The best defense: Anesthesiologist Dr. Stephen Punzak on the value of appropriate preop evaluations

The best defense is good offense. This popular football adage can also be appropriated to fit healthcare goals — namely the fact that better and more appropriate preoperative assessments lead to fewer complications and improved patient outcomes.

A study published in the Journal of Healthcare Risk Management recently found that less than adequate preoperative assessments resulted in more complications, and thereby, more malpractice cases. Researchers analyzed closed anesthesia medical malpractice claims reported to The Doctors Company, a medical malpractice insurance company. The study found that physician experts identified inadequate preoperative assessments in 15 percent of cases filed against anesthesia professionals, according to study co-author Darrell Ranum, JD, vice president of patient safety at The Doctors Company.

Here, Stephen Punzak, MD, founder and CEO of One Medical Passport, and a practicing anesthesiologist, discusses the importance of appropriate


preoperative screening and the anesthesiologists' role in ensuring these assessments are carried out adequately.

Question: In what ways can comprehensive preoperative assessments help reduce anesthesia complications?

Dr. Stephen Punzak: I struggle with the word "comprehensive." To me, comprehensive means doing a very extensive work up on every single patient — regardless of the patient's health status or the planned surgery or procedure. I think a better term is "appropriate." An "appropriate" preoperative evaluation matches preoperative testing with the patient's health status and the planned surgery. To do this properly, you need to be able to get an accurate picture of the patient's health status well in advance of the planned surgery, so that any preoperative testing that is indicated has time to [be] ordered, completed and the results obtained and evaluated.  

When I was a staff anesthesiologist during the 1990s at the New England Deaconess Hospital, I would ask anesthesia residents who suggested that an additional preoperative test needed to be ordered, "What is it going to change in your management of this patient?" It wasn't always a rhetorical question. The knife's edge on which all preoperative testing is cut should be: "What is it going to change in the management of this patient?"

Q: What are some of the most common preoperative assessments that anesthesiologists tend to ignore that could lead to complications later?

SP: The assessment I like the best is also one of the simplest to obtain and costs nothing. I ask: "What can you do for exercise? Can you climb a flight of stairs without getting short of breath? Can you walk a block?" This gives you functional information that is oftentimes more valuable than an EKG, pulmonary function tests or a chest X-ray. In addition, if you are lucky enough to work in a facility where the patient has had previous medical care, see what information you can find on the computer.  

Above all else, look for a cardiac ECHO. For a patient with significant medical problems, knowing the information that an ECHO gives you — the ejection fraction (how well the heart pumps) and whether the heart valves are normal or not — is worth its weight in gold.

Q: What can anesthesiologists do to ensure that comprehensive preop assessments are carried out? Are there best practices you recommend that they follow?

SP: Anesthesiologists need to be actively involved in how the whole preop evaluation process is structured at their facility. Only a true preop evaluation "system" can deliver consistent results, that is, an appropriate evaluation for every patient. Without a system, you will get markedly different levels of preoperative evaluations depending on who is performing the preop evaluations on any given day. But a system is agnostic as to the individuals involved — it delivers consistent care without regard to individual staff.

And by "system," I don't mean complicated or something that only applies to a hospital and not to an ASC.  It just means a consistent process that is uniformly applied by all staff.  

In regards to best practices, it starts by looking at what your facility is currently doing.  Get the nursing staff involved — they are key to the success or failure of creating a great preop assessment program. Start with everyone working together to come up with a written goal for your preop assessment program. It should address consistency, timeliness, creating a better patient experience and the important role that an appropriate preop assessment plays in setting up a safe and positive patient experience at your facility. This may sound like overkill but it is not. You need to start with the goal and then work down to ever increasing levels of detail to design your preop assessment system. I would also recommend that you start with a "clean sheet of paper." If you start with your current preop process and then just make some minor tweaks, you may miss seeing the vision for a completely new preop assessment process.  

In addition, take a look at using web-based software that allows your patients to complete the "history gathering" part of the preop assessment on their own. This yields very accurate information, particularly about current medications and health status, which is often lacking in notes from the surgeons' offices. This will allow your nurses to focus more on being a nurse and less on data entry so that they have the time to really be involved in each patient's care.

Q: What are some steps anesthesiologists can take postoperatively that can help reduce length of stay and improve patient outcomes?

SP: Anesthesiologists can play an important role in length of stay and improving patient outcomes, but usually that starts preoperatively. One of the most exciting areas is in the use of multimodal analgesic/anesthesia combinations that reduce the use of general anesthesia and narcotics. For example, doing a case, with a nerve block and propofol infusion that previously would have been done under general anesthesia. Or giving an NSAID and Neurontin preoperatively and having the surgeon inject a long-acting, liposomal local anesthetic.  

Q: On a more general note, how is the anesthesiologists' role in perioperative care evolving?

SP: The role of anesthesiologists is rapidly changing. It's not just about giving a "good" anesthetic anymore and dropping the patient off in PACU. Anesthesiologists need to "own" the whole perioperative experience, from preop assessment all the way through to discharge and how well the patient does at home. This is a daunting challenge, but it is also very exciting as it holds the promise of markedly improving patient care.

Article originally published in Becker's ASC

Stephen Punzak MD

Written by Stephen Punzak MD

Dr. Stephen Punzak, M.D., Founded One Medical Passport in 2000 and serves as its Chief Executive Officer. For the past 17 years Dr. Punzak has worked as an anesthesiologist for large tertiary hospitals and ambulatory surgery centers.