Preoperative Testing The Preoperative Testing Policy has been revised. The following presentation is a review of the policy (KH# CL46) and the preoperative testing requirements within it.

Preoperative Testing Objectives  The employee will be able to:  Establish uniform guidelines for preoperative testing  Ensure patient safety while minimizing the cost of unnecessary lab work  Assure the anesthesiologist will have all the necessary information  Minimize procedure delay  Assure the surgeon that the procedure will not be delayed provided these guidelines are followed.

Who does this policy apply to?  It is the communication and responsibility of:  The Department of Anesthesia  Site Chief of Surgery  Surgical Directors  Managers of Preoperative Testing Areas  Operating Rooms  Ambulatory Surgery Areas

Scope of Practice This policy falls under the scope of practice of the followig individuals:  Physicians  Physicians Assistants  Residents  Nurse Practitioners

Preoperative Testing Guidelines  Preoperative testing may be conducted at any Kaleida lab  This ensures that tests are performed under appropriate quality controls.  If a surgeon wishes to use a lab outside Kaleida Health, all information must be available preoperatively for review by Nursing and Anesthesia.  All abnormal labs must be reviewed and explained.  It will be the surgeon’s responsibility to ensure this.

Medical Clearance  Medical clearances and consultations need not be long  They must be comprehensive

Medical Clearance The medical clearance needs to include the following :  A thorough review of all major organ systems with a focus on the cardio-pulmonary system  A thorough review of all preoperative tests  A definitive statement as to the patient’s peri-operative risks  A definitive list of recommendations for perioperative management  Clearance of both regional and general anesthesia

Testing Grid  A testing grid is included in the preoperative testing policy to simplify the ordering of preoperative tests (see policy KH#46 for grid)  It represents the minimum acceptable standards.  It remains the surgeon’s responsibility to order additional testing, as appropriate.  The need for supplemental testing will be based upon the patient’s history and physical and tests appropriate to any given surgical procedure.

Delay for Lab Work  Should the surgeon face a delay due to an anesthesiologist asking for lab work not indicated on the testing grid, and in the surgeon’s opinion, is not indicated for the procedure; the anesthesia site coordinator will review and mediate the case.

Delay for Lab Work  If the anesthesia site coordinator’s ruling is in favor of the anesthesiologist:  All steps will be taken to rearrange the schedule to accommodate the surgeon

Delay for Lab Work  If the Anesthesia Site Coordinator’s ruling is in favor of the surgeon:  The procedure will proceed without delay If necessary, a new anesthesiologist will be assigned to the case.

Pre-Surgical Pregnancy Testing  Pre-surgical pregnancy testing must be done on all female patients of childbearing age  This includes pregnancy testing on females age 9 years and older.

Exceptions to Pre-surgical Pregnancy Testing  Exceptions to pre-surgical Pregnancy testing include:  Any woman who is post menopausal.  Has undergone surgical menopause (removal of uterus or ovaries)  Is known to be pregnant  Who has delivered and is a post partum inpatient

Definition of Menopause  The definition of post-menopausal is any woman who has gone twelve months without a menstrual period.

Pregnancy Testing  In the presence of a negative result, if while interviewing the patient on the day of surgery there is a suspicion that the patient could be pregnant, the test can be repeated immediately prior to the procedure  HCG (Human Chorionic Gonadotropin) pregnancy test will be obtained within 7 days of procedure.

Guidelines of Pregnancy (HCG) testing for Elective procedures  The last menstrual period and use of contraception will be documented in the patient’s record.  The HCG will be obtained within 7 days of the surgical procedure  Either a urine or serum HCG may be obtained (Serum requires a 24 hour turnaround). Results will be placed in the patients chart  IF HCG testing is performed in a physician’s office, the physician must provide in the patient chart, test, date, and results in the admission’s note.

Positive Pregnancy Test (HCG)  In the event the pregnancy test (HCG) is positive, the physician is notified by the lab, or a responsible person as designated by each area.

Hemoglobin Indications for testing Hemoglobin testing is required for:  Any procedure for which the patient is typed and screened  Any patient who is tachycardic or hypotensive  Any patient who is short of breath or has dyspnea on exertion.  Any patient with a history of anemia

Age Criteria for Hemoglobin Indications for obtaining a hemoglobin include the age criteria of: Neonates Menstruating Women Women and Men over the age of 65.

Chemistry testing Chemistry testing includes testing for:  Sodium  Potassium  Creatinine  Glucose

Indications for Chemistry Testing Indications for chemistry testing include:  Chronic renal failure/dialysis  History of diabetes  Diuretic therapy  History of abnormal chemistries

Liver Function Tests Liver function tests include tests such as: LDH levels, AST levels and albumin  Liver function tests are performed on patients with suspected liver disease.

Platelet Count Indications The indications for perioperative testing for platelet count include:  Patients with bleeding disorders  History of Petechiae, hemarthrosis, or chronic spontaneous epistaxis  Patients with cancer, especially status post chemotherapy or radiation treatments  Patients with HIV  Chronic Alcoholics  Patients with hypersplenism

Indications for Ordering Clotting studies (PT/APTT) Indications for Ordering Clotting Studies include:  Patients with bleeding disorders  History of hemarthrosis or chronic spontaneous epistaxis.  Patients with suspected liver disease.  APTT is for patients on IV heparin.  PT/INR for patients on coumadin.

Blood Test results  All Blood tests are good for 1 months except:  In patients with renal failure, potassium levels should be drawn within 24 hours of surgery.  In patients on insulin therapy, a finger stick glucose level should be drawn on the morning of surgery.  Blood bank specimens have a maximum number of days between collection and surgery in order to meet specific criteria  HCG will be obtained within 7 days of the procedure.

Urinalysis indications for patients  Urinalysis testing is ordered for:  Patients with suspected urinary tract infections  Patients for prosthetic surgical implants.

Chest X-ray Indications  The are no age criteria for ordering a chest x-ray  Any patient with unexplained shortness of breath or dysnea on exertion may have a chest x-ray ordered  Febrile patients with productive cough or new onset wheezing may have a chest x-ray ordered.

EKG Indications  EKG indications include any patient over 40 years of age  Any patient with a history of: – coronary artery disease, – cardiac arrhythmia, – hypertension, – diabetes, – cocaine use.

Chest x-ray and EKG results  All Chest x-ray and EKG results are good for 3 months, provided the patient has had no apparent change in health.

Other testing  Other testing for Digoxin Levels may be ordered for patients on digoxin and no level has been performed in the last 6 months, or unexplained nausea, or heart rate less than 60 beats/minute.  TSH and/or Free T4 tests will be ordered on any patient on thyroid medication and no level has been performed in the last 12 months, patient has unexplained changes in weight, or level of activity, or patient is experiencing arrhythmias.

Preoperative Testing Policy  The preoperative testing policy can be viewed by going to the Kaleidascope Web Page  Directions for finding the policy are as follows: –Click on the Policy/Document icon at the top of the page –Click on Policy and Procedure Manual icon under Corporate- Related column –Type in “CL.46” (or scroll down to find policy CL.46) –The click on the policy to view