Pre-Operative Assessment In Rural Patients Practical Challenges and SolutionsPractical Challenges and Solutions
B A Knight (FRACP) Ballarat, Victoria
Pre-operative assessment in rural patients presents many challenges; there are often difficulties in access to specialist assessment which involve travel, scheduling appointments. In addition, the range of diagnostic investigation available may be limited depending on the characteristics and skill sets of specialists in individual, rural and regional centres. There may also be a specific issues related to assessments performed in the public and private sector. Each of these difficulties must be over come to minimise the risk of pre-operative adverse events.
The pre-operative assessment often begins well before the anaesthetist or physician sees the patient. Prior planning allows a degree of co-ordination of physician, anaesthetist and surgeon activities in terms of scheduling of appointments and co-ordination of pre-operative investigations. It is worth while noting that some patients have to travel 400 to 500 kilometres each way for a specialist review. Sequential physician pre-operative investigation, anaesthetists and surgeon review over one to three days can be very helpful in providing a comprehensive assessment of patient’s fitness for surgery. As well as giving patients some confidence in the treating team. Much of this co-ordination of appointments can be undertaken by supported administrative staff. It should be noted that this type of flexibility in scheduling appointments and investigations is easy to achieve in the private setting but much more difficult in the public hospital setting where often times for consultant review are inflexible.
Access to pre-operative physician review can be a very difficult issue. The specific availability of physician assessments will vary widely in different regional settings for different reasons. There is variability in physician’s skills for example, general verses sub specialist cardiologist or respiratory physician as well as variability and availability of new appointments. It is in the later that the capacity of public and private assessments is most diversion. (1) There are often significant delays in access to public specialist outpatients appointment. This obviously significantly limits timely pre-operative assessment.
The American Heart Association (AHA), American College of Cardiology (ACC) task force on perioperative evaluation provides a useful frame work for pre-operative assessment.
It comprises several features including, determination of the need for urgent or elective surgery. Coronary revascularisation within the last five years. Assessment of clinical predictors of major coronary events. A stratification based on functional reserve, assessment of surgical risk, non invasive testing to assess ischaemic risk from ocult coronary disease. (2) The specific modalities used in regional settings for non invasive assessment of coronary disease will vary according to local skill and availability. Dobutamine Stress Echo is a useful pre-operative investigation for assessment of ischemic risk (3). It is also suitable for rapid patient assessment provided there is local expertise in this area.
Persanbin Sestamibi Scan has also be validated as a diagnostic tool for assessment of ischemic risk (3) there are some practical issues which may make this less suitable for rural patients. These issues relate to potential delays in scheduling appointments for patients. Isotopes for use in these tests often need to be ordered one to two weeks in advance. This makes rapid access to testing difficult.
Access to coronary angiography and revascularisation in the rural setting can be quite variable. The need for these types of investigation may potentially further delay assessment if there is need for travel and assessment in a larger centre. The use of AHA / ACC guidelines for pre-operative assessment reduces the need for coronary angiography and revascularisation (4).
More recently it has been shown that cardiac testing can be safely omitted in intermediate risk patients, in patients by B-Blockade with tight heart rate control. Beta Blockers are effective in reducing cardiovascular adverse events and also allow significant improvements in time to surgery without the need for pre-operative cardiac testing in selected patients (5).
Rural pre-operative patient assessment presents several challenges primarily these relate to distances patients must travel, difficulty in accessing specialist assessment due to work force issues, and specific limitations of diagnostic investigations available which are highly region specific. Despite there difficulties patients are invariably grateful for being able to have surgical treatment in a familiar, supportive environment.
Reference
1. Australian Medical Work Force Advisory Committee, Sustainable Specialist Services, A Compendium of Requirements, 2004 Update.
2. Fleisher LA, Preoperative Cardiac Evaluation, Anaesthesiology Clin N AM, 22(2004)59 –75
3. Kertai MD, Boersma E, Bax JJ, Heijenbrok-Kal MH, Hunink MGM etal, A meta-analysis comparing the prognostic accuracy of six diagnostic tests for prediction perioperative cardiac risk in patients undergoing major vascular surgery, Heart 2003;89:1327-1334
4. Froehlick JB, Karavite D, Russman PL, Erdem N etal, American College of Cardiology/American Heart Association preoperative assessment guidelines reduce resource utilization before aortic surgery, (J Vasc Surg 2002;36:758-63).
5. Poldermans D, Bax JJ, Schouten O, Neskovic AN etal, Should Major Vascular Surgery Be Delayed Because of Preoperative Cardiac Testing in Intermediate-Risk Patients Receiving Beta-Blocker Therapy With Tight Heart Rate Control, (J Am Coll Cardiol 2006;48:964-9).
Time of Presentation
1030
