Anaesthetic pre‐assessment clinics to identify patients at risk

We would like to follow on from two recent letters (Wright et al. Anaesthesia 2000; 55: 391–2; Cosgrove. Anaesthesia 2000; 55: 405–6). It is important to be able to identify those ward patients who are critically ill and, like Goldhill [1], we are developing a team strategy for prevention of in-hospital cardiac arrests. The use of the simple physiological parameters of the Early Warning Scoring System (EWSS) [2] would facilitate this. However, for elective surgery the problem lies earlier in the admission chain. The identification of patients at risk is an important part of the pre-operative assessment by the anaesthetist. With more patients being admitted on the day of surgery, this assessment may be hurried, leading to inadequacy, potentially higher critical care admissions or patient cancellations. All of these have significant implications to both the patient and the trust. Cosgrove highlights the potential benefits of anaesthetic pre-assessment clinics and their cost effectiveness [3]. At our hospital, we have regular consultant-led clinics for those patients considered high risk by the surgeons. They normally spend around an hour with the anaesthetist, during which time they have a full history and examination, pulmonary function tests (peak expiratory flow rates and spirometry) and, if necessary, arterial blood gas analysis. We are also currently studying a noninvasive outpatient method of assessing cardiac flow. Those deemed to be high risk by the anaesthetist are brought into the High Dependency Unit (HDU) the day before surgery for protocol-based pre-optimisation [4]. Whilst outpatient echocardiograph ejection fractions can sometimes reassure, we have found them to have poor correlation with pulmonary artery catheter flow studies on those admitted for pre-optimisation. Since adopting these strategies we have reduced the number of high-risk patients requiring intensive care postoperatively. They stay on HDU for a shorter time, suffer fewer complications and are discharged home earlier. The cost implications to the trust easily balance the outlay for the assessment clinic and the patients get better care. It may even help change our perception amongst the general public, from people with unknown qualifications who hide in operating theatres with drug-filled syringes and black face-masks, to the critical care doctors that we are.