A few months ago, a patient with a history of hypertension and insulin-dependent diabetes was admitted to Duke Regional Hospital's preoperative clinic before elective surgery for a total knee replacement. The hospitalist on duty noted that while the patient's hypertension and diabetes were under control, she was also taking clopidogrel due to a myocardial infarction 6 months earlier—a red flag for delaying surgery.
“We recommended that the patient not proceed with elective surgery at this point because they were within 12 months of an acute coronary syndrome and should remain on [clopidogrel] for a full year,” said Dawn Brezina, MD, FACP, a hospitalist and co-director of the clinic. “This sort of scenario comes up frequently and it's not necessarily keyed in upon by physicians who aren't specialists in internal medicine.”
Duke Regional in Durham, N.C., is one of a small but growing group of hospitals with preoperative clinics managed or staffed by hospitalists. Traditionally, preoperative assessment has been the realm of anesthesiologists, but hospitalists are finding a niche coordinating the care of medically complex patients prior to elective surgeries.
“Anesthesiologists are highly trained to do preoperative evaluations and assess for common risk factors, but hospitalists are used to managing chronic medical conditions that can be exacerbated during or after surgery,” said hospitalist David Boyte, MD, ACP Member, director of perioperative medicine at Duke Regional Hospital. “When internists and anesthesiologists can partner to evaluate a patient, assess their risks, and reduce them if possible, that's the most patient-centered approach we have available.”
The value that hospitalists bring to the preoperative setting was documented in a recent study of more than 5,000 patients who underwent noncardiac surgery at a tertiary care Veterans Affairs medical center. In the study, published in the November/December 2012 Journal of Hospital Medicine, researchers compared patient outcomes before and after a hospitalist-run, medical preoperative clinic was added to standard anesthesia evaluation.
Adding the clinic was associated with reduced length of stay for higher-risk patients (defined as those with an American Society of Anesthesiologists score of 3 or higher), a trend toward fewer same-day medically avoidable cancellations, and a reduction in inpatient mortality rates. Early intervention by hospitalists, the authors noted, appears to particularly benefit medically complex patients.
“By performing a multisystem evaluation with evidence-based protocols, we possibly identified patients that were at increased risk of perioperative harm and were able to intervene or recommend deferral of the procedure,” the authors wrote. “This could have resulted in better surgical candidate selection with fewer postoperative complications, especially among patients with significant medical comorbidities.”
Such findings are not surprising to Anbazhagan Prabhakaran, MD, FACP, medical director of Cleveland Clinic's Internal Medicine Preoperative Assessment, Consultation and Treatment (IMPACT) Center in Cleveland, Ohio, which has been providing preoperative care by internal medicine specialists since 1997.
“Before the clinic was established, administrators were facing challenges such as a lot of cancellations on the day of surgery,” said Dr. Prabhakaran. “They wanted a standardized model of care, so they approached the internal medicine department and within a few years, hospitalists got involved because the volume of patients was so high.”
The IMPACT clinic complements the Preoperative Anesthesia Consultation and Evaluation (PACE) clinic, run by anesthesiologists, said Dr. Prabhakaran. Medically complex patients visit the IMPACT clinic first for medical management by hospitalists before moving onto the PACE clinic to focus on anesthesia issues.
In 2008 the executive team at Oregon Health & Science University (OHSU) Hospital in Portland, Ore., asked the hospitalist group to lead and expand the reach of the Preanesthesia Testing Clinic, a service that had been performed by anesthesiologists, explained hospitalist and clinic director Cornelia Taylor, MD, ACP Member. “
“There's not a lot you can do to optimize a patient on the day before surgery,” said Dr. Taylor. “We wanted to see if we could intervene a little bit upstream by identifying potential issues and designing a roadmap for managing potential complications.”
Although the hospital does not have specific data on the clinic's impact, an informal review of patient charts revealed a very low cancellation rate (around 1%) for patients who had been evaluated and managed in the clinic.
“Even when a patient is pretty sick, if we take the time to confer with the anesthesiologist and surgeon and remove that element of surprise on the morning of surgery, even medically complex patients can avoid cancellation and proceed on with their planned procedure,” said Dr. Taylor.
Ideally, hospitalists and anesthesiologists work collaboratively as equal partners, said Dr. Taylor.
“They rely on us to make sure we have covered the bases as completely as possible so they can simply double check with patients about what's in the record,” she said. “We streamline and help their workflow so they don't have to spend a lot of extra time gathering information, making clinical decisions, and getting additional tests and can feel confident in putting a patient to sleep.”
Hospitalist-run preoperative clinics may be most cost- efficient at large, tertiary centers that deal with a high volume of medically complex patients. However, the concept can work at some smaller hospitals too.
For example, St. Charles Medical Center in Bend, Ore., a nonprofit community hospital with a level II trauma center, opened its preoperative medicine clinic at the beginning of 2012, said clinic director Brooke Hall, MD, ACP Member, an internist with experience in both inpatient and outpatient care and the clinic's sole clinician. Elective surgery patients visit the clinic if referred by their surgeon or primary care clinician.
“Several years after working as a hospitalist at St. Charles, I met with administrators about the need for a preoperative medicine clinic,” said Dr. Hall, who established another preoperative clinic for a previous employer. “The surgeons appreciate the coordination of care and availability of preoperative consults. My patient volume has doubled over the past year.”
In a traditional model, the surgeon may consult a pulmonologist, cardiologist, or other subspecialist about whether a patient can safely undergo surgery. The hospitalist approach is more comprehensive in that it goes beyond identifying risks to managing them.
“We aren't just deciding whether or not to proceed with surgery,” said Dr. Boyte. “We're integrating and coordinating care in a surgical home model. We don't just recommend that someone see a specialist, we arrange for that appointment and serve as a node through which information flows.”
Such care for a medically complex patient typically starts 2 weeks or more before the scheduled surgery. At St. Charles, for example, Dr. Hall spends about an hour on an initial visit a month prior to scheduled surgery, performing a full history and physical, ordering lab tests, and coordinating any necessary cardiopulmonary testing.
Conditions such as uncontrolled hypertension or diabetes may require medical management in order to stabilize the patient for surgery, said Dr. Hall. In such cases, she may refer patients back to their primary care physicians for care or start them on medication and bring them back for brief follow-up appointments.
“I can typically optimize them in that 30-day time frame without delaying or canceling surgery,” she said.
It is not uncommon for patients to arrive at the clinic with undiagnosed or untreated conditions that require extensive management before surgery, said Dr. Brezina. For example, she might order pulmonary function studies for a patient with chronic obstructive pulmonary disease that has not been evaluated, then prescribe medications and inhalers to optimize his or her breathing.
“It's rare to say that someone cannot have surgery but we sometimes extend the time beforehand in order to get things tuned up,” said Dr. Brezina. “We make sure chronic medical problems that increase the risk of surgery are taken care of, which often prevents late or same-day cancellations.”
Following a complete evaluation, Dr. Hall sends a medical management report to the patient's surgeon with recommendations on when to stop and start medications, such as insulin, and an assessment of the patient's risk for sleep apnea. She draws attention to particular areas of concern, such as high risk for venous thromboembolism.
Hospitalists also provide patients with information and instructions about their upcoming surgery, said Dr. Prabhakaran.
“We give them detailed printed instructions for their medications that they can't take or must stop ahead of time,” he said. “Patients know their risks and have their questions answered beforehand, making it much easier on the day of surgery.”
For Dr. Hall, preoperative care is an opportunity not only to minimize risks during surgery but also to impact long-term health.
“For some patients, having an elective surgery is the only time they enter the system,” she said. “It's an opportunity to counsel them about tobacco or alcohol use and refer them to a primary care physician so they will have follow-up care beyond their surgery.”
It's important to remember that patients, as well as institutions, benefit from presurgical care that reduces the chances of unexpected cancellations, said Dr. Prabhakaran.
“Patients do a lot of things to prepare for the day of surgery from a logistical standpoint, from taking time off work to coordinating with caretakers and relatives,” he said. “If their procedure is cancelled on the day of surgery because their medical conditions are not optimized, it's a huge burden to rearrange everything.”