Beyond the algorithm: Implementation of a hospitalist-led pre-operative clinic assessment before cardiac surgery

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Abstract

With the growth of dedicated pre-operative clinics in recent decades, patients have access to formalized and rigorous assessments in the days to weeks before surgery. The hallmark of pre-operative evaluations is cardiac risk stratification before non-cardiac surgery, yet any organ system has the potential to be addressed or further optimized before surgery. A formal, global clinic-based risk assessment before cardiac surgery seems to be a novel pre-operative clinic practice pattern, especially for a hospitalist-led preoperative medicine clinic. In July 2014, the Pre-Operative Medicine Clinic (PMC) within the Division of Hospital Medicine at Oregon Health & Science University began to formally assess patients before cardiac surgery. Here, we aim to describe our first year’s experience with this patient population and report on its efficacy and practicality.

Introduction

In recent decades, the pre-operative evaluation has shifted from the traditional day-of-surgery assessment by the anesthesiology team to pre-operative clinic assessments in the days to weeks before surgery. Pre-operative clinics have been associated with improved rates of surgical delays or cancellations, complications, length of stay, unnecessary testing, and cost.1, 2, 3, 4, 5, 6 Also during this time period, general internal medicine physicians and hospitalists have expanded their role within pre-operative medicine.

The hallmark of pre-operative assessment is cardiac risk stratification before non-cardiac surgery, with attention to the ACC/AHA guidelines.7, 8, 9, 10 The literature on a multi-organ system based pre-operative risk assessment has also greatly expanded. This includes, but is not limited to, assessment and optimization of pulmonary disease, obstructive sleep apnea, diabetes, hypertension, geriatric syndromes, and high-risk medications such as anticoagulants and immunosuppressants. However, literature on the crucial components of a global assessment before cardiac surgery is limited.11, 12, 13, 14, 15 Furthermore, cardiac surgery patients are likely to be older, more frail, and with more extensive comorbid conditions that have the potential to impact peri-operative morbidity/mortality as well as peri-operative flow and risk of short-term surgery cancellations/delays. We are aware of anesthesiologist-led pre-operative clinic evaluations before cardiac surgery14, 15, 16, 17, 18, 19, 20 and inpatient internist co-management agreements.21 However, we are not aware of any other hospitalist-led pre-operative clinic formally evaluating this patient subset.

In July 2014, our Division of Hospital Medicine’s Pre-Operative Medicine Clinic (PMC) began assessing cardiac surgery patients. Here, we aim to report our first year’s experience with this patient population. We hypothesized that a hospitalist-led evaluation was feasible and pragmatic before cardiac surgery.

Section snippets

Methods

Oregon Health & Science University (OHSU) is a 576 bed urban academic tertiary center performing 23–25,000 surgeries annually. The Pre-Operative Medicine Clinic, created in 2008, is a 2.0 MD plus 6.0 nurse practitioner FTE clinic. The clinic evaluates the majority of elective adult surgery patients (90–95%). Notable exceptions to PMC visits have included transplant and cardiac surgery patients in addition to cosmetic surgery patients and some very low risk procedure-patient combinations.

In

Results

Between 6/2014 and 7/2015, we conducted 294 pre-cardiac surgery PMC visits, reflecting 288 unique patients. This review includes patients having aortic arch or proximal vascular surgeries if left heart bypass was planned. Of the six patients who had two PMC encounters, five had two separate MD visits. Of these, four were rescheduled after medical optimization and one had an updated visit after insurance delays.

Average age was 64.1 years (range 19–96); 57% were male. Sixty-six percent of

Discussion

Pre-operative medicine clinic assessment before cardiac surgery appears to be a novel practice pattern. Here, we demonstrate the feasibility of a hospitalist-led pre-operative clinic evaluation of a large number of patients scheduled for cardiac surgery.

The literature surrounding cardiac surgery certainly abounds, and validated risk calculators such as the Society of Thoracic Surgeons (STS), EuroSCORE23, EuroSCORE II24, and the Frailty Index exist. There is additional literature targeting the

Conclusions

We find data on the efficacy, practicality, and early indicators of value of a structured pre-operative clinic evaluation of cardiac surgery patients well suited to the expanding role of hospitalists in peri-operative medicine. Here, we demonstrate our ability to capture and further optimize a broad range of comorbid pathologies. Additionally, we find this information applicable to general internal medicine care, as primary care physicians might have a role in pre-operative optimization of

Conflicts of interest

The authors declare that they have no disclosures or conflicts of interest.

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