Day Admission Surgery: How to Decrease Hospital Expenses? George Silvay, M.D., Ph.D. Professor, Department of Anesthesiology The Mount Sinai School of Medicine, New York, NY
The Mount Sinai School of Medicine, New York
DISCLOSURE Nothing at present...but I am hoping..
Value of Pre-Anesthesia Evaluation for Surgery: On 1994, France enacted a law making preoperative anesthesia assessment mandatory at least 2 days before a non-emergent operation Ausset S. et al Br J Anesth 2002;88:280-283
Value of Pre-Anesthesia Evaluation for Surgery: Australian Incident Monitoring Study 197 (3.1%) of 6,271 patients were not evaluated pre-operatively by an anesthesiologist. Of these, death followed in 7 cases Major morbidity (preventable) in 23 cases Unscheduled admission to ICU in 17 cases Surgery was cancelled in 9 cases Shaarawy T. et al Anesthesia 2000;55:1173-8
History of Pre-anesthesia Evaluation for Surgery MSSM: From 2000, all patients for major surgery were admitted to hospital one day prior OR, cardiac and major vascular (CMV) + other 1 3 days prior OR. From 2003 majority of patients were evaluated 3 7 days before elective operation. CMV were not satisfied. From 2007 was open new pre-anesthetic clinic only for CMV patients.
Flynn, BC et al Seminars CTVA 2009;13(4):241-248
Pre-Anesthesia Clinic for DAS Cardiac and TAA Patients at MSMC Following indication for elective surgery in the Cardiac Surgical and Aortic Aneurysm Center, the patient is scheduled 3 7 days prior the DAS operation Silvay, G et al T. et al HSR Proceedings 2010;2:40-3
Pre-Anesthesia Clinic for DAS Cardiac and TAA Patients at MSMC Staff: Cardiac anesthesiologist RN practitioner RN trained in CICU Location: Same floor as CICU & CCU Silvay, G et al T. et al HSR Proceedings 2010;2:40-3
Preoperative Assessment of Patients and Organization of the Operating Room is Critical Close communication of anesthesiologist with surgeon, cardiologist, perfusionist, intensivist and OR nurses is necessary to provide an optimal management and perioperative care of the patient. It is important to prevent and avoid surprises in the OR and update the teamwork communication!! Harmony in the OR provide optimal results and decreasing the morbidity and mortality. Silvay G, Stone M Sem Cardiothor Vasc Anesth 2006;10:1015
DAS Clinic for Cardiac and Major Vascular Surgery Day before the operation: Staff of PAC confirms all the arrangements for the OR and ICCU: blood bank order, blood conservation strategies, medication refinement. PAC are preparing all records, tests and other documentation. On the day of surgery, patient is admitted to the hospital in the PAC, after basic assessment of the patient to prevent interval changes, Antibacterial prophylaxis, the patient is escorted to the OR. Silvay G, Stone M Sem Cardiothor Vasc Anesth 2006;10:1015
PAC for TAA Objectives History, basic examination, airway Consultations with all necessary specialists, usually on same day as PAC visit (hematology, pulmonary. cardiology, pain management) Arrange further tests: carotid doppler, PFT s, dental examination, laboratory testing Perioperative medication reconcilaition: statins, beta-blockers, pacemaker, anti-platelet medications (previous stents), pacemaker, glucose lowering medications
PAC for TAA Objectives Neurologic evaluation (cognitive tests) Obtain medical reports: previous cardiac and non cardiac operations, difficulty with previous anesthesia managements, outside care-giver records Inform patients and family about hospitalization, insurance, anesthesia, monitoring and surgery
PAC for TAA Objectives Tour CSICU for patient and family Provide electronic information to the anesthesia team, OR, monitoring team, CSICU, pain management Visit patient after operation
The Day Before DAS All medical, logistics and administrative requirements are again evaluated: - OR schedule - Blood bank - Antibacterial prophylaxis - Blood conservation strategy - Plan for optimal monitoring - Cardiothoracic SICU - Pain management
On the day of surgery Patients are admitted in the same PAC, which maintains familiarity with personnel and location An immediate assessment of the patients is mandatory (no interval changes) IV started and antibiotics begun for prophylaxis!! Smooth, and on time transport to OR
Results (1/2007-9/2010) 3,504 evaluations performed in PAC 379 patients for TAA Ascending 17% Arch 21% Root 41% TAAA 21% 98 patients were seen in cardiac catheterization suite prior to urgent operation 48 patients were cancelled (medical or logistical reasons)
DeMaria, S et al Anesth Analg 2011 In Press
DeMaria, S et al Anesth Analg 2011 In Press
Lau H et al Journal of Clinical Anesthesia 2010;22:237-240
Lau H et al Journal of Clinical Anesthesia 2010;22:237-240
Lau H et al Journal of Clinical Anesthesia 2010;22:237-240
Decrease of Complications: The AA Surveillance Program Improved Surgical and Perfusion Techniques Inform OR, CICU and pain management Controlled distal perfusion; MEP s; CSF drainage; hemodynamic manipulation, avoid hypotension and anemia Castillo JG, Silvay G, Fischer GW: In TAAA: Springer-Verlag Italia 2011
Cost effective reasons for DAS 1) Patient satisfaction (family environment) 2) Avoid waste of resources in case of cancellation 3) Direct communication between OR staff 4) Bed availability 5) Avoid repeated tests 6) Decreased length of stay 7) Resident and fellow education 8) More efficient consults 9) Dental clearance
Conclusion Our preliminary observations include: - Increases in patient satisfaction - Safety and efficiency in the operating room - Decreases cancellation - Ongoing goal to provide cost containment through proper ordering of labs and consultations We believe that not only patients, but all medical personal benefit from a complete preoperative evaluation of these complicated patients and this creates harmony during the entire hospitalization!
Thank You Dakujem za pozornost
Flynn, BC et al Seminars CTVA 2009;13(4):241-248
Complex Aortic Surgery and Surveillance Program 3-6 months F/U all patients with TAA Established and timely execution the type of treatment for elective TAA Medical Conservative approach Surgical repair DAS Endovascular stent Educated patient and family about disease. Silvay, G et al T. et al HSR Proceedings 2010;2:40-3
Chiesa R. et al:h.san Raffaele Proceeding 2009;1: 47-55
DAS Clinic for Cardiac and Major Vascular Surgery 3-7 days before OR: Multi-disciplinary preoperative evaluation, updated history, physical and dental Basic examinations (Physical, EKG, chest X ray) Specific laboratory and clinical test Medication refinement: beta-blockers, recent PCI, antiplatelet therapy, glucose control, etc. Patients and their families are offered a tour of the CICU with discussions on what to expect postoperatively. Silvay G, Stone M Sem Cardiothor Vasc Anesth 2006;10:1015
Preoperative assessment and data collection Preoperative assessment of all organ subsystems. Information about size, location, and extent of TAA. Patient medication (e.g. discontinue Plavix, warfarin or other anticoagulants). Laboratory studies Preoperative antibacterial prophylaxis. Position / one lung anesthesia Silvay G, Stone M Sem Cardiothor Vasc Anesth 2006;10:1015
Preoperative assessment and data collection Plan for brain protection during DHCA (jugular bulb oxygen saturation, brain monitoring) Strategy for spinal cord protection (e.g. CSF drainage, mild hypothermia, SSEPs, MEPs, steroids). Blood conservation strategy (antifibrinolytics, cell saver). Optimize perioperative and postoperative monitoring Silvay G, Stone M Sem Cardiothor Vasc Anesth 2006;10:1015
Decrease of Complications: The AA Surveillance Program Detail Preoperative Assessment - DAS in PAC CMVS Dental clearance!! Avoid surprises in the operating room Silvay G et al Aortic Symposium 2010 Abstract (p 291)
Lau H et al Journal of Clinical Anesthesia 2010;22:237-240