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Czoski-Murray C, Jones ML, McCabe C, et al. What is the Value of Routinely Testing Full Blood Count, Electrolytes and Urea, and Pulmonary Function Tests Before Elective Surgery in Patients with No Apparent Clinical Indication and in Subgroups of Patients with Common Comorbidities: A Systematic Review of the Clinical and Cost-Effective Literature. Southampton (UK): NIHR Journals Library; 2012 Dec. (Health Technology Assessment, No. 16.50.)
What is the Value of Routinely Testing Full Blood Count, Electrolytes and Urea, and Pulmonary Function Tests Before Elective Surgery in Patients with No Apparent Clinical Indication and in Subgroups of Patients with Common Comorbidities: A Systematic Review of the Clinical and Cost-Effective Literature.
Show detailsThe purpose of the survey was to capture current practice of ordering tests for patients classed as ASA grades 1 and 2 undergoing elective minor or intermediate surgery. To do this we chose to approach hospital-based pre-operative assessment clinics directly. We wanted to obtain as wide a picture as possible from those working in a wide variety of settings. Previously, the Abacus International Survey7 comprised a paper and online survey. The investigators contacted members of the Royal College of Anaesthetists (RCoA) Pre-operative Assessment Association and the British Anaesthetic & Recovery Nurses Association (BARNA) and requested that they complete their survey which covered all of the recommendations of the clinical guidelines. This audit was commissioned by NICE to gauge the impact of CG3 on clinical practice.
The questionnaire development
We used some of the questions developed by the Abacus survey7 but excluded those which asked about major surgery and ASA grades above 1 and 2. The questions specifically asked if the indicated tests were carried out routinely. This was to distinguish between those tests that could be considered for the patient in accordance with CG3. We included questions on the testing of patients with common comorbidities of cardiovascular disease, renal disease and respiratory disease. We restricted this to minor and intermediate surgery and for patients aged < 60 years as indicated by the briefing document. We also undertook a very brief snapshot of the level of compliance with CG3 in the range of tests presented in CG3 for ASA grades 1 and 2 and minor and intermediate surgery. We did not include any of the questions relating to the respondents’ opinion regarding the NICE guidance. We included questions about electronic patient administration services (PAS) including how data from patients results were recorded and whether or not the system differentiated between which pre-operative clinic ordered the test. The original survey7 included a number of questions specifically about neurosurgery and cardiovascular surgery that we did not include as these questions were poorly answered in the Abacus survey7 owing to the smaller numbers of centres undertaking this type of surgery. We asked those completing the questionnaire to include a copy of their protocol, if it was locally developed, for use in ASA grade 1 and 2 patients. (See Appendix 14 for questionnaire.)
Once we had the basic structure we consulted with anaesthetic colleagues locally in Sheffield who had an interest in pre-operative assessment. The short questionnaire was ready to be tested once we had checked the status of the project with the National Research Ethics Service (NRES).
We sent details of the project along with the questionnaire to NRES and it was confirmed that this work was classed as service evaluation and did not require ethics approval. The questionnaire requested details about the professional responsibilities of the person completing it. The respondents were assured of the confidentiality of the responses. We had a code for the hospital trust for monitoring purposes so that reminders were not sent to those who had already returned the questionnaire.
As part of our consultation process on the questionnaire we also asked if our strategy of sending directly to the pre-operative assessment clinics would be appropriate. We were advised that this would be likely to obtain a response from those directly involved on a daily basis in assessing patients and ordering tests according to protocols. In the covering letter we asked if the questionnaire could be passed to other clinics run by different specialties in their hospital if they thought that they were using different protocols. We included additional copies of the questionnaire with pre-paid return envelopes.
In the summer of 2008 we sent out 20 questionnaires to hospitals selected to represent teaching hospitals and district general hospitals. Initially we did not receive any back and sent out reminders. We then received four questionnaires. We reviewed the questionnaires and found that only two had sent a copy of their protocol, which was a copy of the NICE guidance in both cases.
We decided to keep with this strategy and the full survey was sent out to pre-operative assessment clinics in 486 hospitals in England and Wales in the autumn of 2008. These hospitals were identified through internet searches for hospitals that appeared to have a surgical unit. Children’s hospitals were excluded. The previous Abacus7 survey did not report on whether or not their respondents (anaesthetists and pre-operative nurses) worked at the same hospital.
To comply with Welsh-language requirements we asked if the respondents would prefer to have a Welsh-language version available.
The survey results
We did not undertake any statistical analysis and these results presented are descriptive.
From the first mailing of questionnaires, 30 questionnaires were returned. We sent out reminders and a further 53 questionnaires were returned, of which five were blank. This gave a total of 83 questionnaires returned (a response rate of 17%). Twenty-four of these had a protocol attached. All of these protocols were copies of the NICE guidance. It was not possible to compare our low response rate with that of the Abacus study7 as they were not clear how many potential respondents they contacted. In addition, a number of the questions they asked were skipped by a large number of respondents, which does not allow for comparisons. However, obtaining a high response rate from busy professionals in a clinical setting is always a challenge.
As expected, all those completing the questionnaire were nurses involved in pre-operative assessment, and all were involved in ordering tests. No one completed a questionnaire passed to them by another pre-operative clinic in the same hospital, i.e. no questionnaires named the same hospital more than once.
We included questions on the number of surgical patients and the proportion of minor, intermediate and major surgeries. In addition, we asked for a breakdown of the numbers of patients in ASA grades 1–4. These were so poorly answered that it was obvious that this information was not readily available to the nurses completing the questionnaire. We asked for this information as it could have potentially been of use in the economic model. We have not reported on these results.
The results tables
The tables below are the results from the survey showing the individual responses to the questions on test ordering.
Table 17 shows that there is 100% compliance with the NICE guidance for those aged < 40 years. The older age groups show more variation, particularly with ECG. Where NICE recommends considering undertaking ECG, FBC, U&E, random glucose and UA in patients aged > 40 years,1 we could perhaps assume that these tests are carried out so frequently in this group as to be classed as routine. However, we did not include a section for tests under consideration which may have limited respondents’ choices.
Tables 18 and 19 show the results for patients ASA grade 2 with cardiovascular comorbidity undergoing minor and intermediate surgery. The results are very similar for minor and intermediate surgery. NICE recommends considering FBC and U&E in this group of patients.
Table 20 shows the results for ASA grade 2 patients with respiratory comorbidity.
Table 21 shows the results for ASA grade 2 patients with respiratory comorbidity. Those with respiratory comorbidities are slightly less likely to be considered for U&Es. NICE guidance recommends considering testing U&Es in this patient group.
Tables 22 and 23 show the results for patients with renal comorbidity. NICE recommends U&Es for these patients and to consider FBC.
The types of hospital responding were teaching hospitals (n = 32) and district general hospitals (n = 51). Slightly more district general hospitals than teaching hospitals responded.
Discussion
In this section of the study we concentrated on finding out if there was still a culture of routine tests for FBC, electrolytes and renal function and pulmonary function in ASA grade 1 and 2 patients undergoing minor and intermediate surgery. Our results show a substantial level of compliance in the reduction of the routine testing of FBC, electrolytes and renal function and pulmonary function in ASA grade 1 and 2 patients. No one reported carrying out PFTs in this patient group.
There was more variation in reporting of tests in patients with comorbidities. NICE guidance recommends that FBC and U&Es be considered for most of these patients with common comorbidities. Our results suggest that in some places these tests may be part of the routine pre-operative work-up. However, the numbers are small and it is equally likely that a clinical judgement is being made whether or not individual patients actually require these tests.
However, we recognise that the ASA grading of patients is likely to be variable and may be subject to grade inflation to enable testing to be carried out within the NICE guidelines. It is possible that there is a degree of familiarity with the guidance in the 7 years since publication and the time of this survey.
There are other considerations including the increasing standardisation of care throughout the NHS and the work of pre-operative assessment clinics. However, we recognise that these do not follow the same structure in each hospital, and indeed some may not have a formal ‘clinic’ setting.
We attempted to spread our net fairly widely so that we could reach a wider group. However, we recognise that in places where there was no formal pre-operative clinic we could still have failed to reach our intended respondents. We targeted those units with a formal set clinic by addressing the questionnaires to them. We are likely not to have any responses from hospitals relying on trainee medical staff to undertake this role. Our demographics showed that only nurses completed this survey. Other categories of staff may not have seen the questionnaire. As we have shown our response rate was relatively poor and our own local very large trust did not respond as part of the survey. By consulting with our anaesthetic colleagues and with our nursing contacts involved in pre-operative assessment we decided that the responses from nurses would reflect local practice. There was some discussion that nurses would be more aware of any deviations from protocol across the board owing to preferences in testing by senior medical staff.
Undertaking surveys of this kind may be an inefficient method of collecting this kind of information. As part of its guidance, NICE recommends the use of internal audit and the use of routine collected data available through electronic systems. This, of course, disadvantages hospitals with less sophisticated methods of accessing test results.
We did not ask about audit arrangements; in contrast, the Abacus survey7 in 2005 found that there was relatively poor preparation to undertake audit of the compliance with the guidance.
- Survey of current practice on pre-operative testing in ASA grade 1 and ASA grade...Survey of current practice on pre-operative testing in ASA grade 1 and ASA grade 2 - What is the Value of Routinely Testing Full Blood Count, Electrolytes and Urea, and Pulmonary Function Tests Before Elective Surgery in Patients with No Apparent Clinical Indication and in Subgroups of Patients with Common Comorbidities: A Systematic Review of the Clinical and Cost-Effective Literature
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