1. Preoperative Assessment in Private Practical Pointers for Private Practitioners Dr Adam Molnar MBBS FANZCA Victorian Anaesthetic Group

2. Conflict of Interest  Family member owns MediTrust  I have no financial interest in the product  I act as a medical consultant to MediTrust  I have never received a payment in the past from MediTrust  I will not receive a payment in the future from MediTrust  I pay a commercial rate to use the product

3. My Practice  Full time private practice  Victorian Anaesthetic Group  Inner Melbourne  Major orthopaedic, colorectal, reconstructive plastic, gynaecology and endoscopy.  IT interest

4. Private Practice in Australia  Around 2 million anaesthetics are given privately in Australia per year  4% increase in procedures per year  Increasing complexity of cases  Increasing age of patients  Little or no current research on preoperative assessment in private

5. Preoperative Evaluation  Cardiac –Fleischer LA et al. ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 2007  Respiratory-Bapoje SR et al. Preoperative evaluation of the patient with pulmonary disease. Chest 2007  Diabetes  OSA  Airway

6. The Problem  Approaching 100% same day admission  Staggered admission  Increasing pressure to provide more information  Compared to public there is a decrease waiting period  Surgeons notify anaesthetists late regarding particular cases  Patient information is on multiple systems which do not interface

7. Preoperative Assessment Establish Rapport ✔ History ✔ Examination ✔ Investigations ✔ Anaesthetic Plan ✔ Informed Consent ✔

8. Australian Incident Monitoring Study  Kluger MT et al Inadequate preoperative evaluation and preparation: A review of 197 reports from AIMS. Anaesthesia 2000  3.1% of adverse events  Preventable in 57% of cases  23 major cases of morbidity. 7 deaths  10% of patients had not been seen  29% poor airway assessment

9. Victorian Consultative Council on Anaesthetic Mortality and Morbidity  Continually emphasis the contribution of poor preoperative assessment to morbidity and mortality  “These included failure to identify patient information details, poor medical status evaluation, inadequate airway assessment, and failure to adequately assess the cardiovascular system.”  15%anaesthetic related mortality  12%anaesthetic related morbidity

10. Preoperative Assessment in Private Anaesthetic ConsultsTotal ServicesDistribution 17610 < 15 minutes193508692.6 % 17615 15 to 30 minutes1027464.9% 17620 30 to 45 minutes134180.6% 17625 >45 minutes26170.1% 17690 In Rooms364371.8%

11. Preoperative Assessment Techniques  Rely on surgeon assessment and investigation  In room consultations  Perioperative physicians  Phone consultations  Hospital Pre-anaesthetic Clinics  Online solutions

12. Preoperative Assessment in Rooms State% Total Anaesthetic Consultations Tasmania4.5% Western Australia3.1% New South Wales2.9% South Australia2.2% ACT1.5% Queensland0.5% Victoria0.4% Northern Territory0.3%

13. Preoperative Assessment in Rooms

14. In Rooms Consultation  Probably the gold standard  Costly  Difficult to see all patients – need to screen  May see patients too late

15. In Rooms Consultation

16. In Room Consultation

17. Perioperative Physician  Renal or general physician  Patient referred by the surgeon  Complete 24/7 cover  Advantages- organise appropriate investigations, optimise medical conditions, send summary to anaesthetist prior to surgery, provide cover.  Disadvantages-lack understanding of the operative process, no anaesthetic discussion, inadequate pain control.

19. Phone consultations  Patients like them  Advantages- History, anaesthetic discussion, screen patients prior to seeing in rooms  Disadvantage – Inefficient, examination and investigation problems, late referrals

20. Hospital Pre-anaesthetic Clinic  Set up by hospitals  Run by nursing staff  Advantages- History, screen patients prior to seeing in rooms  Disadvantages- Late referrals, no examination or investigations, no anaesthetic discussion

27. On-line assessment  Increase use of internet, smart phones and tablets  Capture patient at time of surgical booking  Anaesthetist introduced  Specific anaesthetic information  Provides specific informed financial consent  Health survey  Screen for in room consultation

38. Day of Surgery Admission  Appropriate facilities  Access to rapid investigations  Access to ICU/HDU beds  Willingness to cancel

39. Preoperative Assessment  Challenging  Anaesthetists need to be prepared to adapt  Anaesthetists must maintain their high professional standards  Anaesthetists must be involved in the process of change