ANZCA Bulletin - June 2009 - Australian and New Zealand College ...

fellowship affairsPrivate practice:improving patient careTraditionally, private practitioners have seen their patients for the first time on the night beforesurgery; this has changed with day of surgery, staggered admissions making appropriatepreoperative evaluation difficult. Four anaesthetists have outlined how different structures can beimplemented in private practice to facilitate the perioperative care of patients. There are two grouppractices (ACT and Tasmania), a solo practitioner (metropolitan Sydney) and an informal groupunited by working with the same surgeon (metropolitan Sydney). Each has developed a structurein which to evaluate patients and facilitate communication between different team members.St Vincent’s PrivateHospital, SydneyThe anaesthetists of St Vincent’s PrivateHospital in 1989 had the foresight topurchase rooms off the plan of the StVincent’s Clinic when it was built next tothe hospital.These rooms were designed withspace for four secretaries, two consultingrooms, a library/ lounge and a kitchen.The rooms have not only provided adepartmental centre through which alllists are coordinated and after-hoursrosters maintained but also enable theanaesthetists to run a pain clinic and a preanaesthesiaconsultation service plus, forthose who wish, there is a billing servicevia an associateship.In addition, St Vincent’s Private Hospitalthree years ago opened a day of surgeryadmission ward that the anaesthetistshelped design. It has five consultationrooms.There is also a pre-admission nursingclinic that sees patients pre-operatively.In my practice I have an afternoonnearly every week set aside to see patients.I aim to see all my patients having majorsurgery, or who have significant illnesses,in my rooms some days prior to theirsurgery. I dovetail this with their visit tothe pre-admission nursing clinic. Afterseeing nurses where they are processed,weighed and have blood pressure, pulse,temperature and urinalysis taken, ECGdone if indicated and nursing informationprovided about their admission, they thencome to my rooms to see me.I have their nursing information,admission information from their surgeonand their old notes. I not only have timefor a thorough anaesthesia assessment butI can discuss with them their anaestheticincluding the risks, provide them writteninformation, an “Anaesthesia and You”brochure and a PCA brochure plus mysecretaries provide them with a writtenestimate of the fees which I can alsodiscuss with them. If needed, I can arrangefurther tests or consultations with otherspecialists.After leaving, they have any requiredblood tests and radiology, the results ofwhich I see prior to their anaesthesia. Thisenables even the most complicated patienthaving the most involved surgery to beadmitted on the day of surgery with meconfident that they are fully prepared fortheir anaesthesia.For patients who are ASA 1 and 2 havingreasonably straightforward surgery I seethem in the Day of Surgery Admission wardbefore the morning or afternoon sessioncommences. They are posted an estimateof the anaesthesia fee.I endeavour to see my admittedpatients post-operatively the next day tofollow up particularly on pain and fluidmanagement.There are, I believe, many advantagesto seeing patients in rooms some days priorto their anaesthesia.First, I believe it is simply bettermedicine. In a non-rushed, efficientenvironment significant numbers ofpatients can be thoroughly worked up priorto their anaesthesia. There are, therefore,fewer cancellations and fewer tests areordered, avoiding the shotgun approachof some surgeons when ordering tests. Ibelieve also there are likely to be betteroutcomes due to better preparation.Second, it enables the anaesthetist todevelop a relationship with the patient. Iam wearing a suit when they meet me inthe consulting rooms. It is very professionaland, I believe, far better for the image ofanaesthetists than the cursory chat at thebedside while dressed in scrubs.Third, it serves to greatly improve cashflow and reduce bad debts. The patientsare fully informed about the costs well inadvance of their anaesthesia.Finally, it is far better for my lifestyle tobe seeing patients efficiently in my roomsduring the day than to be scouring thewards trying to find patients, notes, oldnotes, X rays and results of investigationsafter hours and on weekends.Dr Gregory J DeaconSt Vincent’s Private Hospital, Sydney30The ANZCA Bulletin June 2009