Optimising the Pre-Operative Investigative Work Up for Elective Surgical Patients

Abstract

Effective pre-operative assessment of patients awaiting elective surgery should entail appropriate use of scarce NHS resources, as well as underpin patient safety. The pre-operative admissions service in district general hospitals is often junior doctor led, with a new cohort of clinicians taking over its running every four months. Lack of familiarity on the part of these clinicians with the investigative work up required for certain surgical procedures often results in over investigation of patients in the pre-admission setting, wasting time and NHS resources. A retrospective audit of 53 patients who underwent laparoscopic cholecystectomy over a representative two month period demonstrated that 33% of patients received unnecessary pre-admission blood tests, including clotting screen and 'group and save'. Design and implementation of a "Pre-Admission Handbook", for use by junior doctors and nurse practitioners in the pre-operative setting, reduced the rate of over investigation to 12% in a subsequent, prospective audit cycle of 50 patients, and has improved patient care by standardising the preadmissions process for elective surgery at Gloucester Royal Hospital. ProblemThe pre-operative admissions service at district general hospitals is often junior doctor led, with a new cohort of clinicians taking over its coordination and running every four months. New to both the surgical department and to clinical practice, these clinicians are often uncertain about the pre-operative investigative work up required for the range of surgical interventions offered by the department, and therefore request a battery of inappropriate and unnecessary tests in the pre admission setting in an attempt to ensure thoroughness. In particular, lack of awareness of the NICE pre-operative guideline for laparoscopic surgery was anecdotally felt to be resulting in a high rate of over investigation of patients awaiting laparoscopic cholecystectomy at Gloucester Royal Hospital. Inappropriate requests for clotting screens and 'group and save' blood tests increase the workload of the hospital laboratories with no clinical gain, as the risk of major bleeding and need for intraoperative transfusion is low for this procedure. This indiscriminate use of resources has clear financial implications in an increasingly resource limited NHS.

Requirement of preoperative blood typing for cholecystectomy and appendectomy: a systematic review

“…All the abstracts were screened and 15 full-text articles [11,[19][20][21][22][23][24][25][26][27][28][29][30][31][32] strictly met the study inclusion criteria-a total of 477,437 patients. All were retrospective studies: 10 studies [11,19,21,23,[25][26][27][28][29][30] reviewed the necessity of G&S for cholecystectomy procedures only, two studies [31,32] on appendectomy procedures only and three studies [20,22,24] evaluated both procedures. A PRISMA [33] flowchart of the section process for this study is presented in Fig.…”

“…Cholecystectomy is safe with a low transfusion rate. O negative blood has already been screened for the presence of most significant non-ABO antibodies Yes Hack-Adams et al [ 25 ], 2015 Patients over investigated and routine G&S testing should be eliminated Yes Hamza et al [ 11 ], 2015 Routine G&S is unnecessary Yes Li and Low [ 26 ], 2020 A preoperative G&S test did not impact management for any patients undergoing laparoscopic cholecystectomy. It should not form part of the routine work-up, although it may still be required for high-risk cases Yes Lin et al [ 27 ], 2006 G&S may be safely disregarded Yes Magowan et al [ 32 ], 2020 G&S tests are unnecessary and ceasing their requirement as standard may result in significant financial savings.…”

“…Laparoscopic cholecystectomy was completed in at least 469,338 (98.9%) patients. Ten [11,20,21,23,[25][26][27][28][29][30][31] out of 13 studies recorded the number of patients that underwent preoperative G&S testing. Data was extractable in nine of these studies: a total of 177,178/468,981 (37.8%, range 8.5-100%) patients.…”

Pre-Operative Group and Save in Elective and Emergency Laparoscopic Cholecystectomy: Necessity, Cost-Effectiveness, and Own Experience

“…The 2016 National Institute for Health and Care Excellence (NICE) guidelines, which aimed to standardise the process of pre-operative investigation across the United Kingdom (UK), emphasised the reduction of unnecessary pre-operative testing [23]. Several UK publications have similarly concluded that routine Group and Save sampling for laparoscopic cholecystectomy is "unnecessary" [19,[24][25][26]. The 2012 French Society of Anaesthesiology and Intensive Care (SFAR) guidelines, which were endorsed by 17 surgical and medical scientific societies, also highlighted the need to reduce redundant pre-operative tests, advising against the routine use of Group and Save sampling in low-risk patients [27].…”

An Audit on Unnecessary Preoperative Investigations and Their Cost in Dental Hospital Peradeniya Sri Lanka

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Preoperative investigations are important elements of preoperative evaluation to determine the fitness for anaesthesia and surgery. [1,2,3]. The objectives were to assess the number of unnecessary preoperative investigations carried out and repeated in Dental Hospital, Peradeniya and to analyze the cost of investigations that are performed unnecessarily.

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