Improving Preoperative Diagnostic Testing
In Manitoba, many patients presenting for low-risk surgery were receiving full preoperative assessments despite the fact that these assessments did not improve outcomes. In 2014 a multidisciplinary team was formed to restructure the way preoperative assessment is carried out in Manitoba. The goal was to ensure that all Manitobans receive the necessary and appropriate preoperative diagnostic testing for minor surgeries through the sustainable implementation of a standardized, evidence-informed clinical practice guideline.
This project started with an examination of the barriers and facilitators to guideline adoption and implementation including further analysis of audit results, stakeholder consultations and a literature review. The results of this work were then used to develop and implement a new Routine Preoperative Lab Test Guideline. A series of interventions were then developed aiming first to reduce unnecessary testing in cataract surgery and then to reduce unnecessary testing in other types of surgery.
The implementation of a revised Cataract Surgery History and Physical (H&P) Form emphasized that tests are not usually required for cataract surgery and eliminated cuing for unnecessary preoperative tests. At the same time a Red-Green project eliminated preoperative History and Physicals for ~60% of cataract surgery patients. Pre and post-implementation audits showed a 77.5% reduction in patients undergoing preoperative testing from pre to post-implementation.
Building on what we learned through the cataract project, on July 11, 2016, five revised documents were implemented to help reduce cues that prompt unnecessary testing for all other types of surgery. The revised documents were implemented in eight surgical sites across Winnipeg.
- Revised Routine Preoperative Lab Tests Guidelines
- WRHA Preoperative History & Physical Form
- Patient Quick Reference Cover Letter
- Preoperative Care Cover Letter
Our primary outcome, to reduce preoperative diagnostic testing by 25%, was evaluated through retrospective chart reviews of two random samples of surgical patients during typical weeks in the WRHA. The results demonstrated a significant (p<0.0001) 35% reduction in preoperative diagnostic testing.
In order to review adherence to the guidelines and to support implementation by providing feedback and supporting materials, we have conducted approximately 10 audits of surgeons in each of the 8 surgical sites in Winnipeg (excluding cataract and pediatrics). The results revealed that the majority of surgeries were compliant with the guidelines (60%) but that there is a large range in the number of unnecessary tests ordered between surgical specialties from 24% of tests ordered are unnecessary to 72% are unnecessary. Based on these results our next step is to provide feedback to individual surgeons including supporting materials to increase adherence to the guidelines.
See a Summary of the Evaluation Results
For a copy of the full evaluation please contact us at [email protected].