by Paul Govern
When clinical teams at Vanderbilt University Medical Center dramatically reduced several types of preoperative testing for elective surgery patients, there were no repercussions for these patients in terms of case cancellation rates, average length of stay in the hospital or rates of readmission to VUMC.
That’s the finding of a retrospective observational study by Jonathan Wanderer, MD, MPhil, and Gen Li, MS, MS, appearing in the Journal of Clinical Anesthesia.
“We’re very encouraged by these results. Where the rooting out of unnecessary testing is concerned, many health care institutions have been slow to adopt established preoperative testing guidelines, and we think this might be due in part to fear that OR operations might become disrupted, whether by increases in case cancellations or by last-minute testing.
“But our study shows that more refined, targeted protocols can be successful in reducing unnecessary testing without disrupting the OR and without increasing adverse patient outcomes as measured by length of hospital stay or hospital readmission,” said Wanderer, associate professor of Anesthesiology and Biomedical Informatics and medical director of the Vanderbilt Preoperative Evaluation Center (VPEC).
From 2012 to 2015, VPEC refined its protocols based on national guidelines and consensus among VUMC experts, in part to reduce unnecessary patient tests through more discriminating use of chest X-rays, electrocardiograms and lab studies. Concurrently, the preoperative chest X-ray protocol used by surgical teams across VUMC was refined, and surgeons completed brief training modules about the protocol.
When the researchers analyzed 56,425 cases that had been evaluated preoperatively by VPEC before and after the various protocol changes, they found that the rate of preoperative electrocardiogram orders decreased from 62 to 32 percent; preop basic metabolic panels and blood cell counts both decreased from 71 to 51 percent; and preop blood coagulation testing decreased from 38 to 30 percent. To examine preop ordering of chest X-rays, the researchers analyzed 72,605 cases, finding a decrease from 11.8 to 3.1 percent.
After the protocol changes, rates of testing on the day of surgery were unchanged for these tests, except in the case of basic metabolic panels, which increased from 0.28 to 0.66 percent. Among patients evaluated preoperatively, length of hospital stay was found to have decreased by one day and there were no significant increases in case cancellations or readmissions to VUMC within 30 days.
Wanderer and Li were joined in the study by Sarah Nelson, MPH, Hanyuan Shi, MD, Maxim Terekhov, MS, and Jesse Ehrenfeld, MD, MPH.
