Preoperative Evaluation in the Outpatient Setting

(thank you Vicky Soto, Rose Tompkins, Will Greendyke, Kristin Kipps, and Dr. Fiebach)

 

·         Curriculum –During the 1st week of this block, please log on to the Hopkins Learning Center/IM Curriculum and complete the online curriculum. Do understand some components of preoperative evaluation and management are derived from expert opinion, so institutional differences will exist and this will be discussed case by case with your PIC.

·         Preop Clinic is in VC Room 240, please arrive on time as this consultative clinic is busy.  We see pts from your AIM colleagues, as well as pts who are not followed in AIM.  Search and use the “Amb AIM Preop Clinic Structure Note” to write the consult note (10/14 technical glitch note- this note is not working recently/not searchable, so you can use amb aim structure note until it’s fixed). Whenever evaluating a patient of your colleagues (including ACNC or HP6 providers), please forward your note by SHM so they are aware.

·         Outpatient preops are  different from inpatient preop evals as surgeries are often elective and rarely urgently performed on sick pts.  Your evaluation should mainly be focused on performing an accurate H&P, record review, detailed medication reconciliation. The end product of the consult should be a concise and helpful note back to the surgical team. Reviewing the pt’s pertinent Pmhx /functional status, management of surgery specific risk factors, as well as comorbid disease management.  Communication of an accurate med list, as well as recommendations and reasons for holding, lowering, or continuing meds perioperatively is very critical.   At times, you may even need to recommend delaying surgery until pt’s illnesses are better controlled.

·         Beyond ensuring that the pt’s chronic diseases like CHF, HTN, COPD, are adequately controlled, here are some common perioperative disease management teaching points:

o   2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

o   2014 ACC/AHA Guideline on Perioperative Beta Blockade

o   Management of Antithrombotic Therapy in Patients Undergoing Invasive Procedures N Engl J Med 2013; 368:2113-2124

o   Anticoagulant/Antiplatelet Management - summarized by Dr. Rose Tompkins (last updated 9/2012)

o   DM management-   summarized here by Dr. Will Greendyke (last updated 9/2012)

 

·         Preop Note and Paperwork: Sometimes pts will bring you preop forms to fill, realize that the information on your consult notes satisfies that requirement within the institution and you can briefly write a note to refer surgical team to Eclipsys. For outside surgeons, you may have to fax them your note and even labs. There is an art to writing Consult Notes -  learn how to be a thoughtful, helpful, and concise consultant communicator comes with practice.  Work with your Preop attendings on honing your outpatient consultation recommendations, the “clearance” wording may be different from the notes you may write on the floors. Expect your attendings to give you feedback on this.  (Great time to read Dr. Goldman’s article on how to be a great consultant)

·         Preop Testing- There is a lot of inefficiency in getting “routine preop tests”,  the ACP choose wisely compaign and many academic centers are becoming much more cost conscious and evidence based in test selection. Unfortunately you still encounter surgical centers that require perfunctory batches of labs/xray/ekg “to be done within 30 days” no matter the surgery.  As an example, even though a study in NEJM concluded many years ago that cataract surgery pts do not benefit from preop testing, labs and EKG are still routinely required on-site. Our recommendation to you is to focus on your role of being the consultative internist, perform a careful H&P, review old records, and only order tests needed for clinical decision making.  We’ve asked referring surgical offices on campus to preorder their self-mandated “routine” 30 day tests before preop clinic visits so we can provide help in interpretation.    (Occasionally, with a looming surgery date, we will step in to help order these tests to avoid any pt’s surgery from being held up administratively. In those cases please make it clear on your note that the tests were ordered and that the receiving team should also check them to make sure all is okay.)

·         Where can preop testing be done. Most surgical office give patients a list of tests (EKG, CXR, LABs) that can be done all together on the 1st floor of Heart Hospital.  You can order EKGs same day here when needed for decision making.      

·         Billling sheet: In addition to marking the visit as a preop evaluation V72.83 as the primary code, please be sure to check a secondary ICD code that reflects why the pt is getting the surgery.  

·         No Shows: At the end of your session make sure to input an AIM “No Show” note if the patient did not show.  Mention in the note that the no show was for Preop Clinic. This way the surgery office can be kept informed.

·         Learn more medicine and recruit patients into primary care- often we stumble upon pts who are healthy enough for surgery but should receive further are care and evaluation in primary care. Feel free to speak to pts about following up with you in your practice.  It’s a great way to see how the surgery went and provide preventive care to asymptomatic at risk patients.  Preop Clinic is also a place to see some interesting physical signs that you may not see a lot, like “anterior drawer sign” for someone going for ACL repair, “drop arm” sign for someone going for rotator cuff tear repair.

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