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

Hobart AnaesthesiaGroupThe Hobart Anaesthesia Group (HAG)is an organization of some 24 associateanaesthetists and three “locum”anaesthetists. It was formed in theearly 1960s as a two-member group andhas operated continuously since. HAGprovides anaesthesia for approximately80 proceduralists including all surgicaldisciplines except cardiac as well asanaesthesia for endoscopy, imagingand emergency procedures. As part ofthis service, we also provide emergencyanaesthesia cover 24 hours a day,365 days a year.HAG employs 10 staff (seven FTE)at its operations base which is locatedindependently of any hospital. The “rooms”have been expanded in the last 10 yearsand now include five consulting rooms,and office space for reception, accountprocessing, debt collection, as well asco-ordination of lists and pre-operativevisits. There is also a meeting room, libraryand practice manager’s office. The numberof staff has expanded dramatically inthe last 10 years (corresponding with anincrease in number of anaesthetists, plusthe introduction of informed financialconsent (IFC) processes and the growth inpre-hospital pre-anaesthesia assessments).We currently see some 120-150 patientsper week in a pre-anaesthesia assessmentsetting in our rooms.About 10 years ago, a decision wasmade by HAG anaesthetists that, due to theemergence and growth of day-of-surgeryadmissions(DOSA) we would have tore-evaluate the way complex cases werebeing assessed prior to anaesthesia. Inorder to allow sufficient time for appropriateassessment, further specialist referraland investigation where necessary and toavoid late cancellations and disruptionsto operating lists the decision was takento organise pre-anaesthesia assessmentsin our rooms for all patients undergoingmajor surgery (eg. joint replacements,vascular surgery, bariatric surgery, LUSCSs,hysterectomy, etc) or those patients withmajor medical problems. This pre-hospitalprocess also facilitated appropriateinformed consent for patients (which alsoencompassed informed financial consent).The process that now has beenestablished is: all complex medical,surgical, or anaesthetic cases must bereviewed (wherever possible) by ananaesthetist as soon as practicable, usually1-2 weeks prior to the planned procedure.This includes major joint surgery, LUSCS,laparoscopic gastric banding and complexbowel surgery, patients with complexmedical conditions such as Type 1 or 2IDDM, significant IHD and/or CCF,as well as known difficulties withprevious anaesthesia.Cooperation with both proceduralists’rooms and hospital “booking offices”/operating theatre coordinators is essentialand lines of communication need to remainopen. All of our proceduralists are informedof our preferred system for pre-anaesthesiaassessment. and a reminder letter is usuallyre-sent annually.The proceduralist’s rooms now liaisewith our pre-anaesthesia co-ordinatorand an appointment is made with amember of HAG. Our rooms then sendout a confirmation letter which includesinformed financial consent and an“anaesthesia brochure” prior to arrivingfor a pre-anaesthesia assessment. Thepatient, having filled in the healthquestionnaire, will have their personaldetails checked for the billing system andbe asked to sign a privacy agreement (sameas for any hospital) by the office staff. Theconsultation then takes place, generallylasting anywhere between 10 and 30minutes, although the more complex casesoften take up to an hour. Notes are madeon hospital anaesthesia records, indicatingthe type of anaesthesia, what type of intraoperativemonitoring may be likely, and thelikely post-op destination of the patient.During the consultation, other specialistssuch as intensivists, cardiologists, orendocrinologists may be contacted to makeappropriate arrangements. The patient isthen given clear, consistent instructions.At the end of the interview, thecompleted pre-anaesthesia record isscanned into our computerized databaseof patient records and “tagged” to thepatient’s file. It is also faxed to the hospitalwhere the procedure will take placeand is incorporated into the patient’shospital record. The original is kept bythe anaesthetist so that it can be referredto as required and to ensure that it isnot mislaid.While this change in practice has beenrelatively costly to implement, the benefitsof early pre-hospital pre-anaesthesiaassessment have far outweighed the costsinvolved. All parties benefit with hospitalsbeing less disrupted by late cancellationsand delays in operating lists (awaitingthe anaesthetist “seeing patients”),communication between our practice andboth surgeons and hospitals has improved,allowing a greater degree of co-ordinationand therefore better planning andallocation of resources. Finally, and mostimportantly, our patients have benefitedallowing a very high rate of DOSA for majorsurgery and delivering an improved qualityof anaesthesia care.Dr Andrew Mulcahy,Ms Elizabeth Stanick,Dr Richard WaldronPhotos courtesy of Dr Michael MartynAbove: The computerised managementsystem and examples of patient informationbrochures; Patient reception at HobartAnaesthetic Group consulting rooms.The ANZCA Bulletin June 2009 31