Improving agreement of ASA physical status class between pre-anesthesia screening and day of surgery by adding institutional-specific and ASA-approved examples: a quality improvement project

Abstract

Background A successful anesthesia pre-assessment clinic needs to identify patients who need further testing, evaluation, and optimization prior to the day of surgery to avoid delays and cancelations. Although the ASA Physical Status Classification system (ASA PS) has been used widely for over 50 years, it has poor interrater agreement when only using the definitions. In 2014, ASA-approved examples for each ASA physical status class (ASA PS). In this quality improvement study, we developed and evaluated the effectiveness of institutional-specific examples on interrater reliability between anesthesia pre-anesthesia clinic (APAC) and the day of surgery evaluation (DOS). Methods A multi-step, multi-year quality improvement project was performed. Step 1, pre-intervention, was a retrospective review to determine the percentage agreement of ASA PS assignment between APAC and DOS for adult and pediatric patients. Step 2 was a retrospective review of the step 1 cases where the ASA PS assignment differed to determine which medical conditions were valued differently and then develop institutional-specific examples for medical conditions not addressed by ASA-approved examples. Step 3 was to educate clinicians about the newly implemented examples and how they should be used as a guide. Step 4, post-intervention, was a retrospective review to determine if the examples improved agreement between APAC and DOS ASA PS assignments. Weighted Kappa coefficient was used to measure of interrater agreement excluding chance agreement. Results Having only ASA PS definitions available, APAC and DOS agreement was only 74% for adults (n = 737) and 63% for pediatric patients (n = 216). For adults, 20 medical co-morbidity categories and, for pediatric patients, 9 medical co-morbidity categories accounted for > 90% the differences in ASA PS. After development and implementation of institutional-specific examples with ASA-approved examples, the percentage agreement increased for adult patients (n = 795) to 91% and for pediatric patients (n = 239) to 84%. Weighted Kappa coefficients increased significantly for all patients (from 0.62 to 0.85, p < .0001), adult patients (from 0.62 to 0.86, p < .0001), and pediatric patients (from 0.48 to 0.78, p < .0001). Conclusions ASA-approved examples do not address all medical conditions that account for differences in the assignment of ASA PS between pre-anesthesia screening and day of anesthesia evaluation at our institution. The process of developing institutional-specific examples addressed the medical conditions that caused differences in assignment at one institution. The implementation of ASA PS examples improved consistency of assignment, and therefore communication of medical conditions of patients presenting for anesthesia care.

Feasibility and Safety of Outpatient Thyroidectomy: A Narrative Scoping Review

“…The ASA score is determined by pre-anesthetic medical co-morbidities. An ASA score of II or below indicates a patient with mild systemic disease ( 53 ). One study indicated a criterion of ASA risk score of III or less with a stable medical condition ( 52 ), while the other indicated an ASA score of I/II ( 50 ).…”

Discordant American Society of Anesthesiologists Physical Status Scoring between Anesthesiologists and Surgeons Is Correlated With Adverse Patient Outcomes: A Retrospective Cohort Study of 46284 Elective Surgical Patients

“…[26] Another real-world study by Abouleish et al of concordance between anesthesiologists in the preoperative clinic and on the day of surgery had similar results ( value 0.62), but subsequently demonstrated 'almost perfect' agreement ( value 0.85) after the introduction of examples that were ASA and institutionally approved. [27] The majority of the discordant scores were scored lower by surgeons, with the largest group comprising those assigned ASA 2 by the anesthesiologist but ASA 1 by the surgeon. We observed that patients with discordant ASA scores had a signi cantly higher proportion of comorbid clinical conditions (raised creatinine, diabetes mellitus on insulin, history of congestive heart failure, cerebrovascular accident, ischemic heart disease and smoking).…”

“…Other studies have shown that the addition of examples to the ASA score and reinforcement of its use were required to improve reliability. [27,29] Standardization efforts are needed to improve the utility of ASA scores in clinical practice and for uses beyond the original intention of communicating patient healthcare status.…”

Cardiac Arrest during Interventional Radiology Procedures: A 7-Year Single-Center Retrospective Study

“…Based on medical records, several factors were analyzed retrospectively. After identifying the patients' underlying health conditions from the medical history and clinical diagnosis, the patients' statuses, at the time of IR treatment, were classified retrospectively using the American Society of Anesthesiologists (ASA) physical status classification [4]. The primary cause of each cardiac arrest event was also speculated according to details documented in the respective operative reports.…”