Preop clearance guidelines

[Aunt Val]

Hey all,

I was recently hired to provide locum tenens coverage at an eye surgery center.  This is my first PA job, and while I would rather be doing something permanent, I'm grateful for the opportunity to get some experience to put on my resume.  My job is to provide preop clearance for patients undergoing eye surgery, most often cataract removal.  I'm expected to do H&Ps, read EKGs, and interpret bloodwork (when ordered).

My first day I was put in an exam room and given basically no guidance except from my MA, who is very helpful but doesn't know everything I need to know--like what exactly I should be looking for in approving or not approving a patient for surgery.  The MA showed me a list of a few basic things that would preclude a patient from having surgery (like MI in the last 3 months).  Other than that, I was left to figure it out on my own.  I talked with the practice manager, who said he would get me in touch with one of the anesthesiologists, but that never happened.  A few days later, I got to talk with a part-time MD at the practice, but she just mumbled something about "you're just looking for their general health status."  I sought out an anesthesiologist to double check a couple of EKGs for me, and he was pretty dismissive of my questions.

Does anybody have any sources where I could find specific guidelines to use in decision making?  I did some digging on my own and found some general algorithms, but nothing with hard and fast rules.  I get that you have to take the whole patient into account, not just their data on paper, but seems like there should be something out there to use beyond just a clinically-educated gut feeling.

I've also found a few articles suggesting that extensive testing for preop clearance is unneccessary (especially for low-risk procedures like cataracts) and just drives up healthcare costs.  This makes me wonder why I'm even there.

Am I making too big a deal of this?  Basically, I just don't want to kill anybody or have anyone sue me for negligence if I give the green light for surgery and then a patient dies on the table, however unlikely that may be.

[rev ronin]

Congratulations on your job!

Locums work is tough on a new grad, for exactly the reasons you're encountering.

I trust that some of our handy surgery PAs will weigh in, but as a non-surgical PA, I tend to go to whatever UpToDate says, follow it, and document that that was the basis for my evaluation.

If you don't have access to UpToDate, it's a great buy, especially when you factor in the CME you get just from reading about stuff you need to figure out for your job regardless.

[UGoLong]

We use the ACC/AHA (American College of Cardiology/American Heart Association) guidelines for preoperative clearance for noncardiac surgery. It hasn't changed since 2014. Here is a link to the pdf. If you have trouble with the link, you can search for "ACC Guidelines" and get to it. I don't believe you have to be an ACC member to read it or download as a pdf:

 https://www.jacc.org/doi/10.1016/j.jacc.2014.07.944?_ga=2.147267639.182671638.1634460817-1223100178.1633263420

Eye surgery (and surgery without requiring a general anesthetic or more extensive hemodynamic impact) are considered lower risk but there are still some things to look for. Take a look at this and it should steer you in the right direction, plus make you look like a star because you are following the guidelines.

Best wishes on a long and happy career!

[Aunt Val]

Thanks to you both!  I had found part of the ACC/AHA guidelines, but not the full document, so that's helpful.

[sas5814]

Let me add (having recently started doing pre-ops after a long hiatus) you don't clear anyone. You stratify their risk. I have found a form in our computer (that I cannot share unfortunately) that lets me fill in a few blocks , check a few more, and then rate their peri and post-operative risks. At the end of the day the anesthesiologist and surgeon make the final decision based on your assessment.

Good luck!

[turnedintoamartian]

Scream it from the mountains: We provide risk assessment and optimization but not clearance.

 

[cinntsp]

Read the "Evaluation of cardiac risk prior to noncardiac surgery" article on uptodate if you have access.