Orthopaedic Surgery/Preoperative Evaluation

Prevention of iatrogenic injury is the first goal of planning, management, and execution of surgery. This harkens back to the founding principles of medicine as set forth by Hippocrates whose words are used by Galen in their latin translation "primum non nocere". "Above all, not knowingly to do harm."

The process for preparing a patient for surgery can be taken as three different processes. One for elective same day surgery, one for emergency same day surgery, and one for inpatients. Each involves a coordinated effort by nursing, primary care physicians, specialty consultants anesthesiology and the operating room coordinator and staff. The weakest link will cause the whole chain to fail.

A case flow board is a mainstay of all operating rooms and keeps a running visual display of what is going on in each room, what resources are available, and for many operating rooms this is tracked by computer and displayed graphically facilitating in principle the role to the nurse who is typically "running the board". Depending upon how busy the emergency room is, it may be efficient to have a designated trauma room which is released for overflow patients if it happens to be unused, for example the room might be scheduled no more than 24 hours in advance. It may be efficient of not to schedule an operating room with block time made available to surgeons with a predictable steady volume of cases. The goal is to have cases run in the time predicted avoid being bumped and minimize turnover time.

Turnover time can have several meanings. Time out of the room, to next patient in the room is one definition.

As a patient is prepared for the operating room then undergoes surgery it is necessary to coordinate the activities of all concerned with aspects of the patients care. The operating room works from a schedule and "pulls" the cases that are scheduled for the next day, working from the surgeons "case card" to know what to pull. Lack of precision as to what specific case is to be done, pulling the wrong card. The card for a given case has a tendency to stagnate unless the card is updated after each case. If the wrong equipment is pulled the case will take longer, the surgeons concentration will be distracted.

Patients undergo baseline screening typically in pre-anesthesia testing, and then more specifically directed diagnostic testing which becomes increasingly elaborate with age and the anticipated physiologic stress that will occur with the surgery. All patients want to know that all has been done to optimize their chance of a successful outcome.

Obsesity, Cardiac and Pulmonary risk, peripheral vascular disease, familial history of anesthetic complication, all the ducks need to be in a row before the surgery can take place. When the system fails it can happen in a number of ways. An indicated test not done or the result ignored, a complication may then occur. The failure to recognize the problem in advance of the surgery is intolerable. Then again sometimes a test ordered in the name of being thorough may lead to results that then require further perhaps more invasive tests and or unnesessary.

When a patient is confronted by a surgery it is taken as the most risky part of their hospital experience and therefore a period when all efforts focus on minimizing the risk. At the same time the operating room is a limited resource which tends to be in high demand and thus cases go on time and end on time, to avoid overutilization or underuse which also is detrimental to efficient practice.

http://web.archive.org/20011109195604/www.geocities.com/everwild7/noharm.html

http://www.chestjournal.org/cgi/content/full/115/suppl_2/96S

Cardiac Risk Assessment