Documentation of individualized preoperative risk assessment: a multi-center study

Abstract

Background Individual surgical risk assessment (ISRA) enhances patient care experience and outcomes by informing shared decision-making, strengthening the consent process, and supporting clinical management. Neither the use of individual pre-surgical risk assessment tools nor the rate of individual risk assessment documentation is known. The primary endpoint of this study was to determine the rate of physician documented ISRAs, with or without a named ISRA tool, within the records of patients with poor outcomes. Secondary endpoints of this work included the effects of age, sex, race, ASA class, and time and type of surgery on the rate of documented presurgical risk. Methods The records of non-obstetric surgical patients within 22 community-based private hospitals in Arizona, Colorado, Nebraska, Nevada, and Wyoming, between January 1 and December 31, 2017, were evaluated. A two-sample proportion test was used to identify the difference between surgical documentation and anesthesiology documentation of risk. Logistic regression was used to analyze both individual and group effects associated with secondary endpoints. Results Seven hundred fifty-six of 140,756 inpatient charts met inclusion criteria (0.54%, 95% CI 0.50 to 0.58%). ISRAs were documented by 16.08% of surgeons and 4.76% of anesthesiologists (p < 0.0001, 95% CI −0.002 to 0.228). Cardiac surgeons documented ISRAs more frequently than non-cardiac surgeons (25.87% vs 16.15%) [p = 0.0086, R-squared = 0.970%]. Elective surgical patients were more likely than emergency surgical patients (19.57 vs 12.03%) to have risk documented (p = 0.023, R-squared = 0.730%). Patients over the age of 65 were more likely than patients under the age of 65 to have ISRA documentation (20.31 vs 14.61%) [p = 0.043, R-squared = 0.580%]. Only 10 of 756 (1.3%) records included documentation of a named ISRA tool. Conclusions The observed rate of documented ISRA in our sample was extremely low. Surgeons were more likely than anesthesiologists to document ISRA. As these individualized risk assessment discussions form the bedrock of perioperative informed consent, the rate and quality of risk documentation must be improved.

Preoperative Pulmonary Risk Assessment

“…Although this sounds like an obvious expectation, studies of preoperative notes demonstrate a very high failure rate ($ 80%) to demonstrate organspecific perioperative morbidity or mortality risk. 144 There is a paucity of standardized guidelines for preoperative pulmonary risk documentation and recommendations for perioperative optimization for risk mitigation. We favor identifying the patient's risk for the development of PPCs and providing a clear outline of the risk from a clinical standpoint, and then providing a recommendation for specific interventions throughout the perioperative continuum of care to mitigate the risk of PPCs.…”

Major liver resections, perioperative issues and posthepatectomy liver failure: A comprehensive update for the anesthesiologist

“…The presence of cirrhosis, if properly assessed, is no longer an absolute contraindication due to advancements in surgical techniques[ 26 , 37 ], increased anesthesiologic expertise in the perioperative period[ 47 ], high volume activity, and multidisciplinary collaboration in the indication and scheduling of surgery. Clear communication of risks and benefits to the patients and their relatives and adherence to the surgical proposal are crucial in such a complex setting[ 48 ]. Decision-making support is now improved not only by the subjective ASA classification[ 31 , 32 ], but also by more objective evaluation methods based on clinical data supported by large databases such as ACS NSQIP, SURPAS, VOCAL – Penn Risk score (all developed in the United States), or SORT (developed in the United Kingdom)[ 49 - 54 ].…”

Six-minute walk test as a predictor for intraoperative anesthesia complications: a prospective cohort at a tertiary hospital, southwestern Uganda

“…Preoperative assessment plays a crucial role in identifying high-risk patients for optimal intraoperative care (7)(8)(9). Individualized care and prior optimization based on these assessments have been associated with improved patient outcomes (10). While widely used in medical practice, tools like the simpli ed acute physiological score or acute physiological and chronic health evaluation score have not been extensively applied in surgical settings (11).…”