Thesis Nurs. 1995 B877r c.2 Brown. Grace C. A retrospective study of preoperative 1995. A Retrospective Study of Preoperative Standardized Screening Tests in Healthy Ambulatory Surgical Patients by Grace C. Brown Submitted in Partial Fulfillment of the Requirements for the Masters of Science in Nursing Degree Approved by: fl u 7 , C£ajP: MD 7) Advisor zq //Av' Date Committee Member Date Committee Member Date Abstract A retrospective study of 100 patient medical records was done to determine whether preoperative standardized screening tests could be reduced in healthy ambulatory surgical patients age 40 or older without compromising patient surgical outcome. A two way chisquare test of association was utilized to determine if there was any association between the outcome of patients’ elective ambulatory surgical procedures and the preoperative assessments which included the health history and physical examination, electrocardiogram, chest x-ray, and laboratory tests. This study found no statistically significant association between the preoperative assessments and patient surgical outcome. The results of this study indicate that preoperative tests are of little significance in predicting surgical outcome in healthy ambulatory patients. The study further indicated that the health history and physical examination should be done first and used as a tool in determining what preoperative standardized screening tests need to be performed. ACKNOWLEDGMENTS I would like to take this opportunity to express my sincere appreciation to those people who helped me make my graduate education possible. I would like to thank my thesis committee for their direction, time and energy. Dr. Schilling, Dr. Paul and Mr. Steve Anderson. I would like to express my sincere gratitude to my friends for their consistent support and encouragement to complete this thesis, Mr. and Mrs. Ernest Crider, Mrs., Cleopatra Barnwell and her son, Marcel S. McKnight Jr. for his expertise on the computer, time and dedication to see me graduate. Last, but not least, I would like to thank my husband, Marvin and my two sons, Christopher and Marsalis for their consistent support throughout my education. My heart felt appreciation to each of you. ii Table Of Contents Acknowledgments. ii List of Tables v List of Figures. vi page Chapter 1 1. Introduction Background of the Problem. 1 Purpose of the Study 3 Statement of the Problem. .3 Research Questions 3 Definition of Terms .4 Assumptions 6 Limitations. 6 7 2. Review Of Literature. 17 3. Methodology Sample and Setting. 17 Instrumentation 18 Procedure for Collection of Data. 19 Procedure for Analysis of Data. 20 21 4. Presentation And Analysis Of Data. Characteristics of the Total Sample. 21 Results of Statistical Analysis .21 iii Chapter page 5. Conclusion 32 Discussion 32 Recommendations For Further Research 36 References 37 Appendixes .41 .42 A. Nursing Policies and Procedure B. S.D.S. GENERAL ANESTHESIA Preoperative Nursing 44 Assessment. C. Standard of Care, Discharge of a Patient. 45 D. Ambulatory Surgery, Patient Follow-up Call .46 E. Data Collection Tool .47 F. Letter Requesting Permission to Conduct Research .48 G. Letter Granting Permission to Conduct Research 50 H. Request for Records for Study 51 iv List Of Tables page 23 1. Contingency Table of Data. 2. Comparision between Favorable and Unfavorable Findings in the Electrocardiogram, Chest X-Ray, Laboratory Test, Health History and Physical Examination and Patient .25 Surgical Outcome. v List Of Figures page 1. Preadmission Standardized Screening Tests and Patient Outcome. .28 2. Comparison Between the Health History and Physical Examination and Preoperative Standardized Screening Tests and Patient Outcome. vi 30 Chapter 1 Introduction Background of the Problem The health care industry is an ever advancing field for both consumers and providers. New drugs, new technology, legislative actions, reimbursement requirements, and the increasing cost of health care has lead to efforts to minimize the use of hospital resources. Ambulatory surgery has emerged as one of the most effective means of reducing health care costs, while providing quality care (Kambouris, 1986; Epstein, 1987; Cruz, 1990). A large number of surgical procedures are currently performed in hospital-based operating rooms on an outpatient ambulatory basis. In 1977 the American Hospital Association speculated that if the percentage of ambulatory surgery was increased from 10% to 30%, the annual savings to the nation’s health care system would be $733,947,208 (Marks, Greenlich, Hurtado, & Johnson, 1980). Ambulatory surgery is an attempt to keep healthy patients out of hospitals by caring for them in outpatient settings. New technology, new laser applications, and new concepts of health care will keep the ambulatory surgery industry moving and growing (Cruz, 1990). Kambouris (1986) wrote that, “Under appropriate settings, ambulatory surgery applies to 30-50% of all surgical case loads, it is economically desirable, it is safe, it carries minimal risks when appropriately employed and provides flexibility of action for the patient and surgeon” (p. 350). An increasing number of ambulatory surgical procedures are performed on otherwise healthy patients. Nathanson (1988) indicated that ambulatory surgery made up 1 2 40% of all surgery in 1986, and his projection for 1990 was that ambulatory surgery would constitute 40-60% of all surgery performed in the United States. This implies that over 50% of all surgical procedures are performed on otherwise healthy individuals. As defined in the Pennsylvania Blue Shield Policy Review News Vol. 1 (1995), the American Society of Anesthesiologists (ASA) classifies a patient’s physical status into five categories. Ambulatory surgery is generally performed on patients classified under physical status I or II. The Pennsylvania Blue Shield defines ASA physical status I as, “a normally healthy patient. There is no organic, physiologic, biochemical or psychiatric disturbance. The pathological process for which the operation is to be performed is localized and not conducive to systematic disturbance” (p 8). ASA physical status II is defined as , “a patient with mild to moderate systemic disturbance caused either by the condition to be treated surgically or by other pathophysiologic process” (p. 8). The overall goal of the health care industry is to provide efficient, cost effective services without compromising quality care. With the growth of ambulatory surgery, it is necessary to address specific issues and concerns to assure safe quality care and minimize risks. A major issue is patient selection and screening for surgical procedures to be performed in an ambulatory surgical unit. Anesthesiologists and nurse anesthetists participate in the process of patient selection, screening, evaluation, and management of patients prior to surgery (preoperatively), during surgery (intraoperatively), and after surgery (postoperatively). All patients undergoing surgery must have a complete health history taken and physical examination performed. In screening this group of patients, the anesthesiologist or nurse anesthetist is screening for asymptomatic conditions that are silent and do not manifest 3 themselves to the patient, but which may have an impact on surgical outcome (Robbins & Mushlin, 1979). The screening process helps anesthesiologists and nurse anesthetists make decisions in scheduling surgical procedures in ambulatory surgical settings without compromising the quality of care. It involves a detailed patient health history, current drug therapy, physical examination, and laboratory data. Questions asked of the patients must be directed and focused on identifying risk factors that may influence the management and outcome of the anesthetic and surgical procedure (Epstein, 1987). The Purpose of the Study The purpose of this study was to determine whether preoperative standardized screening tests can be reduced in healthy ambulatory surgical patients, without compromising patient surgical outcome. Patient health history and physical examination findings were correlated with preoperative standardized screening tests. Did laboratory tests results reveal new data that was not present in the patient health history and physical examination and did this data aid in altering patient care management? S tatement of the Problem This study investigated whether the health history and physical examination was sufficient without standardized screening tests, for the adult patient age 40 or over whose ASA physical status was I or n, without compromising the outcome of an elective surgical procedure. Research Questions 1. What is the relationship between the patient surgical outcome and the preoperative electrocardiogram report if an adequate health history and physical 4 examination has been performed? 2. What is the relationship between the patient surgical outcome and the preoperative chest x-ray report if an adequate health history and physical examination has been performed? 3. What is the relationship between the patient surgical outcome and preoperative laboratory tests if an adequate health history and physical examination has been performed? Definition of Terms The following terms were defined to clarify their precise meaning in this study: 1. Adult - All persons age 40 years or over. 2. Chest x-ray - A radiograph of the chest used for the diagnosis of pulmonary disease and diseases of the mediastinum and bony thorax (Pagna & Pagna, 1992). 3. Electrocardiogram (EKG) - A graphic representation of the electrical activity of the heart. Used as an indication of heart function (Pagna & Pagna, 1992). 4. Elective surgery -Surgical care scheduled more than 24 hours in advance. 5. Hematocrit - A measure of the percentage of red blood cells in the total blood volume. Normal adult value for males is 42-52 % and for adult females is 37-47 % (Pagna & Pagna, 1992). 6. Hemoglobin - The main component of the red blood cells which serves as a vehicle for the transportation of oxygen. Normal adult values for males are 14-18 grams per deciliter and for females 12-16 grams per deciliter of blood (Pagna & Pagna, 1992). 5 7. Outpatient surgery - Surgical procedure performed on patients with an understanding that the patient will be discharged from the hospital on the day of surgery (Barash, Cullen, & Stoelting, 1989). 8. Preoperative Assessment - Includes the health history and physical examination, electrocardiogram, chest x-ray, and laboratory tests. 9. Serum potassium - The principle electrolyte of intracellular fluid. It is used to evaluate and diagnose disorders of acid-base and water balance in the body. Normal value are 3.54.5 milliequivelant per liter of blood serum (Pagna & Pagna, 1992). 10. Serum Creatinine - A by-product in the breakdown of muscle creatinine phosphate excreted by the kidneys. It is used to diagnose renal function. Normal value is 0.2-0.5 milligram per deciliter of blood serum (Pagna & Pagna, 1992). 11. Blood Urea Nitrogen - A test used as a gross index of kidney function. Normal value is 10-15 milligrams per 100 milliliterof blood (Pagna & Pagna, 1992). 12. Favorable Surgical Outcome - Patients who experience no limitation in comfort, tissue integrity, nutrition, elimination, and activities of daily living 24 hours postoperatively. 13. Unfavorable Surgical Outcome - Patients who experience one or more limitations in comfort, tissue integrity, nutrition, elimination, and activities of daily living 24 hours postoperatively. 14. Urinalysis - A chemistry analysis of the urine that includes the pH, appearance, color, odor, specific gravity, protein, glucose, ketone, blood, leukocystic esterase and microscopic examination for red blood cells, white cells, casts, crystals, and bacteria. (Pagna & Pagna, 1992). 6 Assumptions The following assumptions were identified for this study: All health histories and physical examinations were performed by board certified anesthesiologists who had similar training and used the same standards of practice. All health history and physical examination reports, laboratory reports, electrocardiogram reports, and chest x-ray reports were accurate. The physical status classification of patients into ASA I or II was performed by board certified anesthesiologists who had similar training and followed the same standard of practice. Limitations The following limitations were identified: All data was collected at one hospital in northwestern Pennsylvania. The research sample was limited to 100 patients aged 40 years or over. Chapter 2 Review of Literature Preparing a patient for surgery is an important component of a successful surgical outcome. The protocol for performing preoperative screening tests falls under the institution s policies and procedures. Since quality care is an absolute essential in all aspects of patient care, patients undergoing same-day surgery under general or regional anesthesia are afforded the same care and safety provided to hospital inpatients. Consequently, each patient has a complete health history and physical examination, preoperative anesthesia evaluation, and a complete blood count and urinalysis done. According to Davis (1977) and Witchler (1981) electrocardiograms, chest x-rays and blood chemistry determinations need to be done only when specifically indicated. In looking at preoperative screening, Cebul & Beck (1987) reported that 50% of surgical procedures are performed on primarily healthy individuals. The ASA physical status classification defines this group of patients as being class I or IL The ASA classification is not an estimate of operative risk. Instead, it simply describes the patient’s preoperative condition (Pennsylvania Blue Shield, 1995). Robbins & Mushlin (1979) raise the following question, “In addition to a complete history and physical examination, what type and extent of medical examination can be done to ensure and improve upon this already low surgical mortality rate?” (p. 1145). The major reason for performing the preoperative health history, physical examination, and standardized preadmission screening tests is to identify patients at operative risk. This helps reduce perioperative morbidity by allowing for preoperative 7 8 planning and perioperative management. Perioperative mortality and morbidity increase with the severity of preexisting disease (Roizen, 1990; Roizen, Kaplan, Schreider, Lichtor, & Orkin, 1987). The most important part of the preoperative evaluation is a thorough, directed health history and physical examination. In a study by Sandler (1979) on the relative importance of the health history, the physical examination, and routine or special investigations, he concluded that the history was the most important factor in both diagnosis and management of patient care. The health history determined 56% of all diagnoses and 46% of all management decisions in patient care. Screening is an effort to detect disease in unselected populations of asymptomatic persons. Anesthesiologists and nurse anesthetists screen patients for acute and chronic systemic disease. They seek to gain insight into the patient’s general state of health, and whether chronic disease, if present, is well controlled. Wong (1990), Roizen (1990), and Macpherson (1993) all addressed the same issues. They contended that preoperative evaluations by screening tests may not be the most effective procedure. They also added that when abnormalities are found on laboratory tests, these results are often ignored since evidence exists that the test abnormalities are not associated with preoperative morbidity. Furthermore, they stated that this practice represents a potential medicolegal problem because failure to pursue an abnormal laboratory test result may be riskier than failing to order the test in the first place. Routine preadmission laboratory tests have been promoted and widely used. Routine refers to a policy whereby an institution or physician performs biochemical profiles without regard to clinical evidence of disease in the individual patient. 9 The emphasis on scientific investigational approaches utilizing routine laboratory screening minimizes the importance and value of a good health history and physical examination in diagnosis and management. In an era of increasing concern for cost containment this can no longer be ignored (Cebul & Beck, 1987). According to Wyatt, Reed, & Apelgren (1989) it was estimated in 1985 that $30 billion was spent on routine diagnostic testing representing 7% of all health care spending. Roizen (1990) brought out that Blue Cross and Blue Shield have estimated 60% of the $30 billion spent in North America on preoperative testing could be saved by more appropriate ordering of tests based on the health history and physical examination. Korvin, Pearce & Stanley (1975) looked at the clinical benefits that could be derived from hospital preadmission laboratory screening. Of 1,000 patients admitted over a six month period, each underwent an average of at least 20 chemical and hematological profile tests. The results of this study showed 2,223 abnormal results of which 675 were predicted by the health history and physical examinations. Of the other 1,325 findings, 223 test results led to 83 new diagnoses in 77 patients. Of the new diagnoses made, none were unequivocally beneficial to the patients. They concluded that there was little benefit in showing that which is already known, predictable, or untreatable. Cebul & Beck (1987) stated that the overall yield of laboratory screenings, in terms of disease detection that materially improves patients’ health, was found to be very low in various testing situations. Kaplan et al. (1985) looked at the usefulness of routine laboratory screening for patients undergoing elective surgery. They randomly selected laboratory samples from 2,000 patients. Results of this study showed that 66% of these routinely ordered tests 10 would not have been performed if the test had only been done for recognizable indications. Only 0.22% of the tests performed revealed abnormalities that might have influenced perioperative management. On conducting a chart review of these abnormalities, it was discovered that they were not acted upon nor did they have adverse surgical or anesthetic consequences. They further suggested that in the absence of specific indications, routine laboratory testing contributed little to patient care. Laboratory tests can aid in assuring that the patient’s preoperative condition is optimal once a disease is suspected and diagnosed. Routine admission laboratory tests used as a screening device for discovery of unknown disease in asymptomatic patients, however, frequently fail to uncover pathologic conditions. Roizen (1990) presented studies indicating that the health history and physical examination are the best ways to screen for disease. Laboratory tests are usually requested to seek confirmation of clinical impressions or new diagnoses. Therefore, preoperative laboratory screening must represent a particular group of screening tests adapted for the surgical situation. Macpherson (1993) stated that physicians choosing to practice selective testing will be conforming to the recommendation of the American College of Physicians, as well as several other well recognized physician groups. He further expounded that the practice of selective testing is recommended in the major textbooks of anesthesia, surgery, and medical consultation. Robbins & Mushlin (1979) wrote that they were unable to find scientific justification or substantiation for routine preoperative testing. Several disease conditions have potential effects on surgical outcome, identified by Robbins & Mushlin (1979) as anemia, ischemic heart disease, cardiac arrhythmias, chronic obstructive lung disease, diabetes mellitus, chronic nephritis, clotting abnormalities, nephrotic syndrome, and chronic interstitial lung 11 disease. They also identified those disease conditions whose early detection would benefit both the patient and hospital staff, but not necessarily affect surgical outcome, such as glaucoma, gonorrhea, hepatitis, pregnancy, syphilis, tuberculosis, and urinary tract infections. Patients with any of these conditions are often not totally asymptomatic, and a good history and physical examination may identify the majority of these patients. Abnormal laboratory tests results from asymptomatic patients may not indicate disease, but rather the health status of the patient. The recommendations from the Medical Necessity Project of the American College of Physicians and Blue Cross and Blue Shield are that diagnostic screening tests should compliment and not replace a careful health history and physical examination (Kaplan et al. 1985) The injudicious use of diagnostic screening laboratory tests greatly affects the cost of medical care. The question arises again, are all preoperative screening tests necessary? Most facilities providing ambulatory surgery have adopted routine preadmission screening consisting of standardized blood studies, electrocardiograms, and chest x-ray studies. As the economy of health care delivery becomes crucial, support for ambulatory surgery will grow because of its cost effectiveness (Wyatt, Reed, & Apelgren, 1989). Which preoperative laboratory tests should be performed on healthy patients scheduled for elective surgery? Roizen (1990) listed six considerations in ordering preoperative testing. These are the incidence of abnormalities of the test in specific age groups, the importance of an abnormal test result to perioperative outcome, the cost of the test, the ability to favorably alter the perioperative course once the abnormal test has been obtained, other benefits to the patient, and medicolegal considerations. Roizen further suggested the following recommendations for healthy patients undergoing elective minor blood loss 12 operations. Men under 40 years of age require a hemoglobin or hematocrit; in addition, men and women 40 to 59 years old should have an electrocardiogram, and a blood urea nitrogen and plasma glucose determination; and finally, men and women over 60 years old also require a chest x-ray. In addition, all women of childbearing age should be asked about the possibility of pregnancy and, if possible, a urine pregnancy test should be performed preoperatively. Hansen & Nicholson (1989) wrote that most of the cost of medical care stems from small things physicians control on a daily basis. They estimated that laboratory testing can account for 25% of a patient’s hospital bill. The complete blood count and leukocyte differential count are two of the most common clinical laboratory tests performed. They are also common components of screening batteries in asymptomatic patients. Shapiro & Greenfield (1987) found no evidence to support the use of these two tests in screening for anemia or infection in asymptomatic ambulatory presurgical patients. In otherwise healthy patients undergoing surgical procedures in which blood loss was minimal, Kaplan et al. (1985) found that the complete blood count almost never contributed to patient care. Bean & DeCresce (1989) reported no value in doing routine prothrombin time and activated partial thromboplastin time in screening for unsuspected coagulopathy in both ambulatory and asymptomatic presurgical patients. A biochemical profile may include 6 to 20 different serum tests of which only a few such as serum potassium and glucose are significant prior to surgery. Krieg, Gambino, & Galen (1975) noted that unless physicians regard the ordering of tests as a serious responsibility worthy of thoughtful consideration, the privilege to select such services may not remain unrestricted in the future. 13 Preadmission standardized screening not only involves laboratory tests, but also includes electrocardiograms and chest x-rays in selected age groups. Morbidity and mortality increases in patients who have had recent, as opposed to over 6 month-old, myocardial infarctions. The electrocardiogram has become an essential preoperative screening test for that population. Macpherson (1993) stated that electrocardiographic abnormalities are quite common in the surgical population, ranging from 14% to 53%. The frequency of these abnormalities rises with age. Preoperative cardiac complications are often serious and associated with a high mortality. Therefore, physicians are vigilant in trying to identify high risk individuals. The electrocardiogram abnormalities that may alter anesthetic management have been identified by Roizen (1990), as follows: atrial flutter or fibrillation; first, second or third degree heart block; changes in S-T segment suggesting myocardial ischemia or recent pulmonary embolism; premature ventricular and atrial contractions; left or right ventricular hypertrophy; short PR interval; Wolf-Parkinson- White syndrome; myocardial infarction; and prolonged QT and tall peaked T-waves. Myocardial infarction occurs in 0.1% to 0.7% of surgical patients during the perioperative period. This emphasizes the need to accurately, as far as possible, assess those patients at risk for myocardial injury. Rao, Jacobs & El-Etr (1983) found that the reinfarction rate in patients with a history of myocardial infarction is around 7% following anesthesia and surgery. In patients who suffered myocardial infarction within 0-3 and 4-6 months before the time of anesthesia and surgery, the rates were 37% and 16% respectively. They looked at the incidence and factors related to recurrent perioperative myocardial infarction retrospectively and prospectively. They found that in both study groups patients with prior myocardial infarction and congestive heart failure had a higher reinfarction rate. 14 Patients who had intraoperative hypertension, and tachycardia or hypotension, also had a higher incidence of infarction. These studies indicated that preoperative electrocardiograms helped identify the patients with a greater potential for incurring postoperative myocardial infarction. Roizen (1990) suggested that preoperative screening electrocardiograms are indicated for patients over 40 years of age prior to elective surgery. There has also been a marked increase in the utilization of diagnostic radiology in recent years. Golub, Cantu, Sorrento & Stein (1992) found that the use of the preoperative chest x-ray examination has become a routine part of assessing the patient before general anesthesia. Routine tests are performed for a variety of reasons: to detect unsuspected serious diseases, out of habit, due to hospital policies, requirements of anesthesia and for medicolegal reasons. Even though preadmission testing does detect some diseases that might be important to the patient’s health, Golub et al. argued that this is not the role of the preadmission process. The preadmission testing process is only concerned with detecting conditions that might influence the subsequent surgery. Anesthetic management is often altered on the basis of abnormal test results, making it important to know which abnormalities found on a chest x-ray examination should influence one’s anesthetic approach. Roizen (1990) and Roizen et al. (1987) listed the chest x-ray abnormalities that would influence one’s anesthetic approach, as follows: tracheal deviation; mediastinal masses; pulmonary nodules; a solitary lung mass; aortic aneurysm; pulmonary edema; pneumonia; atelectasis, new fracture of vertebrae, ribs or clavicle; and cardiomegaly. Chronic lung disease was not included in that list because the chest x-ray examination does not detect the degree of chronic lung disease that would 15 alter one s anesthetic technique with more precision than does a health history and physical examination. Sagel, Evens, Forrest, & Bramson (1974) reported that preoperative chest x-ray examinations comprised 45% of all radiology studies performed in the U.S. How useful is the chest x-ray examination in detecting disease, undiscoverable through a health history and physical examination, that would alter anesthetic technique and reduce anesthetic mortality and morbidity in asymptomatic patients? Roizen (1990) reported that the sensitivity (positive in disease) for chest x-ray examination varies from 56% to 75% and specificity (negative in health ) from 97% to 98.7%. He also reported a preoperative anesthetic mortality rate of 1 per 5,000 in a population under 40 years of age, 1 per 2,000 in the population aged 40 to 50, 1 per 1,000 in the population aged 51 to 60, and 5 per 1,000 in the population over 60 years of age. He concluded, therefore, that preoperative screening chest x-ray examinations are not cost effective until the patient is over 60 years of age. Sagel et al. (1974) conducted a prospective study of chest x-ray examinations to determine if the elimination of some of the examinations done routinely would be medically and economically justifiable. Data from over 10,000 chest x-ray examinations were reviewed. They concluded that routine chest x-ray examinations on patients under 20 years of age, admitted to the hospital for scheduled surgery, were not warranted. In patients 20 to 39 years of age, a chest x-ray examination should be done whenever chest disease is suspected and chest x-ray screening should be done on all patients 40 years of age and older. Rees, Roberts, Bligh & Evens (1976) conducted a similar study looking at preoperative chest x-ray examinations in patients undergoing elective noncardiopulmonary surgery. Their study concluded that there was no appreciable 16 abnormalities found in patients under 30 years of age. Significant abnormalities on the chest x-ray examination, due to cardiomegaly and chronic respiratory diseases, were found in 5% of patients aged 30 to 49, 8% aged 50 to 59, 15% aged 60 to 69, 27% aged 70 to 79, and 40% aged 80 years and over. Berkmoes & Blues (1987) reported current guidelines endorsed by the American Society of Anesthesiologists, the American Thoracic Society, American Society of Radiology, and American College of Physicians. These groups recommended not performing routine chest x-rays unless, in the judgment of the physician, signs and symptoms of chest disease called for a chest x-ray to provide a basis for subsequent diagnosis. Similar recommendations pertained to the use of electrocardiogram for patients with no evidence or history of heart disease. In summary, although the literature has mixed recommendations on what specific preoperative screening laboratory tests should be done, and when an electrocardiogram and chest x-ray should be done, the literature does provide information in support of the need for a thorough health history and physical examination to be conducted on each patient scheduled for elective surgery. The health history and physical examination is often a better tool in screening for disease in asymptomatic patients than are routine laboratory tests, electrocardiograms, and chest x-ray. It is less expensive and avoids medicolegal problems and inefficiency associated with testing. Chapter 3 Methodology This chapter describes the sample and setting, the instruments used in this study, and procedures for data collection and analysis. Sample and Setting This was a retrospective study using the medical records of 100 patients aged 40 and over with ASA physical status class I or IL These patients underwent elective surgery in the Same-Day Surgical Care Unit at a hospital in northwestern Pennsylvania between June 1, 1990 and December 31, 1990. All patients studied received general anesthesia, regional anesthesia, or local-standby anesthesia from personnel in the Department of Anesthesia. Patients who received only local anesthesia administered by the surgeon were excluded from the study, as no anesthesia personnel were involved in those cases. A sample of convenience was chosen utilizing the daily ambulatory surgery schedule. Each patient had been scheduled for elective surgery by the surgeon’s office. On the day of surgery, each patient was admitted to the Same-Day Surgical Care Unit and had standardized screening protocol consisting of a complete blood count, urinalysis, and a biochemical profile (potassium, sodium, blood urea nitrogen, creatinine, chlorine, and carbon dioxide). Each patient also had an electrocardiogram and chest x-ray examination done, same day surgery program policies are contained in Appendix A. A preoperative health assessment form was also completed by the nursing staff, Appendix B. A complete health history and physical examination was then completed by an anesthesiologist, and the patient’s ASA physical status was determined. Surgery was implemented based on these findings. 17 18 Following the surgical procedure, patients were admitted to the Post Anesthesia Care Unit for recovery. Patients were then discharged with individualized instructions in accordance with the hospital’s discharge standard of care, Appendix C. Patient outcome following the surgical procedure was assessed and documented postoperatively by a nurse who made a follow-up telephone call the day after surgery, Appendix D. Instrumentation A checklist was formulated by the researcher to be utilized for each patient’s medical record review, Appendix E. The checklist covered three major areas: the health history and physical examination, the preoperative standardized screening tests, and the patient surgical outcome. The health history and physical examination included the cardiovascular system, the pulmonary system, other existing diseases, and medications being taken. The preoperative standardized screening tests included an electrocardiogram, chest x-ray, and laboratory tests. Assessment of patients’surgical outcome covered areas related to comfort, tissue integrity, nutrition, elimination, and activities of daily living. The checklist was designed to record favorable (No) or unfavorable (Yes) results under the health history and physical examination, electrocardiogram, chest x-ray, laboratory test, and patient outcome. In order to have a favorable health history and physical examination the patient presented with no angina, congestive heart failure, hypertension, myocardial infarction, dysrythmia, cough, difficult breathing, asthma, cigarette smoking, pneumonia, emphysema, anemia, renal disease, diabetes and was not taking any diuretic or antihypertensive medications. If one “Yes” was noted on the checklist in these areas, the health history and physical examination was considered unfavorable. 19 The preoperative standardized screening tests included the electrocardiogram, chest x-ray, and laboratory tests. These areas were examined individually. In order to have a favorable electrocardiogram, the patient’s electrocardiogram had to present with no dysrythmia, ST elevation or depression, left or right ventricular hypertrophy, or prior myocardial infarction. If one “Yes” was noted on the checklist the electrocardiogram was considered unfavorable. In order to have a favorable chest x-ray, the report findings had to indicate no tracheal deviation, pulmonary or mediastinal masses, pneumonia, atelectasis, fractures, or cardiomegaly. If one “Yes” was noted on the checklist the chest x-ray was considered unfavorable. In order to have favorable laboratory tests the hemoglobin, hematocrit, creatinine, blood urea nitrogen, potassium, glucose, protein in urine, had to all be within normal limits. If one “Yes” was noted on the checklist the laboratory tests were considered unfavorable. The assessment of patient surgical outcome covered areas related to comfort, tissue integrity, nutrition, elimination, and activities of daily living. In order to have a favorable patient outcome the patient had to report no pain, drainage, redness, swelling, nausea, vomiting, urinary retention, constipation, diarrhea, or activity intolerance. If one “Yes” was noted on the checklist the patient outcome was considered unfavorable. Procedure for Collection of Data Permission to access the patients’ medical records was obtained from the institution’s Nursing Research Committee and the Medical Records Committee, Appendixes F, G and H. Medical record numbers were used for the researcher’s reference only. Anonymity was assured in that tabulation of the final results made no reference to individuals. 20 The researcher personally collected all data from the medical record of each patient who met the criteria for inclusion in the study. The relationship between the health history and physical examination, the preoperative standardized screening tests, and patient surgical outcome were the factors studied. Procedure for Analysis of Data Analysis of data was performed using a two-way chi-square test to determine the relationship between patient surgical outcome and the health history and physical examination, and the preoperative standardized screening tests. The independent variable, patient outcome with two levels [favorable (No) or unfavorable (Yes)], was analyzed at a significance level of p < .05. This methodology chapter has described sample and setting, instrumention, procedures for data collection, and data analysis. Chapter 4 Presentation and Analysis of Data The purpose of this study was to determine whether preoperative standardized screening tests (electrocardiogram, chest x-ray, and laboratory tests) can be reduced or eliminated in healthy ambulatory surgical patients age 40 or over, without compromising the surgical outcome. Patient surgical outcome was correlated with the health history and physical examination, with the electrocardiogram, with the chest x-ray, and with laboratory tests. Did the electrocardiogram, the chest x-ray, and the laboratory tests reveal new information that was not present in the health history and physical examination, and did this information alter the surgical outcome? Characteristics of the Total Sample A retrospective study of the medical records of 100 patients age 40 or over who had surgery in the Same Day Surgery Center at a hospital in northwestern Pennsylvania was conducted. These patients had each had a health history and physical examination done, as well as preoperative standardized screening tests that included an electrocardiogram, a chest x-ray, and laboratory tests. Each patient’s medical record was examined to determine the results of these examinations and tests. Results were tabulated as favorable (No) or unfavorable (Yes). Favorable results meant that no abnormality was found in that category. Unfavorable results meant that there were one or more abnormal findings. Results of Statistical Analysis Analysis of data was performed using a two-way chi-square test to determine the relationship between the patient surgical outcome with the health history and physical 21 22 examination, with the electrocardiogram, with the chest x-ray, and with the laboratory tests, at a significance level of p < .05. The chi-square was chosen based on two independent variables, unique group size with each group varying two ways, and because the chi square is a test of association. In the test of association there are two variables and each individual is listed once and a contingency table used for the test of significance. These data are shown in Table 1. The purpose of the contingency table analysis was to determine whether a dependence exists between the two qualitative variables, patient surgical outcome and health history and physical examination; patient outcome and electrocardiogram; patient outcome and chest x-ray; and patient outcome and laboratory tests. At a significance level of p <.05 the data in Table 1 indicate that patient surgical outcome and the health history and physical examination were independent of each other. The computed value of X2 = 1.144 is less than the critical value 3.841 at one degree of freedom. Statistical analysis of the health history and physical examination chi-square test of association showed no significant correlation at 0.284 level. Patient surgical outcome and electrocardiogram were independent of each other. The computed value of X2 = 2.548 is less than the critical value of 3.841 at one degree of freedom. Statistical analysis of the electrocardiogram chi-square test of association showed no significant correlation of 0.110 level. Patient surgical outcome and chest x-ray were independent of each other. The computed value of X2 = 1.523 is less than the critical value of 3.841 at one degree of freedom. Statistical analysis of the chest x-ray report chi-square test of association showed no significant correlation at 0.217 level. Patient surgical outcome and laboratory tests were also independent of each other. The computed value of X2 = 0.867 23 Table 1 Contingency Table of Data Patient Outcome _________ Preoperative Assessment Tests Health History & Physical Preoperative Standardized Screening Test Examination H&P UN FAV FAV EKG___ UN FAV FAV CXR___ UN FAV FAV LAB___ UN FAV FAV FAV OUTCOME 34 33 47 20 64 3 61 6 UNFAV OUTCOME 13 20 28 5 33 0 28 5 SUBTOTAL 47 53 75 25 97 3 89 11 100 100 100 100 X2 = 1.144 = 2.547 1.523 = 0.867 C = 0.284 = 0.110 0.217 0.351 TOTAL Note. H&P Health History and Physical Examination, EKG = Electrocardiogram, CXR = Chest X-ray, LAB = Laboratory Tests, FAV = Favorable, UNFAV = Unfavorable, X2 = Chi-Square, C = Test of Significance. 24 is less than the critical value of 3.841 at one degree of freedom. Statistical analysis of the laboratory test chi square test of association showed no significant correlation at 0.351 level. Table 2 presents data showing findings of the preoperative standardized screening tests that were either present or not present in the results of the health history and physical examination, and the resulting patient surgical outcome. Of the 100 electrocardiograms performed, 75 were normal (favorable) and 25 were abnormal (unfavorable). Of the 75 patients with favorable electrocardiogram results, 39 had favorable health history and physical examinations, and 36 had unfavorable health history and physical examinations. The patient surgical outcome of those 39 with both a favorable electrocardiogram and favorable health history and physical examination were as follows: Twenty-seven had a favorable patient surgical outcome, and 12 had an unfavorable patient surgical outcome. The surgical outcome of the 36 patients with favorable electrocardiograms and yet had unfavorable health history and physical examination were as follows: Twenty had favorable surgical outcomes and 16 had an unfavorable surgical outcome. Of the 25 patients found to have unfavorable electrocardiograms, 17 were identified by their health history and physical examination because there were found to be unfavorable, the remaining 8 were not identified by their health history and physical examination. The surgical outcome of the 8 with unfavorable electrocardiograms who also had favorable findings in their health history and physical examination were as follows: Seven of them had favorable surgical outcome, and only one had an unfavorable surgical outcome. The surgical outcome of the 17 patients with both unfavorable electrocardiogram and health history and physical examination were as follows: Thirteen of them had a favorable 25 Table 2 Comparison Between Favorable and Unfavorable Findings in the Electrocardiogram, Chest X Ray, Laboratory Test. Health History and Physical Examination and Patient Surgical Outcome Preoperative Standardized Screening Tests Patient Surgical Outcome FAV EKG/FAV H&P FAV EKG/UNFAV H&P FAV 27 20 47 UNFAV 12 16 28 7 1 4 5 TOTAL UNFAV EKG/FAV H&P UNFAV EKG/UNFAV H&P TOTAL FAV CXR/FAV H&P FAV CXR/UNFAV H&P 39 36 75 8 17 25 13 20 13 20 33 47 50 97 34 30 0 3 3 0 3 3 0 44 45 89 31 30 61 13 15 28 UNFAV LAB/FAV H&P UNFAV LAB/UNFAV H&P 3 8 3 3 0 5 TOTAL 11 6 5 TOTAL UNFAV CXR/FAV H&P UNFAV CXR/UNFAV H&P TOTAL FAV LAB/FAV H&P FAV LAB/UNFAV H&P TOTAL 64 0 0 Note. FAV = Favorable, UNFAV = Unfavorable, EKG = Electrocardiogram, CXR = Chest X-ray, H&P Health History and Physical Examination, LAB = Laboratory Tests. 26 surgical outcome and the other four had an unfavorable patient surgical outcome. Of the 100 chest x-rays performed, 97 had normal reports and 3 had abnormal chest x ray reports. Of the 97 patients with normal chest x-ray reports, 47 had favorable health history and physical examinations, and 50 had unfavorable health history and physical examinations. Of the group of 47 with both favorable chest x-ray reports and health history and physical examinations, their surgical outcome were as follows: Thirty- four had favorable patient surgical outcome and 13 had an unfavorable surgical outcome. The 50 patients with a favorable chest x-ray report and yet having unfavorable findings in their health history and physical examination, their surgical outcome were as follows: Thirty of them had a favorable surgical outcome and 20 had unfavorable surgical outcome. The three patients with abnormal chest x-ray reports, all had unfavorable health history and physical examination findings, but all had favorable patient surgical outcome. Of the laboratory tests performed on 100 patients, 89 had normal findings and 11 patients were found to have had abnormalities in their laboratory tests. Of the 89 patients with normal laboratory test results, 44 had favorable health history and physical examinations and 45 had unfavorable health history and physical examinations. The patient surgical outcome of the 44 with both favorable laboratory test results and favorable findings in their health history and physical examination were as follows: Thirtyone had favorable surgical outcome and 13 had an unfavorable surgical outcome. The patient surgical outcome of the 45 patients with favorable laboratory test results and unfavorable health history and physical examination was as follows: Thirty had a favorable surgical outcome, and 15 had an unfavorable surgical outcome. Of the 11 patients with unfavorable laboratory test, three were found to have favorable health 27 history and physical examination, and eight had an unfavorable health history and physical examination. The patient surgical outcome was favorable for the three patients who had unfavorable laboratory test results. The surgical outcome of the eight patients with both unfavorable laboratory test results and unfavorable health history and physical examination was as follow. Three had favorable surgical outcome and five had unfavorable surgical outcome. Figure 1A shows the patients age 40 years or over and classified into either ASA I or II who had both a favorable surgical outcome and favorable findings in their preoperative assessment. This graph shows that of the .patients with a favorable outcome. 34% had a favorable health history and physical examination, 47% had favorable electrocardiogram, 64% had favorable chest x-ray report, and 61% had favorable laboratory test results. Figure IB presents those patients age 40 years or over classified as ASA I or II who had favorable surgical outcome despite unfavorable findings in their preoperative assessment. Of this group, 33% had unfavorable findings in their health history and physical examination, 20% had unfavorable electrocardiogram findings, 3% had unfavorable chest x-ray reports, and 6% had unfavorable laboratory test results. The bar graph in Figure 1C presents those patients with unfavorable outcome and who had favorable preoperative assessments. They were also ASA I or II patients age 40 or over. They had unfavorable outcomes even though 13% had a favorable health history 28 100% A ■ H&P EEKG HCXB □ LAB 80% 60% 34% FAVORABLE 40% OUTCOME 20% 47% 34% 0% FAVORABLE H&P/EKG/CXR/LAB 100% B ■ H& P E1EKG BCXR □ LAB 80% 60% 33% FAVORABLE 40% OUTCOME 20% 20% 3% o% UNFAVORABLE H&P/EKG/CXR/LAB 100% c ■ H&P □EKG BCXR DLAB 80% 60% UNFAVORABLE 40% OUTCOME 20% 13% 23% 33% 23% 0% FAVORABLE H&P/EKG/CXR/LAB ■ H&PSEKG BCXR DLAB 100% D 80% 60% UNFAVORABLE 40% OUTCOME 20% 20% 5% 0% o% UNFAVORABLE H&P/EKG/CXR/LAB Figure 1. Preadmission Standardized Screening Tests and Patient Outcome. Abbreviations: H&P = Health History and Physical Examination, EKG = Electrocardiogram, CXR Chest X-ray, LAB = Laboratory Test Results /o 29 and physical examination, 28% had a favorable electrocardiogram, 33% had a favorable chest x-ray report, and 28% had favorable laboratory test results. Figure ID presents those ASA I or II patients 40 years or over who had both unfavorable outcomes and unfavorable findings in their preoperative assessment. Here we see that only a small percentage of the total population studied had unfavorable outcomes where 20% had unfavorable health history and physical examination, 5% had unfavorable electrocardiogram, 0% had unfavorable chest x-ray reports, and 5% had unfavorable laboratory tests. Figure 2 shows an overall comparison between the health history and physical examination, preoperative standardized screening tests, and patient outcome. Figure 2A presents those patients with both a favorable surgical outcome and a favorable preoperative assessment. Of these patients, 34% had a favorable health history and physical examination and 57% had favorable preoperative standardized screening tests. The bar graph in Figure 2B presents the findings of those with unfavorable preoperative assessments that resulted in a favorable surgery outcome. Thirty-three percent had unfavorable health history and physical examinations and 10% had unfavorable preoperative standardized screening tests. Figure 2C presents those with unfavorable outcomes and yet had favorable health history and physical examinations and preoperative standardized screening tests. Here 13% had a favorable health history and physical examination and 30% had favorable preoperative standardized screening tests. 30 1 00% ■H & P 13 P R E-0 p | 8 0% A 6 0% 57% 3 4% 4 0% FAVORABLE OUTCOME 2 0% 0% FAVORABLE H&P AND PRE-OP 1 00% ■H & P E1PRE-0 P | 8 0% B 6 0% 33 % 4 0% FAVORABLE OUTCOME 2 0% 4-0%. o% UNFAVORABLE H&P AND PRE-OP 1 00% ■ H& P □ PRE-OP| 8 0% C 6 0% UNFAVORABLE OUTCOME 4 0% 1 3% 2 0% 0% FAVORABLE H&P AND PRE-OP ■H & P E1PRE-0 P| 1 00% 8 0% D 6 0% UNFAVORABLE OUTCOME 4 0% 20% 2 0% 3% 0% UNFAVORABLE H&P AND PRE-OP FIGURE 2. Comparison Between the Health History and Physical Examination and Preoperative Standardized Screening and Patient Outcome. Abbreviations: H&P = Health History and Physical Examination, Pre-Op = Preoperative Standardized Screening Tests 31 The last Figure 2D looks at patients who had both unfavorable surgical outcome and unfavorable health history and physical examination and preoperative standardized screening tests. Twenty percent had an unfavorable health history and physical examination and only 3% had abnormal findings in the electrocardiogram, chest x-ray, and laboratory tests combined, with an unfavorable surgical outcome. Chapter 5 Conclusion This chapter discusses the research findings and makes recommendations for further study. Discussion In order to assess the needs for preoperative standardized screening tests in ambulatory surgical patients classified into ASA I or II physical status, age 40 or over, 100 medical records were reviewed. The review of literature supports the health history and physical examination as the most important determinant for diagnosis and management of patient care, and also for identifying patients at operative risk. Routine preoperative standardized screening tests are performed in an effort to detect disease that could affect patient outcome. However, they frequently fail to uncover meaningful pathologic conditions. The chi-square test of association showed that there was no statistically significant association between patient surgical outcome and the health history and physical examination, between patient surgical outcome and electrocardiogram, between patient surgical outcome and chest x-ray, between patient surgical outcome and laboratory tests. At a significant correlation of p < .05 the data indicated that the health history and physical examination, electrocardiogram, chest x-ray, and laboratory tests were independent of the patient surgical outcome. This study investigated whether the health history and physical examination was sufficient, without preoperative standardized screening tests for the adult patient age 40 or 32 33 over whose ASA physical status was I or D, without compromising the outcome of patients’ elective surgical procedure. Of the 100 patients medical records reviewed, the researcher found 47 with favorable health history and physical examinations. Of these, 34 had a favorable surgical outcome and only 13 had an unfavorable surgical outcome. Fifty-three of the 100 patients' medical records reviewed had an unfavorable health history and physical examination, as shown in Table 1. Of these 53, it was found that 33 had a favorable surgical outcome and only 20 had an unfavorable surgical outcome. This indicates that of 100 ambulatory surgical patients, over one-half would be found to have an unfavorable health history and physical examination. The health history and physical examination identified those patients with abnormal findings that may have had a need for further testing to seek confirmation of the clinical impressions or new diagnosis. Upon further review of the 100 patients' medical records, 67 were found to have had a favorable surgical outcome and 33 had an unfavorable surgical outcome. Looking at the preoperative standardized screening tests it was found that the electrocardiogram had 75 favorable results and 25 unfavorable results, the chest x-ray reports found 97 with favorable reports and 3 with unfavorable reports, the laboratory tests found 89 with favorable reports and 11 with unfavorable reports, also shown in Tables 2. The higher number of abnormal health history and physical findings indicated that the health history and physical examination were important determinants in screening for asymptomatic conditions that could have impacted on the surgical outcome. ■ere identified. The first of these stated: What is the Three research questions w< relationship between the patient surgical outcome and the preope.au.e eiectrccardiogram 34 if an adequ... heal* histay and physical examination has been perforated? This study found that as a screening tool, the electrocardiogram identified 25 abnormalities out of the total 100 electrocardiograms. Of the 25 abnormal electrocardiograms, 17 had been identified by the health history and physical examination. Of these 17 patients, 13 had favorable patient surgical outcome and four had unfavorable patient surgical outcome. Of the remaining eight patients with unfavorable electrocardiograms that were not identified by the health history and physical examination, seven had a favorable surgical outcome and only one had an unfavorable patient surgical outcome. This suggests that the routine electrocardiograms are essential in a small population, and should be done selectively in this population age group after an adequate health history and physical examination has been performed. The second research question asked: What is the relationship between the patient surgical outcome and the preoperative chest x-ray report if an adequate health history and physical examination has been performed? As a screening tool the chest x-ray reports identified only three abnormal chest x-ray reports out of 100. These three patients were identified by the health history and physical examination, and despite having unfavorable findings on their chest x-ray reports, they had favorable patient surgical outcome. Since only three out of 100 patients had abnormal findings on their chest x-ray report and these abnormalities had been identified on their health history and physical examination, and the other 97 had normal chest x-ray reports, and normal findings in their health history and physical examination, it can be concluded that the routine chest x-ray reports are not essential in this population age group if an adequate health history and physical examination has been performed. 35 The third research question was: What is the relationship between the patient surgical outcome and the preoperative laboratory tests if an adequate health history and physrcal exammation has been performed? It was found that as a screening tool 11 out of 100 laboratory tests were abnormal. Of the 11 patients with abnormal findings in their laboratory tests, eight had been identified by their health history and physical examination. Of these eight patients, three had a favorable surgical outcome, and five had unfavorable patient surgical outcome. The remaining thitree patients with unfavorable laboratory tests who were not identified by the health history and physical examination had a favorable surgical outcome. Since only a small number had unfavorable laboratory tests results, it can be concluded that it is not essential to have routine laboratory tests done if an adequate health history and physical examination has been performed. These research findings indicate that unnecessary routine testing was done in this group of patients and that preoperative standardized screening tests were of little significance to the patients’ surgical outcome. The overall results of the 100 patients medical records reviews showed that 67 had favorable surgical outcomes and 33 had unfavorable surgical outcomes irregardless of whether abnormalities were found in the health history and physical examination, electrocardiogram, chest x-ray, and laboratory tests. The researcher found that the health history and physical examination was an adequate tool for preadmission testing for the ambulatory surgical patient age 40 or over whose ASA physical status is I or D, without compromising patient surgical outcome. examination is a low cost method of screening for The health history and physical e. asymptomatic diseases that could affect patient surgical outcome. 36 Recommendations For Further Research The following recommendations for additional research were made based on the results of this study. 1. The study should be repeated using a larger population sample. 2. Instead of a retrospective study, a concurrent study could be done with patients being admitted for a short hospital stay of less than 23 hours following surgery, whereby the researcher would personally follow-up and evaluate the patients' surgery outcome prior to discharge. 3. Develop a tool that would better aid in measuring or identifying the unexpected abnormalities of the patients' surgical outcome 1 to 7 days postoperatively. In conclusion the following recommendations were made based on the results of this study. The health history and physical examination is a significant determinant of diagnosis and it should be used as the primary tool to determine the need for any further testing prior to the surgical procedure. The health history and physical examination covers all body systems, along with the past medical history and medications. From this information the need to have an electrocardiogram, chest x-ray or laboratory tests performed can be determined. 37 References Barash, P.G., Cullen, B.F., and Stoelting, R.K. (Eds). (1989). Clinical Anesthesia. Philadelphia: J.B. Lippincott Company. Bean, B., & DeCresce, R. (1989). Using the laboratory effectively without running up the bill unnecessarily. Postgraduate Medicine, 85 (1), 75-82. Berkmoes, R.V., & Blues. (1987, April 10). ACP offers diagnostic test guide. American Medical News, 10-11. Cebul, R.D., & Beck, R.J. (1987). Biochemical profiles applications in ambulatory screening and preadmission testing of adults. Annals of Internal Medicine, 106 (3), 403-413. Cruz, L.D. (1990). Ambulatory surgery - the next decade. American Operating Room Nurse Journal. 51 (1), 241 -247. Davis, J.E. (1977, August). Pre-op testing. Same-Pay Surgery, 1 (5), 63. Epstein, B.S. (1987). The future of ambulatory surgery. Anesthesiology Clinics of North America, 5 (1), 217-275. Golub, R., Cantu, R., Sorrento, J.J., & Stein, H.D. (1992) Efficacy of Preadmission Testing in Ambulatory Surgical Patients. The American Journal of Surgery, 163_, 565-571. Hansen, K.K., & Nicholson, L.R. (1989). Cutting health care costs. Can physicians make a difference? Postgraduate Medicine, 86 (5), 91-98. Kambouris, A.A. (1986). Ambulatory surgery - it’s impact on general surgical practice. The American Surgeon, 54 (7), 347-350. 38 Kaplan, E.B., Steiner, L.B., Boeckmann, A.J., Roizen, M.F., Beal, S.L., Cohen, S.L., & Nicoll, C.D. (1985). The usefulness of preoperative laboratory screening. Journal of American Medical Association. 253 (24). 3576-3581. Korvin, C.C., Pearce, R.H., & Stanley, J. (1975). Admissions screening: Clinical benefits. Annals of Internal Medicine. 83 (2), 197-203. Kreig, A.F., Gambino, R., & Galen, R.S. (1975). Why are clinical laboratory tests performed? When are they valid? Journal of American Medical Association. 233 (1), 76-78. Marks, S.D., Greenlich, M.R., Hurtado, A.V., & Johnson, J.D. (1980, June). H.M.O. study highlights benefit of same-day surgery. Same-day Surgery. 4 (6), 48-50. Macpherson, D.S. (1993). Preoperative Laboratory Testing: Should any Tests be “Routine” Before Surgery? Medical Clinics of North America, 77 (2), 289-308. Nathanson, S.N. (1988), Ambulatory surgery: Characteristics of a successful ambulatory surgery program. American Operating Room Nurse JOURNAL, 47 (2), 592-598. Pagna, K.D., & Pagna, T.J. (1992), Mosbys Diagnostic and Laboratory Test Reference. St. Louis: Mosby Year Book. Pennsylvania Blue Shield, (1995, January 20). Policy Review and News^j, 8. Rao, T.L.K., Jacobs, K.H., & El-Etr. A. A. (1983). Reinfarction following anesthesia in patients with myocardial infarction. Anesthesiology, 59 (6), 499-505. 39 Rees, A.M., Roberts, C.J., Bligh, A.S., & Evens, K.T., (1976, May 29). Routine preoperative chest radiography in non-cardiopulmonary surgery. British Medical Journal, 1 1333-1335. Robbins, J. A., & Mushlin, A.I. (1979). Preoperative evaluation of the healthy patient. Medical Clinics of North America. 63 (6), 1445-1156. Roizen, M.F. (1990). Preoperative Evaluation. In R.D. Miller. (Vol. Ed.), Anesthesia: Vol- 1 -(3rd ed., pp 743-772). New York: Churchill Livingston. Roizen, M.F., Kaplan, E.B., Schreider, B.D., Lichtor L.J., & Orkin, F.K. (1987). The relative roles of the history and physical examination, and laboratory testing in preoperative evaluation for outpatient surgery: The starling curve of preoperative laboratory testing. Anesthesiology Clinics of North America, 5 (1), 15-34. Sagel, S.S., Evens, R.G., Forrest, J.V., & Bramson, R.J. (1974). Efficacy of routine screening and lateral chest radiographs in hospital based population. New England Journal of Medicine, 291 (19), 1001-1004, Sandler, G., (1979, July 7). Cost of unnecessary tests. British Medical Journal, 2, 21-24. Shapiro, M. F., & Greenfield, S., (1987). The complete blood count and leukocyte differential count. Annals of Internal Medicine, 106 (1), 65-74. Witchler, B. (1981, January). Outpatient anesthesia: Expert relates pearls and pitfalls. Sarne-Day Surgery, 5 (1), 1 -5. Wong, C.A. (1990). Preoperative patient preparation. Journal of Post Anesthesia Nursing, 5 (3), 149-156. 40 Wyatt, W.J., Reed, D.N., & Apelgren, K.N. (1989). Pitfalls in role of standardized preadmission laboratory screening for ambulatory surgery. The American Surgeon, 55(6), 343-346. Appendixes 42 Appendix A NURSING POLICY AND PROCEDURE SDS PROGRAM POLICIES G. PAGE 3 OF 5 Availability of Service 1. 7:00 AM to 5:00 PM, Monday through Friday. 2. The first procedure will begin at 8:00 AM. The last procedure shall not begin after 2:00 PM or at the discretion of the head nurse. 3. Strict adherence to the schedule is imperative. If delay occurs, the incident is documented. The documentation will provide indicators for Quality Assurance activity. 4. Scheduling will be accomplished with SDS staff and attending physicians. 5. Specific procedures must be indicated on the schedule. 6. Unrelated elective procedures on an already scheduled patient may only be added if the time allows or at the discretion of the head nurse and if the OR consent is appropriate. 7. Cases requiring frozen section should be posted at the time the case is scheduled. H. Types of Anesthesia 1. General 2. Local 3. Axillary Block 4. Bier Block I. Laboratory, EKG, X-ray studies 1. CBC, urinalysis and APPT are drawn in the SDS unit and sent to the lab. The results are transmitted via computer to SDS. General Anesthesia and Blocks performed by Anesthesia require: 2. a. CBC b. Urinalysis c. Dental Cases: APPT d. EKG for patients 40 years & older X-ray, for patients 60 years & older e. Chest _ 3. Axillary Blocks performed by the surgeon require NO CBC, Urinalysis, EKG, or Chest X-ray Chest X-rays, EKG’s may be done the AM of patients surgery if he/she is 4. scheduled for an 8:00 AM or 9:00 AM procedure, the patient’s laboratory work-up must be done at least the day before the scheduled procedure. 43 Appendix A NURSING POLICY AND PROCEDURE SDS PROGRAM POLICIES PAGE 4 OF 5 J. Pre-op Procedural Requirements. 1. All patients receive pre-op instructions via telephone or brochure. The patients are instructed to enter the hospital via the State Street entrance. 2. Patients are informed of their arrival times on the unit via brochure or telephone. a. Axillary Block - 1 hour before b. Local - 1 hour before c. Unassisted Local - 45 minutes before d. General - 1 hour & 15 minutes before e. General with Chest and EKG - 2 hours before f. Bier Blocks - 1 hour and 15 minutes before 3. Patients are informed of fasting procedures via brochure and/or telephone. a. General anesthesia patients are NPO after midnight. b. Local AM patients are NPO after midnight. c. Local PM patients may have a clear liquid breakfast. d. Infants having general anesthesia are to skip one feeding if they are fed q4h. - q6h. otherwise, NPO after midnight. 4. All patients admitted to the unit will have an identification band which shall be applied at the out-patient registration desk in SDS. All patients will have a pre-op assessment performed and documented. 5. The Anesthesiologist will perform and dictate a history and physical. 6. 7. No pre-op meds are given for patients having general anesthesia unless otherwise ordered by the Anesthesiologist. K. Post Procedural Requirements 1. All patients receiving general anesthesia will be admitted to the recovery room. These patients are discharged by an Anesthesiologist and so documented. 44 Appendix B S.D.S GENERAL ANESTHESIA Pre-Operative Nursing Assessment Scheduled Procedure: Chief Complaint: History: When appropriate: L.M.P. G P .AB Previous Illness: Previous Surgery: Family History: Social History: Mother: Father: Smoking: Yes ( ) No ( ) Alcohol: Yes ( ) No ( ) Sister(s): Brother(s): amount: amount: Allergies: Medications; REVIEW OF SYSTEMS: Head & Neck: _ _________________________ Heart & Lungs: __________ ________________________ Abdomen: (digestion, bowel habits, liver, kidney, bladder, menstrual) Extremities: P T NPO since R BP HT WT Phone: Phone: Notify in case of emergency: Escort & arrangements:----- Pre-operative instructions VIA: Brochure ( ) Physicians office ( ) SDS pre-op phone call ( ) at time of assessment ( ) Patients response to pre-op teaching: SIGNATURE: 45 Appendix C STANDARD OF CARE DISCHARGE OF A PATIENT CRITERIA Evaluation of patient teaching. CUES Assess patient or family capability of self or assisted care in the following areas: 1. Medications. 2. Treatments (dressing changes, irrigations, urine/blood tests, etc. 3. Activity/restrictions 4. Diet Follow-up Care. Reinstruct as needed. Physician or clinic appointment made. Prescriptions, lab or diagnostic tests scheduled and instructions given. Documentation. Agency referrals made and documented. See Policy & Procedures for “Discharge of Patients”, section IV. Include in note who accompanies patient at time of discharge - wife, friend, ambulance attendant. 46 Appendix D AMBULATORY SURGERY PATIENT FOLLOW-UP CALL OPERATIVE PROCEDURE: DATE OF SURGERY: DATE OF CALL: PATIENT PHONE NO.: PATIENT AVAILABILITY TIME OF CALL: Signature of Nurse 47 Appendix E MR# Age A. Procedure ASA Class Sex HEALTH HISTORY AND PHYSICAL EXAMINATION Cardiovascular System Y Y N N Y N Y N Y N B. PREOPERATIVE STANDARDIZED SCREENING TESTS Electrocardiogram Angina Congestive Heart Failure Hypertension Y Y N N Y N Myocardial Infarction Dysrrythmia Y N Dysrrythmias ST elevation/ depression L/R ventricular hypertrophy Prior Myocardial infarction Chest x-ray C. PATIENT OUTCOME Comfort Y N Pain Tissue Integrity Y N Drainage Y Y N N Redness Swelling Pulmonary System Y N Cough Y Y Y Y Y N N N N N Difficult Breathing Asthma Cigarette Smoking Pneumonia Emphysema Y Y N N Y Y Y Y N N N N Tracheal deviation Masses-pulmonary or mediastinal Pneumonia Atelectasis Fractures Cardiomegaly Laboratory Reports Other Existing Diseases Y Y N N Anemia Renal Disease Y Y Y N N N Hemoglobin Hematocrit Creatinine Y N Diabetes Y N Y N Blood urea nitrogen Potassium Y Y N N Glucose Protein in Urine Medications Y Y N N Diuretics Antihypertensives Nutrition Y Y N N Nausea Vomiting Elimination Y Y Y N Urinary retention N Constipation N Diarrhea Activity of Daily Living Y N Activity intolerance 48 Appendix F Grace Brown 1610 Volney Road Youngstown, Ohio 44511 Susan Miller RN, MSN. Director of Nursing Education and Research Hamot Medical Center 201 State Street Erie, Pa 1650-0001 Dear Ms. Miller: I am currently pursuing a Masters of Science in Nursing from Edinboro University of Pennsylvania. I am also a graduate of the Hamot School of Anesthesia and currently working in the Department of Anesthesia as a Graduate Registered Nurse Anesthetist. Pursuits in these areas have led me to a topic of interest for my thesis project. I would like to conduct a retrospective study o Preoperative Standardized Screening Tests on Healthy Ambulatory Surgical Patients, looking at the overall patient outcome. Included is the first chapter of my thesis for your review. The intent, purpose, problem statements, definition of terms, assumptions and limitations of the proposed study are enclosed. The desired sample I will obtain will include a review of 100 patient’s medical records, aged 40 and above, ASA classification I and II only scheduled for elective surgery, under general, regional or local-standby surgery in the Same Day Surgery unit. The sample will be a sample of convenience utilizing the daily Same Day Surgery schedule to select the patients that meet the criteria for the study. The instrumentation which I have chosen covers specific areas to be investigated preoperatively, prior to the administration of anesthesia as found in the review of literature. Anonymity will be granted and no reference to individual patients will be made in the final analysis. Utilization of patients medical record numbers will be for the researcher’s records only. Permission to access patient records will also be obtained from the Medical Records Committee. The proposed time frame encompasses June 1990 to December 1990 or later, based on the attainment of desired sample. No budget allocations are required. 49 Ms. Debra Myers, CRNA, Med, Research Coordinator for the School of Anesthesia, has agreed to act as the researchers main contact person, pending nursing research approval. Ms. Myers or the researcher may be contacted during the day at 870-6000 extension 2137. The above information is submitted for your review according to Hamot Medical Center’s policy and procedure for nursing research. Any clarification of unclear issues will be provided at your request. Thank you for your time and consideration in this matter. I look forward to expanding my nursing education through this research/thesis project. Sincerely, Grace C. Brown, RN, BSN Appendix G 50 Maron 7, 1991 Grace C. Sr own 1613 Volney Read Youngstown, Onio 44511 Dear Grace, We are pleased to inform you that tne Nursing Research Apcroval Committee has recommenced permission to pursue your research study entitled A Retrospective otucy on Preooerative Standardized Screening Tests on Healthy Amouxatory Surgical °atients. ?er Marge DeVitt in Medical Records, you need to have either the Department Chairman of Surgery or the Medical Director of Ambulatory Surgery sign your request for medical recorcs form. Your contact person will continue to be Debra Myers. If you require our further assistance, please contact either of us at (814) 870-6000 Ext. 2513. The Nursing Research Approval Committee requests a summary of your results or an abstract to be kept in our files. Good luck in this ano future research snoeavors. Sincerely, Ctnuj ■j.’hCciu *my J. McClune, RN, MSN Iblyng Agostink) RN, M •^“Chairoersons, Nursing Research Approval Committee ^70/6 Appendix H FROM\ffiC3^^FA?R STUDIE$ and/or statistics 51 medical record department infc=mation reol PURPOSE: :d; t'.AJ Sr- c. c- TIME PERIOD: y '-vS ? / $5/ £,\) ( a CH&TS TO =E REVIEWED: ZcaJ/t; /> vs zr//^zy5 (MINIMLM CF -3 HR. NOTICE) b race CATE APPROVAL GRANTED: ‘OR O' CEPARTS'ENT/DIVISICN/UNIT/COMMI ” SIGNATURE OF ONE CF TrE FOLLOWING: 'COMMITTEE CHAIRMAN DIVISION CHIEF CEPARTMENTAL CHAIRMAN VICE PF.ESICENT FOR MEDICAL AFFAIRS COMMENTS: I I CATE RECUEST RECEIVED: I CORES: 7OR «R r-S5ISir«N» I RETURN COMPLETED FCRM *C: -■ Si > I NO YES MUST =E APPROVED =Y ‘>E I APPROVAL TO POLL - NO YES CATE TO =E COMFLET RECLESTED 3Y: /7-/ IRENE SMITH ‘•'EDICAL RECORDS