Pre-Operative Evaluations
October 2013 – August 2014
CLINICAL INTEGRATION
“THE RIGHT CARE, IN THE RIGHT SETTING, AT THE RIGHT TIME”
CME JUNE 2014
Preoperative Evaluations: WORK GROUP
Executive Sponsor

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Dean Danner
Sr. VP and ACI Chief Operating Officer
Core Work Team
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John Wheat, D.O.
Kristen Rahn, M.D.
Erik Anderson, M.D.
Gary Sweet, M.D.
Timothy Logemann, M.D.
Dean Kellner
William Holm, M.D.
Aaron Anderson, M.D.
Nathan Grabher, M.D.
Jennifer Baumann
Primary Care Physician
Primary Care Physician
Primary Care Physician
General Surgery
Cardiovascular Associates
Central Wisconsin Anesthesiology
Anesthesiologist
Anesthesiologist
Anesthesiologist
Clinical Integration Project Coordinator
Supporting Work Team
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Carrie Murray
Gregory Sewall, M.D.
Tristan Laszewski
Andrea Blaubach
Susan Courtney
Angela Guden, CRNA
Patient Centered Medical Home
ENT
IT/EPIC
Fiscal Services
MHC Quality Services
MHC Anesthesia
Preoperative Evaluations: GUIDING PRINCIPLES
 Patient Centered
 System-Wide Approach
 Physician Compact
Preoperative Evaluations: OBJECTIVE
Pre-operative visits are conducted in a
timely manner to provide standardized,
essential, evidence-based, preoperative
information to anesthesia and surgical care
teams.
Preoperative Evaluations:
OPPORTUNITIES FOR IMPROVEMENT
 Wide Variation in Care
 Inconsistent pre-operative information and process flow between clinics and providers
 No consistent, documented evidenced–based pathway guiding appropriate care
 Unnecessary or duplicated tests
 Incomplete information, increased cost, inconvenience for patients
 Out-of –System evaluations add variation, complexity to process
 Expertise alignment with Severity of Care
 No process to evaluate appropriate preoperative work-up based on surgical risk
 Non-complex cases H&P could be conducted at the time of the surgical consult
 Non-Integrated Process
 Difficultly with Timeliness/Access of H&P visit in Primary Care
 Inefficient for providers and patients
 Communication difficulty/gap between involved specialties
Preoperative Evaluations
OPPORTUNITIES FOR IMPROVEMENT
Expertise Alignment
with Severity of Care
Risk Assessment Tool
Surgical Groups
performing low
risk Evaluations
Wide Variation in
Care and Process
Evidence Based Epic
Template
Standardized clinic
work flow and
provide guideline
based evaluations
Suboptimal
Integration and
Access
ACI Pre-Operative
Clinic Integrated
with Anesthesia
• Out-Of-System
patients
• High surgical risk
procedures
Preoperative Evaluations: TIMELINE
2013
2014
October November December January February March April May June July August
Workgroup representing all stakeholders to improve the HnP process.
Pilot: Risk Algorithm
Assess and Improve
Develop Epic template
based on ICSI guidelines
Communicate with Primary Care,
Anesthesia and Surgical Sites.
Assess and Improve
Implement Risk Algorithm Tool
and Evidence Based Guidelines
at Clinic and Surgical Sites.
ACI Preoperative
HnP Clinic
Pre-Operative Evaluations:
SURGICAL ASSESSMENT TOOL
Yes
Is patient
scheduled for a minor OP
surgery under MAC
anesthesia?
Refer to
Pre-Op
Visit
No
Surgeon refers directly
to Pre-Op Visit for specific
concerns.
Yes
No
Will patient be
admitted Post-op for greater
than 24 hours?
Proceed to scheduled surgery
without further work-up.
Surgeons H&P should be completed
and will satisfy requirement.
Yes
No
Developed by Dr. William J. Holm with the support of CWA
and in collaboration with the AWH Pre-Op Workgroup
Pre-Operative Evaluations:
SURGICAL ASSESSMENT TOOL
Is patient on
anti-coagulant therapy or
blood thinning drugs?
No
Does the patient have insulin
corrected diabetes?
Yes
Refer to
Pre-Op
Visit
No
Age 12 months or less?
Yes
(If of premature birth –
24 months or less)
No
Developed by Dr. William J. Holm with the support of CWA
and in collaboration with the AWH Pre-Op Workgroup
Pre-Operative Evaluations:
SURGICAL ASSESSMENT TOOL
Greater than three
positive answers on Pre-Op
Assessment Survey?
Yes
No
Any positive
answers on Pre-Op Assessment
Survey?
No
Proceed to scheduled surgery
without further work-up.
Surgeons H&P should be completed
and will satisfy requirement.
Refer to
Pre-Op
Visit
Yes
No
Has patient
completed therapy or is
established with a PCP & has
been seen in the
Yes
last year?
Developed by Dr. William J. Holm with the support of CWA
and in collaboration with the AWH Pre-Op Workgroup
Pre-Operative Evaluations:
PATIENT ASSESSMENT TOOL
Assessment Survey
1. Patient is either Male, over 50 or Female, over 60?
2. Patient has a BMI of greater than 35? (?)
3. History of severe Gastro Esophageal Reflux Disease (Heartburn)?
⃝ Yes
⃝ Yes
⃝ Yes
⃝ No
⃝ No
⃝ No
⃝ Yes
⃝ Yes
⃝ Yes
⃝ No
⃝ No
⃝ No
- continue current drug therapy through day of surgery.
4. History of Pulmonary Disease or related (ie. COPD, Asthma)?
5. History of Obstructive Sleep Apnea (Excessive Snoring)?
6. History of Hypertension (High Blood Pressure)?
- continue current beta blockers, hold ACE inhibitors and diuretics for the day of surgery.
7. History of Coronary Artery Disease (Heart Attack or Blockage of Arteries in the Heart)?
⃝ Yes
⃝ No
Pre-Operative Evaluations:
PATIENT ASSESSMENT TOOL
Assessment Survey (Continued)
8. History of other Heart Disease?
⃝ Yes
⃝ No
9. History of High Cholesterol?
⃝ Yes
10. History of Endocrine Disease, Diabetes, Hyper/Hypothyroid or related?
⃝ Yes
11. History of Renal Disease (Kidney Failure)?
⃝ Yes
12. History of Hepatic Disease or Chronic Hepatitis or other Liver Problems?
⃝ Yes
⃝ No
- cardiomyopathy, arterial fibrillation, other arrhythmia, pacemaker or AICD.
⃝ No
⃝ No
⃝ No
Pre-Operative Evaluations:
PATIENT ASSESSMENT TOOL
Assessment Survey (Continued)
13. History of Alcohol Abuse or Illicit Drug Use?
⃝ Yes
⃝ No
14. Does the patient get winded when climbing just one flight of stairs?
⃝ Yes
⃝ No
NOTES:
TOTAL
Refer to
Pre-Op
Visit
NUMBER
OF YES
ANSWERS
If total is greater
than three
Developed by Dr. William J. Holm with the support of CWA
and in collaboration with the AWH Pre-Op Workgroup
Preoperative Evaluations
CARDIOVASCULAR
Class I
 Emergency Surgery
OR
 Active Cardiac Conditions
Evaluate, Manage First
 Low-Risk Surgery
OR
 No Clinical Risk Factors
OR
Preoperative Evaluations:
CARDIAC RISK INDEX
• Hx of ischemic heart disease
• Hx of compensated or prior HF
• Hx of cerebrovascular disease
• Diabetes mellitus
• Renal insufficiency
Lee et al. Circulation 1999
Preoperative Evaluations:
GUIDELINE: ELECTROCARDIOGRAM
 ICSI EKG Guidelines
 Perform EKG for all patients age 65 and older within one year
prior to procedure

EKGs not indicated, regardless of age for patients having
cataract surgery

EKGs not recommended for patients undergoing other
minimal risk procedures unless medical history/assessment
indicate a high risk patient.
Preoperative Evaluations:
GUIDELINE: ELECTROCARDIOGRAM
ICSI EKG Guidelines
Preoperative history and physical examination
No Signs or symptoms of
cardiovascular disease
Signs or symptoms
of cardiovascular
disease
High Risk Surgery
At least 1 Clinical Risk Factor **

Cerebrovascular disease

Congestive heart failure

Creatinine level >2.0 mg per dL
(176.80 umol per L)

Diabetes mellitus requiring
insulin

Ischemic cardiac disease

Suprainguinal vascular surgery,
intrathoracic surgery, or intraabdominal surgery
Electrocardiography
Intermediate Risk Surgery
Low Risk Surgery
No Clinical
Risk Factors **
NO Electrocardiography
Preoperative Evaluations
NON-INVASIVE STRESS TESTING
 Class I - NONE
 Class IIa
 Pts
with > 3 RFs
 Functional Capacity < 4 METs
 Vascular Surgery
JACC 2009
Preoperative Evaluations
WHICH STRESS TEST ?
ABLE TO EXERCISE?
YES
NO
Exercise Echo if normal LV
Pharmacologic
Or MIBI
Stress Imaging
JACC 2009
Preoperative Evaluations
ANTICOAGULATION BRIDGING THERAPY
Recent Stenting
o Aspirin 81 mg should be continued.
o Patients anticipating “necessary elective” surgical procedures that meet the
following criteria may hold their medications based on the following
recommendations:
• > than 2 weeks post angioplasty
• > than 4 weeks post bare metal stent
• > 6 months post drug eluding stent (DES)
o Clopidegrel should be stopped 5 days before procedure
o Prasugrel should be stopped 7 days before procedure
o Ticagrelor should be stopped 5 days before procedure
o Medications should be resumed 48 hours post-surgery, if there are no signs of
active bleeding.
Preoperative Evaluations
ANTICOAGULATION BRIDGING THERAPY
Atrial Fibrillation
o Use the CHADSVASC risk calculator
o Use the online creatinine clearance calculator
o Briding therapy is recommended for patient with the following:
• CHADS 2 > 4 or CHADSVASC of 6
• Prior CVA or TIA
• Mitral valve stenosis
• Prior embolic event
• Intra-cardiac thrombus
Preoperative Evaluations
ANTICOAGULATION
BRIDGING THERAPY
Pre-Operative Evaluations:
BASIC HEALTH
ASSESSMENT
Preoperative Basic Health Assessment
Preoperative Basic Health Assessment
MEDICAL HISTORY
PHYSICAL EXAMINATION
Indication for surgical procedure
Allergies and intolerances to medications, anesthesia or
other agents (specify reaction type)
Known medical problems
Surgical history
Trauma (major)
Current medications (prescription, over-the-counter
medications, herbal and dietary supplements)
Risk factors for development of surgical site infections
(e.g., smoking, diabetes, obesity, malnutrition, chronic
skin disease)
Basic nutritional assessment – lab verification reserved
for those patients felt to be at risk.
Focused review of issues pertinent to the planned
anesthesia and procedure

Current status of pertinent known medical problems

Cardiac status

Pulmonary status

Functional status (ability to perform at four or more
METs)

Hemostasis status (personal or family history of
abnormal bleeding)

Possibility of severe (symptomatic) anemia

Possibility of pregnancy

Past personal or family history of anesthesia
problems

Smoking, alcohol history and illicit drugs
Weight, height and body mass index
Vital signs

Blood pressure

Pulse (rate and regularity)

Respiratory rate
Cardiac
Pulmonary
Other pertinent exam
Preoperative Evaluations:
GUIDELINE: LABORATORY TESTS
Coagulation Studies
Hemoglobin
Potassium
Pregnancy Test
Patient has a known history of coagulation
abnormalities or recent history suggesting
coagulation problems or is on anticoagulants.
Patient needs anticoagulation postoperatively
(where a baseline may be needed.
Patient has a history of anemia or history suggesting
recent blood loss or anemia.
Patient is taking one or more of the following:
 Digoxin
 Diurectics
 ACE inhibitors
 Angiotension Receptor Blockers
Patient is of child-bearing age and:
 Is sexually active and history suggest possible
pregnancy, e.t. delayed menstruation
 Patient is concerned about possible pregnancy
 Possibility of pregnancy is uncertain
Pre-Operative Evaluations:
MEDICATION GUIDELINES
Considerations For
Medications
Discontinued PreOperatively
Medications that do not contribute to the medical
homeostasis of the patient should be discontinued
in preparation for surgey
DRUG TYPE
DRUG/DRUG CLASS
CONSIDERATIONS
Anticoagulant/Antiplatelet
Aggrenox
Stop at least seven days before surgery
Aspirin
Stop at least five days before surgery
Cilostazol
Stop three days before surgery
Dabigatran
Stop two days before surgery (CrCl >/= 50 mL/min.)
Stop five days before surgery (CrCl < 50 mL/min.)
Plavix
Stop at least five days before surgery – may need to
hold elective procedures off for at least six months
after stent
Ticlopidine
Stop at least five days before surgery
VKA (warfarin)
Stop at least five days before surgery.
ACEI/ARB
Hold morning of surgery/suspend for 1 dosage
interval before surgery.
Cardiovascular
If drug already taken, watch blood pressure closely at
induction.
Pre-Operative Evaluations:
MEDICATION GUIDELINES
Considerations For
Medications Discontinued
Pre-Operatively
Medications that do not contribute to the medical
homeostasis of the patient should be discontinued in
preparation for surgey
DRUG TYPE
DRUG/DRUG CLASS
CONSIDERATIONS
Diabetes
Oral agents
Metformin
Hold morning of surgery/while nothing by mouth
Hold at least 24 hours before surgery to prevent lactic
acidosis
Endocrine
Hormone therapy
(estrogen)
Stop four weeks before surgery if able
If unable to stop, ensure adequate venous
thromboembolism prophylaxis perioperatively
Weigh risk of symptoms/unwanted pregnancy vs. risk
for developing clot.
Herbals
All types
Stop at least one week before surgery.
Many prolong bleeding time/increase blood pressure.
Inadvertent omega-3 administration day of surgery is
not a contraindication to surgery.
Pre-Operative Evaluations:
MEDICATION GUIDELINES
Considerations For
Medications
Discontinued PreOperatively
Medications that do not contribute to the
medical homeostasis of the patient
should be discontinued in preparation for
surgey
DRUG TYPE
DRUG/DRUG CLASS
CONSIDERATIONS
Endocrine
Hormone therapy (estrogen)
Stop four weeks before surgery if able
If unable to stop, ensure adequate venous
thromboembolism prophylaxis perioperatively
Weigh risk of symptoms/unwanted pregnancy vs. risk
for developing clot.
Herbals
All types
Stop at least one week before surgery.
Many prolong bleeding time/increase blood pressure.
Inadvertent omega-3 administration day of surgery is
not a contraindication to surgery.
NSAID
Non-COX selective
Short-acting (ibuprofen, indomethacin, etc.) – stop
one day before surgery.
Long-acting (naproxen, sulindac, etc.) – stop three
days before surgery.
Osteoporosis
Raloxifene
Stop at least one week before high risk venous
thromboembolism procedures.
Alendronate
Stop perioperatively due to difficult administration
during hospitalization.
Pre-Operative Evaluations:
MEDICATION GUIDELINES
Considerations For
Medications Continued
Pre-Operatively
“Medications contributing to the patient’s
current state of homeostasis should be
continued.”
DRUG TYPE
DRUG/DRUG CLASS
CONSIDERATIONS
Cardiovascular
Beta-blockers
Continue if patient has been taking
Consider initiating if patient has high CV risk
(ACC/AHA guideline)
Clonidine
Continue – utilize patch formulation if anticipate
extended NPO status
Calcium channel blockers
Continue pre-operatively
(Consider holding if left ventricular dysfunction)
Statins
Continue if patient taking chronically
Consider initiating if patient has high CV risk
(ACC/AHA guideline)
Diabetes
Anti-arrhythmics
Continue preoperatively
Insulin
Decrease basal/long acting insulin by up to 50%
Cover with sliding scale, short-acting insulin
Pre-Operative Evaluations:
MEDICATION GUIDELINES
Considerations For
Medications Continued
Pre-Operatively
“Medications contributing to the patient’s
current state of homeostasis should be
continued.”
DRUG TYPE
DRUG/DRUG CLASS
CONSIDERATIONS
Endocrine
Thyroid replacement
Continue preoperatively
Corticosteroid therapy
Continue – add stress dosing if > 5 mg
prednisone per day (or equivalent) in six
months prior to surgery, or on chronic
therapy
HIV
All types
Continue – if necessary to discontinue, reinitiate all medication at the same time
Neuro/Psych
All types
Continue pre-operatively;
With exception of MAO Inhibitors.
(Consult with Anesthesia)
Osteoporosis
Tamoxifen
May increase risk of deep vein thrombosis –
Discuss with oncologist before decided to
stop medication preoperatively
Rheumatology
All types
Continue –per-operatively.
Anecdotal evidence of increased wound
infections/delayed healing.
Preoperative Evaluations:
AIMS and MEASURES
 Increase the percentage of COMPLETE preoperative history and physical
examination obtained for patients two years of age and older undergoing elective,
non-high-risk surgery and eliminate diagnostic tests performed without
clinical indications.
 Increase the percentage of patients two years of age and older undergoing elective
non-high-risk surgery who receive appropriate management of stable
comorbidities prior to procedure.
 Eliminate canceled or delayed elective, non-high-risk surgical procedures for
patients two years of age and older due to incomplete preoperative history and
physical examination and ineffective communication between clinics.
 Fiscal Implications
Preoperative Evaluations:
Summary
o All:
 Review/Familiarize with ICSI guidelines.
 Provide insight on areas of input and communicate with Work Group or others
involved in process.
o Surgical Groups:
 Incorporate Preoperative assessment tool and identify lower risk surgeries that
may not need separate evaluation and perform at time of surgical
consult/scheduling.
 When separate evaluation needed, allow guidelines to direct preoperative testing at
time of evaluation.
o Primary Care:
 Trial use of SmartSet / Template, give constructive feedback and move towards
standardizing visits around a set of guidelines.
o Anesthesia:
 Serve greater role in consulting, communication with surgical teams and primary
care in guiding pre-operative management.
Preoperative Evaluations:
Implementation Plan
o Surgical Groups:


Operations/Board meetings: introducing Pre-Operative Assessment tool and
asking to incorporate into work flow
Monitor trend/number of Pre-operative Evaluations that can be done at time of
consultation.
o Primary Care:



Operations meetings.
Managers, Super-Users, and Epic Trainers trained on use of template to provide
on-site physician support.
Identification of upcoming pre-ops and use of tools on subsequent visits.
o Anesthesia:


Collaborating with Anesthesia Department, PARC, other surgical centers to adapt
current guidelines in their protocols.
Monitoring process with subgroup focused on aims/measures listed above.
Pre-Operative Evaluations:
Dr Joseph F Smith Medical Library
o Select Staff Picks
o Select Aspirus Guidelines
• Preoperative Evaluation Section
 Presentation
 ICSI Guidelines
 Patient Risk Assessment Tools
 Epic Tip Sheet
 ACVA Protocol for Bridging Therapy
Pre-Operative Evaluations:
October 2013 – August 2014
CLINICAL INTEGRATION
“THE RIGHT CARE, IN THE RIGHT SETTING, AT THE RIGHT TIME”
CME JUNE 2014