons recorded in our EPIC electronic medical record system included those mentioned previously, but it is unclear whether the MD in “MD canceled” is a surgeon or an anesthesiologist. Thus a thorough analysis regarding cancellation reasons was not done. As a result, although the data show a significant decrease in same-day cancellations, it is not clear whether that is all due to a decline in anesthesia cancellations specifically. The system for recording these reasons must be made more specific, and a subsequent review can be used to further evaluate the efficacy of the PCCs. Another limitation is the ineligibility criteria used. Normally, patients are seen within 30 days prior to surgery,(11) but this was not used as a cutoff due to the frequent reschedulings that occur at our institution. In November of 2016 a new hospital was opened, and a shift in operating room scheduling availability occurred as well. Therefore, to accommodate for this change, a longer evaluation window was selected. Although the criteria were largely inclusive, eliminating those evaluated just 60 days or more prior to surgery may still have excluded patients who should have been included, and ultimately may have included those who should have been excluded, thus blurring the accuracy of our day-of-surgery case cancellation rates. In addition, we reviewed only cases that were cancelled on the day of surgery, whereas a preoperative evaluation could have led to a higher cancellation rate prior to the day of surgery.

The cost analysis calculated savings based on data and averages gathered from other studies done at other institutions. The actual benefits and savings realized from PCC anesthesia staffing would need to be calculated based on an institution’s unique caseload and per-minute OR costs. The calculation done for our institution includes assumed anesthesia costs based on national average and, therefore, may not be completely accurate.

The future of perioperative management includes much more than a preoperative anesthesia evaluation. Trends until now have shown the overall benefits of establishing a PCC.(2,3). However, optimal staffing models have not been proven(1). Having a PCC staffed with only NPs and RNs can be limiting, because they do not take part in intraoperative management, and, ultimately, are not trained in anesthesia. Aside from improved patient evaluation and clinic workflows, having a full-time anesthesiologist also can allow for better interdisciplinary coordination and communication preoperatively(12) among surgeons and primary care providers. In addition, evaluation with an anesthesiologist-led team has been shown to further reduce costs by decreasing postoperative hospital stays and postoperative inpatient mortality.(13)

Aside from an anesthesiologist’s presence in PCC, clinic workflows and setup play an important role in ensuring that patients are seen in a timely manner. The NP-to-patient ratio per day should be optimal to ensure the maximum number of patients is seen per NP per day, while still maintaining a high-quality preoperative evaluation. We believe that our workflow model provides that balance of efficiency and effectiveness. Establishing an RN role that is primarily chart review has helped to free up time for the NPs to spend with patients and allows for consistency when creating protocols for RNs to follow up on patient workup. Our communication tool (see Appendix A) also assists with effective communication among staff.

Conclusion

The role of anesthesiologists in the perioperative period is continuing to expand. We have shown the benefits of having a full-time anesthesiologist on staff at PCC in regard to case cancellations and quality of preoperative evaluations; however, an institution’s resources, patient population, and case load largely determine its ability to establish such staffing.(1,5) Given industry trends and our growing role as anesthesiologists in preoperative planning, it is important to establish a PCC where centralized communication and coordination can occur. Although there is an initial cost to scheduling a full-time anesthesiologist in the PCC, the future cost savings and streamlined patient care processes largely offset this cost.

References

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5. Tariq H, Ahmed R, Kulkarni S, et al. Development, Functioning, and Effectiveness of a Preoperative Risk Assessment Clinic. Health Serv Insights. 2016;9s1:HSI.S40540. doi:10.4137/hsi.s40540

6. Physicians and Surgeons: Occupational Outlook Handbook. U. S. Bureau of Labor Statistics, U. S. Department of Labor. https://www.bls.gov/OOH/healthcare/physicians-and-surgeons.htm#tab-5 . Published 2018. Accessed November 15, 2018.

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9. Childers C, Maggard-Gibbons M. Understanding Costs of Care in the Operating Room. JAMA Surg. 2018;153(4):e176233. doi:10.1001/jamasurg.2017.6233

10. Costa A Jr. Assessment of operative times of multiple surgical specialties in a public university hospital. Scielo. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1679-45082017000200200 . Published 2017. Accessed November 8, 2018.

11. Pollard J, Olson L. Early Outpatient Preoperative Anesthesia Assessment. Anesthesia & Analgesia. 1999;89(2):502-505. doi:10.1213/​00000539-199908000-00048

12. Aronson S, Attarian D. The Future of Perioperative Medicine. ASA Monitor. https://dukespace.lib.duke.edu/dspace/bitstream/handle/10161/12040/Aronson_Attarian.pdf%3Bsequence=1 . Published 2016. Accessed November 18, 2018.

13. Blitz J, Kendale S, Jain S, Cuff G, Kim J, Rosenberg A. Preoperative Evaluation Clinic Visit Is Associated with Decreased Risk of In-hospital Postoperative Mortality. Anesthesiology. 2016;125(2):280-294. doi:10.1097/aln.0000000000001193

Appendix