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Correspondence |
Penticton Regional Hospital, Penticton, Canada., E-mail: andy.hamilton{at}interiorhealth.ca
To the Editor:
Three recent articles and an editorial1 in this journal have discussed the value of preoperative testing. Joo et al.2 concluded that, in agreement with current Canadian guidelines, routine preoperative chest x-rays should not be performed without risk factors. Finegan et al.3 demonstrated that selective test ordering by staff anesthesiologists reduced the number and cost of preoperative investigations. Finally, Yuan et al.4 documented marked disparities in the practice of preoperative testing by members of the Canadian Anesthesiologists’ Society of patients undergoing ambulatory surgery.
In the Interior Health Authority of British Columbia, which is responsible for two tertiary care hospitals, four regional and several smaller hospitals, we are in the process of standardizing pre-surgical screening. Part of this involves agreeing on guidelines for preoperative testing. After reviewing the literature, we have chosen, and agreed, to use the guidelines for preoperative investigations as published by the National Institute for Health and Clinical Evidence in the UK5 (NICE). These were developed by NICE in conjunction with the National Collaborating Centre for Acute Care in the UK. Details of the evidence, method and the guidance can be found on their web-site.6 These take into account the complexity of the surgery, the American Society of Anesthesiologists status of the patient and the major comorbidity. For each test, they use a traffic light system: red – no evidence that test indicated; green – evidence that test indicated; yellow – consider this test. These guidelines may be downloaded in poster form from their website, and we have had them printed in large format for our pre-surgical screening clinics.
We feel that these guidelines tailor the patient to the procedure using as much evidence as possible, while allowing sufficient leeway for clinical judgment. Unfortunately, it will be difficult to document any influence in either costs or outcome, as we do not have an adequate data base prior to implementation. However, this initiative should result in a more consistent approach to ensuring appropriate selection of preoperative investigations.
Footnotes
Accepted for publication November 6, 2005.
References
1 Bryson G. Has preoperative testing become a habit? (Editorial). Can J Anesth 2005; 52: 557–61.
2 Joo HS, Wong J, Naik VN, Savoldelli GL. The value of screening preoperative chest x-rays: a systematic review. Can J Anesth 2005; 52: 568–74.
3 Finegan BA, Rashiq S, McAlister FA, O’Connor P. Selective ordering of preoperative investigations by anesthesiologists reduces the number and cost of tests. Can J Anesth 2005; 52: 575–80.
4 Yuan H, Chung F, Wong D, Edward R. Current pre-operative testing practices in ambulatory surgery are widely disparate: a survey of CAS members. Can J Anesth 2005; 52: 675–9.
5 National Collaborating Centre for Acute Care. CG3 – Preoperative testing, the use of routine preoperative tests for elective surgery – NICE Guideline. National Institute for clinical Excellence. Cited 25 June 2003; accessed 25 May 2004. Available from URL; http:/www.nice.org.uk/page.aspx?o=56818.
6 National Collaborating Centre for Acute Care. CG3 Preoperative tests, the use of routine preoperative tests for elective surgery: evidence, methods and guidance - Full guideline. National Institute for Health and Clinical Excellence. Cited 27 August 2003; accessed 25 May 2004. Available from URL; http://www.nice.org.uk/page.aspx?o=77801.
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