Preoperative investigations in elective surgery: practices and costs at the National Hospital of Sri Lanka

Abstract

Background: During preoperative preparation patients undergo investigations to detect asymptomatic diseases. The probability of finding significant abnormalities on such "routine" investigations is small, unnecessarily increasing costs of perioperative care. We evaluated current practices, compliance with guidelines and costs of preoperative investigations at the National Hospital of Sri Lanka (NHSL).
Methods: Patients undergoing elective surgery at seven general surgical units of the NHSL from January- Februaary 2009 were included. NICE-UK guidelines on pre-operative investigation was the standard of assessment. Data on preoperative investigations were collected using an expert validated pre-tested interviewer administered questionnaire. A self-administered questionnaire was used to assess the ward practices and House Officers' (HOs) knowledge.
Results: Sample size was 367. Mean age 45.7±15.8 years and males were 46.9%. Majority were ASA-I (68.7%) and surgical grade-II (56.7%). Urinalysis and arterial blood gases demonstrated good adherence (70%-100%) to guidelines. Electrocardiography, full blood count, renal function tests and blood grouping demonstrated moderate adherence (40-69%), all other investigations demonstrated poor adherence ( < 40%). Non-recommended investigations were requested mostly by the HOs and Medical Officers and registrars in anaesthesia. Total excess cost incurred due to non-recommended investigations during the study period was LKR 241,300- 375,270. HOs decisions on preoperative investigations were based on; past experience of similar patients, directives given by seniors or their clinical training. Investigations requested by all members of the surgical/anesthetist team are commonly done with minimal utilization of guidelines. The HOs ability to plan preoperative assessment for model case scenarios was insufficient.
Conclusions: Unnecessary preoperative investigations are common at our institution leading to substantial excess costs. There is ample opportunity to rationalize practices and reduce expenditure

Key words: Anaesthesia, audit; Surgery, preoperative period; Assessment, preanaesthetic

DOI: 10.4038/slja.v18i1.1558

Sri Lankan Journal of Anaesthesiology 18(1): 29-35 (2010)