Pre-admission preparation for elective surgery is common practice in the U.S. and is
being implemented in Canada as hospitals seek fiscally responsible patient care
alternatives. Health care resources are limited and all facets of service are currently
being scrutinized in an effort to reduce costs. A review of the traditional pattern for
elective surgical patients indicates that several areas, including pre-operative and
post-operative length of stay, may be modified to reduce costs. Pre-admission programs
have been identified in the literature1, as a cost effective method of meeting
patient care objectives. These programs focus on improved pre-operative preparation,
inpatient bed utilization, surgical suite efficiency and enhanced quality of patient care
and satisfaction. Unfortunately there is no prototype and there are almost as many models
as there are units in existence. However, the common goal of the Pre-admission program is
to maintain current volumes of surgical patients and quality of patient care while
reducing expensive inpatient admissions. 2 The creation of Pre-admission Units
should not be ignored by anaesthetists. In fact, anaesthetists should welcome the
opportunity to become involved as leaders in the planning, administration and daily
operations of these units in the interest of better patient care. 3 During the
course of this lecture, the Ottawa Civic Hospital model will be presented, outlining the
planning, implementation, and daily operation of the unit.
Ideally, patients should be assessed in a Pre-admission Unit between 1 and 3 weeks
pre-operatively. Pre-operative preparation involves a wide range of activities therefore a
multi-disciplinary unit is most efficient. Clerical staff pre-register the patient, nurses
evaluate and educate the patient, and an anaesthetist assesses the patient to ensure
optimal medical conditions. In addition, the anaesthetist can discuss various anaesthetic
options and address questions and concerns that may arise during the visit. Consultation
with other physicians may be necessary, laboratory investigations are completed, and
services of other professionals such as physiotherapy, occupational therapy, social
services, etc. are employed. Old charts are reviewed and discharge planning is completed.
The anaesthetist who completes the pre-operative assessment will generally not provide the anaesthetic care for a given patient. The patient must clearly understand that the anaesthetist in the clinic provides an opportunity to discuss anaesthetic concerns and the various anaesthetic options. The final decision regarding anaesthetic technique and whether to proceed with the procedure will be made by the anaes- thetist who is administering the anaesthetic.
In order to evaluate the impact of Pre-admission Units on reducing hospital costs and improving patient care and satisfaction it is necessary to critically examine the three important objectives of the unit:
In keeping with anaesthesia "outcome studies'', savings related to development of Pre-admission Units are difficult to quantify. Intuitively, preparing patients on an outpatient basis and having them arrive on the day of surgery minimizes the expensive hospital stay. For each patient that arrives on the same day of their surgery, rather than the day before, the hospital will require one less surgical bed. This allows for bed closures without adversely affecting surgical volumes. Substantial savings can be realized in a busy hospital by decreasing the pre-operative length of stay for each surgical procedure by one day. In a recent article, Boothe and Finegan1 compared the cost of a laparoscopic cholecystectomy in patients who were admitted one day pre-operatively vs those who were admitted the day of their surgery. They showed substantial savings and concluded that a same day admission process reduces costs and serves to enhance hospital productivity. Similarly, Conway et al2 demonstrated that the use of a Pre-admission Clinic resulted in important reductions in hospital costs and improvement in operating room efficiency by reducing last minute delays and cancellations of surgical procedures. Patient satisfaction surveys demonstrate overwhelming support for the Pre-admission program with 100% of 440 patients surveyed at the Ottawa Civic Hospital indicating that it was overall a positive experience. 4
Despite significant surgical bed closures at the Ottawa Civic Hospital since 1992-93 surgical volume has remained stable: there were 15,194 non-emergent surgical procedures in 1993-94 and 15,329 in 1994-95. The total number of operative hours has also increased each year. There have been no Same Day Admit cancellations due to lack of beds or incomplete pre-operative preparation. A small number of operations have been cancelled because the patient developed a change in medial status, most commonly an upper respiratory infection, since the pre-operative visit.
Pre-admission Units will improve the quality of anaesthesia care by ensuring that the
patient is better informed and more thoroughly evaluated than has been possible
previously. Patients now have the opportunity to discuss their concerns in a relaxed
environment without feeling the pressure of the increasingly rushed and stressful hospital
environment. Operating room efficiency will improve with fewer delays and last minute
cancellations. Anaesthesia involvement in these clinics will improve the stature of our
specialty by demonstrating to the hospital community and the general public that the
practice of anaesthesia is not limited to technical procedures and does involve
physician-patient interactions and complex medical decision making. Dr. Finegan said it
best in his editorial3 "anaesthetists must recognize their responsibility
to preserve and defend an appropriate standard of care and, in doing so, maintain the
rights of the patient and the dignity of the specialty''.
Winterlude 96 Programme