Society for Technology in Anesthesia Section Editor: Maxime Cannesson E BRIEF REPORT Development of a Preoperative Patient Clearance and Consultation Screening Questionnaire Thomas R. Vetter, MD, MPH, Arthur M. Boudreaux, MD, Brent A. Ponce, MD, Joydip Barman, PhD, MBA, and Sandra J. Crump, DNP, MBA, NP-C * * † * * The optimal timing of the preanesthesia evaluation varies with the patient’s comorbidities. As anesthesiologists assume a broader role in perioperative care, there may be opportuni- ties to provide additional patient management beyond historical routine anesthesia services. This study was thus undertaken to survey our institutional perioperative clinicians regarding their perceptions of patient medical conditions that (a) need additional time for preoperative clearance by anesthesiology before actually scheduling the date of surgery and (b) warrant additional preoperative evaluation and management services by an anesthesiologist. These data were used to create a pilot version of a Preoperative Patient Clearance and Consultation Screening Questionnaire. (Anesth Analg 2016;123:1453–7) ccording to the 2012 American Society of care in the United States by promoting greater standard- Anesthesiologists (ASA) Practice Advisory for ization, integration, and shared decision making, thus Preanesthesia Evaluation, an anesthesiologist is improving clinical outcomes and decreasing unnecessary A 2,3 responsible for medically assessing and optimizing a sur- resource utilization. The Perioperative Surgical Home gical patient.1 This involves “(1) discovery or identifica- can broaden anesthesiologists’ scope of practice with their tion of a disease or disorder that may affect perioperative participating in the more coordinated continuity of preop- anesthetic care; (2) verification or assessment of an already erative, intraoperative, and postoperative care.4 known disease, disorder, medical or alternative therapy As anesthesiologists assume this broader role in periop- that may affect perioperative anesthetic care; and (3) for- erative care, there may be opportunities to provide addi- mulation of specific plans and alternatives for perioperative tional clinical services beyond historical routine anesthesia anesthetic care.”1 services (ie, the global anesthesia fee).5 The ASA has thus The ASA Practice Advisory for Preanesthesia Evaluation also promulgated, “In some cases, a surgeon might request stratified patients on the level of surgical invasiveness that the anesthesiologist determine if a patient’s clinical (high, medium, or low) and severity of disease (high or condition is optimized to allow scheduling of a surgical low). The solicited consultant and ASA membership opin- procedure and, if not, request assistance in managing the ions regarding the timing of the preanesthetic interview preoperative care (eg, assessing and managing underlying and physical examination (before the day of surgery; on or clinical conditions, such as coronary artery disease, chronic before the day of surgery; or only on the day of surgery) obstructive pulmonary disease, asthma, diabetes mellitus, were generally convergent.1 However, the ideal timing of etc). These management services are beyond the scope of this preanesthesia evaluation was not clearly defined by this routine preoperative evaluation and are separately bill- ASA practice advisory. Furthermore, it would appear opti- able with appropriate documentation.”5 However, there mal that patients with complex medical conditions be fully is a need to efficiently and consistently identify patients evaluated and optimized by an anesthesiologist well before who are appropriate candidates for additional preopera- the day of surgery. tive evaluation and management (E&M) services by an The Perioperative Surgical Home is a new model of care anesthesiologist. that seeks to remedy the currently fragmented and costly This preliminary, exploratory study was thus under- taken to survey our institutional perioperative clinicians regarding their perceptions of patients with specific medi- From the Departments of Anesthesiology and Perioperative Medicine and Surgery, Division of Orthopaedic Surgery, University of Alabama at Bir- cal conditions who may (a) need additional time for pre- mingham, Birmingham, Alabama.* operative clearance by the anesthesiology service before † Accepted for publication June 20, 2016. actually scheduling the date of surgery and (b) warrant Funding: University of Alabama at Birmingham (UAB) Department of additional preoperative E&M services by an anesthesi- Anesthesiology and Perioperative Medicine Internal Funds. ologist. These data were then used to create a pilot ver- The authors declare no conflicts of interest. sion of a Preoperative Patient Clearance and Consultation Supplemental digital content is available for this article. Direct URL citations Screening Questionnaire. This initial brief report is also appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). intended to make this questionnaire available to others Reprints will not be available from the authors. who might want to adapt it for their institutions. Address correspondence to Thomas R. Vetter, MD, MPH, Department of Anesthesiology and Perioperative Medicine, University of Alabama at METHODS Birmingham, 619 19th St. South, JT862, Birmingham, AL 35249. Address e-mail to [email protected]. This study was approved by the University of Alabama Copyright © 2016 International Anesthesia Research Society at Birmingham (UAB) Institutional Review Board DOI: 10.1213/ANE.0000000000001532 (E110311001). Written informed consent was obtained from December 2016 • Volume 123 • Number 6 www.anesthesia-analgesia.org 1453 Copyright © 2016 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. E BRIEF REPORT all clinician study subjects before participation via their Based on the qualitative survey responses and the itera- affirmative response on the initial page of the online elec- tive effort of the above 4 clinicians, a final pilot version of a tronic survey. Preoperative Patient Clearance and Consultation Screening We administered an electronic, online clinician survey.a Questionnaire was created (Figure). This study survey assessed clinician opinions. This quali- tative survey asked the study participants to list as free DISCUSSION text up to 15 diseases or clinical conditions in surgical As noted in 2007 and 2014 by the American College of patients that they felt would indicate the need for a preop- Cardiology/American Heart Association, the goal of a erative clearance from the anesthesiology service before preoperative patient assessment is not to give perfunc- scheduling an actual surgical date. No formal psychomet- tory “medical clearance” for surgery but rather to provide ric validity or reliability testing was performed on this comprehensive perioperative E&M, including risk stratifi- qualitative survey. cation and optimization, as well as shared decision making Potential clinician study participants were recruited among all clinicians, the patient, and family members.6,7 from the faculty in the UAB School of Medicine “The timing of an initial preanesthetic evaluation is Department of Anesthesiology and Perioperative guided by such factors as patient demographics, clinical Medicine and Department of Surgery, as well as the cohort conditions, type and invasiveness of procedure, and the of certified registered nurse anesthetists and Preoperative nature of the healthcare system.”1 Based on a survey of Assessment, Consultation, and Treatment (PACT) Clinic our practicing clinicians, we generated a pilot version of a nurse practitioners employed by UAB Hospital. These Preoperative Patient Clearance and Consultation Screening clinicians were invited to participate in this study via an Questionnaire. The goal of the questionnaire is to provide e-mail from the principal investigator (T.R.V.). The e-mail greater clarity on the amount of time needed for preopera- described the purpose of the study and provided the recip- tive clearance by the anesthesiology service before actu- ient with a hyperlink to the online electronic qualitative ally scheduling the date of surgery and the indication for survey through SurveyMonkey.com (SurveyMonkey®, additional preoperative E&M services by an anesthesiolo- Palo Alto, CA). To maximize the survey response rate, 2 gist. This effort was intended to build on previous such additional survey e-mail invitations were sent at 7-day reported efforts,8–10 while enlisting much needed input and intervals to all potential study participants. The clinician buy-in from our local stakeholders. survey responses were completely anonymous. In collaboration with our institutional health infor- The clinician survey response rates were described matics team, we have created an electronic, tablet-based using frequency counts and percentages. The raw survey version of this Preoperative Patient Clearance and responses were categorized by specific disease/clinical con- Consultation Screening Questionnaire, which will be dition. A simple numerical count was determined for the self-completed by patients during their surgical clinic frequency of each unique survey response. visit. The completed electronic questionnaire will be Based on the qualitative clinician survey data, includ- reviewed by a surgical clinic nurse, and its additional ing prioritization by the frequency (numerical count)