Thesis Nurs. 1995 B877r
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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:

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Committee Member

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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
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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

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51

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