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Effectiveness outcomes of preadmission testing for presurgical patients Home, Elfriede 1983

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EFFECTIVENESS OUTCOMES OF PREADMISSION TESTING FOR PRESURGICAL PATIENTS By Elfriede Home B.S.N., The University of British Columbia, 1978 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE (Health Services Planning) in THE FACULTY OF GRADUATE STUDIES (Department of Health Care and Epidemiology) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA MAY 1983 ©El f r iede Home, 1983 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e h e a d o f my d e p a r t m e n t o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f /^r /cu_TH Q\(j£. 4A1P The U n i v e r s i t y o f B r i t i s h C o l u m b i a 1956 Main Mall V a n c o u v e r , Canada V6T 1Y3 DE-6 (3/81) i i ABSTRACT A prospective c o n t r o l study comparing e l e c t i v e s u r g i c a l patients who had some or a l l of t h e i r p r e s u r g i c a l t e s t i n g done before admission with those who were tested a f t e r admission, was done at a 300 bed teaching and r e f e r r a l h o s p i t a l i n Vancouver, B r i t i s h Columbia. The intent of the study was to determine whether or not a program of preadmission t e s t i n g (PAT) resulted i n fewer inappropriate admissions and fewer delayed, postponed or cancelled s u r g i c a l procedures. In addition, the amount of repeated t e s t i n g was compared i n the two groups. A matched subsample of 62 p a i r s from an o v e r a l l sample of 90 PAT and 277 nonPAT patients admitted during an eight week period, was examined. Some interviews with surgeons, anesthetists, head nurses and s i g n i f i c a n t others, also were c a r r i e d out. It was found that preadmission t e s t i n g did not s i g n i f i c a n t l y e f f e c t s u r g i c a l workflow nor r e s u l t i n fewer inappropriate admissions. Preadmission tested patients, on the other hand, were f a r more l i k e l y to have t e s t s repeated and had more venipunctures than patients who were tested a f t e r admission. i i i TABLE OF CONTENTS ABSTRACT i i LIST OF TABLES . i v LIST OF FIGURES v ACKNOWLEDGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v i CHAPTER I. INTRODUCTION ........................................... 1 II. REVIEW OF THE LITERATURE ........ ................... 6 II I . MAIN METHODOLOGY .......................................14 Objectives of the Study ............................14 D e f i n i t i o n s 15 Study Setting 17 General Methodology 19 S p e c i f i c Methodology ..22 IV. FINDINGS FROM MAIN METHODOLOGY .........................26 Findings Related to Age, Scheduled Surgery, Contributing Co-morbidity and Preoperative Length of Stay ...........26 Use of PAT Program by Physicians and Surgeons 30 Observations and Findings from Interviews 30 Objectives of the PAT Program at ACU - HSCH 32 Decision to Develop a Subsample of Matched Pa i r s 33 V. SECONDARY METHODOLOGY AND FINDINGS .35 Methods Used to Obtain a Matched Subsample 35 Findings 38 Discussion 43 Findings Related to the Objectives of the PAT Program at ACU - HSCH .45 Answering the Questions Considered at the Outset ....46 VI. POLICY CONSIDERATIONS .47 SUMMARY ...........52 NOTES BIBLIOGRAPHY APPENDIX i v LIST OF TABLES 1. Goals Considered by Various Individuals and Groups When Setting Up a Preadmission Testing Program 3 2. C l a s s i f i c a t i o n of Patients Receiving and Not Receiving Preadmission Testing 29 3. S u r g i c a l S p e c i a l i t y C h a r a c t e r i s t i c s of PAT Patients and Numbers of Patients i n the Groups and Subgroups ..36 4. Age and Sex D i s t r i b u t i o n Within the Matched Samples 38 5. Inappropriate S u r g i c a l Admissions Due to A l l Reasons 39 6. Delays and Inconveniences Due to Unavailable Presurgical Laboratory Tests 40 7. Reasons f o r and Numbers of a l l Delays i n S t a r t i n g Surgery ....40 8. Numbers of Patients Who Had Repeated Tests by Type of Test and Category 41 9. Repeated Venipunctures by Category of Patient 42 V LIST OF FIGURES 1. Determinants of Length of Stay I d e n t i f i e d i n the L i t e r a t u r e ...10 2. I l l u s t r a t i o n of How I n i t i a l Sampling Was Carried Out ..........21 v i ACKNOWLEDGEMENT I am g r a t e f u l to the many people who contributed to the various aspects of t h i s t h e s i s project. P a r t i c u l a r l y , f o r helping me get s t a r t e d , thanks t o — Nancy Waxier, Annette Stark and Bob Modrow; fo r keeping me on track, thanks t o — Cort Mackenzie, Derek Gellman, and Mel Bernstein; f o r s t a t i s t i c a l help, thanks t o — Brenda Morrison; and f o r t h e i r enthusiasm and encouragement, a d d i t i o n a l and s p e c i a l thanks t o — Cort Mackenzie and Nancy Waxier. A s p e c i a l thanks also to the employees and s t a f f at the Acute Care Unit of the Health Sciences Centre at the University of B r i t i s h Columbia, who helped with t h e i r comments, questions and i n t e r e s t during the data c o l l e c t i o n phase. CHAPTER I INTRODUCTION Su b s t i t u t i o n of outpatient care f o r inpatient care i s a popular issue at present. Outpatient t e s t i n g , done f o r diagnostic and screening purposes, has been promoted as one area where s u b s t i t u t i o n i s both appropriate and c o s t - e f f e c t i v e . In the United States, outpatient t e s t i n g has been f a i r l y common f o r at l e a s t two decades. Ambulatory t e s t i n g was offe r e d by some i n s t i t u t i o n s to e i t h e r completely replace an episode of h o s p i t a l i z a t i o n , as i s generally the case of diagnostic evaluation f o r medical patients, or to p a r t i a l l y s u bstitute f o r one, as i s generally the case i n diagnostic work-ups and screening f o r s u r g i c a l patients. The l a t t e r was the more common approach encouraged by government, insurance c a r r i e r s or i n d i v i d u a l i n s t i t u t i o n s . Preadmission t e s t i n g f o r s u r g i c a l patients has so f a r been a r a r i t y i n Canada. Very few programs e x i s t , and those that do e x i s t , are e i t h e r quite new or r e l a t i v e l y informal. The V i c t o r i a General Hospital has, perhaps, the most formalized program. Its objectives are to provide f o r both preadmission t e s t i n g and early i d e n t i f i c a t i o n of p o t e n t i a l discharge problems. Ultimately, the h o s p i t a l hopes to reduce preoperative length of stay. In the lower mainland, some form of preadmission t e s t i n g i s offered by three h o s p i t a l s f o r patients scheduled f o r admission f o r e l e c t i v e surgery: the Vancouver General 2. Hospital, Shaughnessy Hospital and the Acute Care Unit of the University of B r i t i s h Columbia Health Sciences Centre Hospital (ACU-HSCH). The Vancouver General Hospital allows physicians to submit screening and diagnostic t e s t s done by outside l a b o r a t o r i e s while at the Shaughnessy Hospital and the ACU-HSCH patients are asked to come to h o s p i t a l p r i o r to admission i n order to have routine t e s t i n g done. Preadmission t e s t i n g , whenever i t has been found, has generally been used i n connection with e l e c t i v e s u r g i c a l admissions. In these s i t u a t i o n s the function of the t e s t i n g may be e i t h e r a diagnostic or a screening one, or both. Programs may be set up to promote effectiveness or e f f i c i e n c y , or various degrees of the two, depending on who sets up the program and what i n t e r e s t s are considered. Table 1 serves to i l l u s t r a t e some of the p o t e n t i a l goals that may be of i n t e r e s t to the various i n d i v i d u a l s or groups involved. Other goals may e x i s t but these are the most l i k e l y motivators f o r planning and implementing preadmission t e s t i n g programs. 3. TABLE 1: GOALS CONSIDERED BY VARIOUS INDIVIDUALS AND GROUPS WHEN SETTING UP A PREADMISSION TESTING PROGRAM GROUP/INDIVIDUAL EFFECTIVENESS GOALS EFFICIENCY GOALS Insurer (private or government) Community Hospital provide care i n the most appropriate s e t t i n g • reduce cost of care by eliminating unnecessary admissions and shortening length of stay • increase number of a v a i l a b l e beds by reducing inappropriate admissions and shortening length of stay • decrease delays i n operating room work-flow due to unavailable, unexpected or abnormal t e s t s r e s u l t s •reduce costs i n a n c i l l a r y departments by handling more t e s t s during "normal" working hours Surgeon Patient • avoid inappropriate s u r g i c a l admissions, cancelled/postponed s u r g i c a l procedures due to abnormal t e s t r e s u l t s • improve access to h o s p i t a l beds by decreasing length of stay and avoiding inappropriate admissions • have t e s t r e s u l t s a v a i l a b l e e a r l i e r i n h o s p i t a l stay o provide an opportunity to become f a m i l i a r with h o s p i t a l p r i o r to admission »reduce losses i n wages or time by shortening time spent i n h o s p i t a l 4. Much controversy e x i s t s as to the actual success of preadmission t e s t i n g i n reducing length of stay. This i s the e f f i c i e n c y outcome most often studied. The i n t e r e s t of t h i s study, however, was i n the eff e c t i v e n e s s goals from the h o s p i t a l point of view. The questions considered were: ( i ) Does preadmission t e s t i n g (PAT) lead to fewer inappropriate s u r g i c a l admissions since more evaluation and screening i s done p r i o r to h o s p i t a l i z a t i o n ? ( i i ) Are there fewer postponed or cancelled s u r g i c a l procedures a f t e r patients enter the h o s p i t a l i n the preadmission tested group, that are due to unavailable, unexpected or abnormal t e s t r e s u l t s ? ( i i i ) Does preadmission t e s t i n g (PAT) improve the workflow i n the operating room since delays due to unavailable, unexpected or abnormal t e s t r e s u l t s are more l i k e l y to be avoided by early t e s t i n g ? and, (iv) Is there an adverse e f f e c t i n that i t may be more l i k e l y that t e s t s are repeated a f t e r admission? The hypotheses to be tested are: 1. Preadmission t e s t i n g r e s u l t s i n fewer inappropriate s u r g i c a l admissions due to unexpected or abnormal t e s t r e s u l t s compared with the standard method. 2. Preadmission t e s t i n g r e s u l t s i n fewer postponed or cancelled s u r g i c a l procedures due to unavailable, unexpected or abnormal t e s t s r e s u l t s compared with the standard method. 3. Preadmission t e s t i n g r e s u l t s i n fewer delayed s u r g i c a l procedures due to unavailable t e s t r e s u l t s compared with the standard method. 4. Preadmission t e s t i n g does not r e s u l t i n more repeated p r e s u r g i c a l laboratory t e s t s than the standard method. 6. CHAPTER II REVIEW OF THE LITERATURE In the United States the concept of preadmission t e s t i n g goes back to the 1940's"*" but the e a r l i e s t reference found to an actual program, was to a project undertaken through Blue Cross of Maryland i n 1965. A review of the project concluded that shorter length of stay resulted f o r s u r g i c a l patients who had t h e i r t e s t i n g done p r i o r to h o s p i t a l i z a t i o n . In 1967 the Health Planning Council of Central Iowa, i n cooperation with p r o f e s s i o n a l groups and insurance c a r r i e r s , introduced preadmission t e s t i n g i n t o Des Moines' s i x general h o s p i t a l s . PAT was seen as a means "to a l l e v i a t e the current h o s p i t a l bed shortage"." 5 This goal was only minimally achieved due to low use of the program. The low use was at t r i b u t e d to incomplete coverage by the insurance companies and the reluctance of surgeons to use the program. 4 Shorter length of stay was the object of a 1969 study by Fogel where outpatient r a d i o l o g i c a l work-ups were scheduled f o r patients undergoing operations such as hernia re p a i r s , hemorrhoidectomies, cholecystectomies and e x c i s i o n of neoplasms. Routine laboratory t e s t i n g was done a f t e r admission because i t was f e l t that t h i s could e f f e c t i v e l y be done l a t e r . The average length of stay i n the study group was found to be shorter and i n a ddition, when t e s t r e s u l t s indicated c a n c e l l a t i o n of surgery, these c a n c e l l a t i o n s were usually early enough to allow f o r the booking of another 7. patient in the time slot. Automated multiphasic testing began at a Utah hospital in 1968, and when done prior to admission, was found to reduce preoperative length of stay.^ With the introduction of the Professional Standards Review Organization in the United States, the pressure for substituting outpatient for inpatient care increased. Boaz writes: In 1972 Congress legislated the establishment of Professional Standards Review Organizations (PSRO's) to assure that medically necessary services would confirm to recognized professional standards and would be rendered in the most appropriate setting.7 Presurgical testing was one form of medical service which could be provided in an alternative setting. Proceeding on the assumption that PAT would in fact reduce length of stay and allow for smoother workflow in the admitting department, a Detroit hospital began, in 1973, testing for elective medical and surgical admissions. In addition, Feurig writes: Realistically, the hospital also has the objective of preparing itself for any anticipated future requirements and controls that may be applied to its operations.8 He was listing the PSRO legislation and its requirement for preadmission certification as an important reason for implementing preadmission testing at the hospital. However, the program did not succeed in its overall objectives of reducing length of stay and improving organizational efficiency, because of low use of the service by physicians. Other studies report success in reducing length of stay through preadmission testing but, according to a careful review by Dumbaugh and Neuhauser, in terms of reducing length of stay " . . . the evidence of the 9 effectiveness of PAT has not been established definitely." They criticized previous studies for their limited scope, lack of consideration 8 . of i n s t i t u t i o n a l v a r i a b l e s , questionable i n t e r n a l v a l i d i t y and questionable g e n e r a l i z e a b i l i t y . In discussing t h e i r own findings they stated: The data on the 60 Massachusetts h o s p i t a l s confirmed that a preadmission t e s t i n g program has a n e g l i g i b l e e f f e c t both on o v e r a l l length of stay and on standard LOS (Std.LOS) of hospitals.10 Barbaro, Shuman and Swinkola also maintained that "no study to date has demonstrated conclusively that a reduction i n length of stay occurs because of preadmission testing.""'"''' They compared three h o s p i t a l s , two using PAT and one using ambulatory prebed t e s t i n g (patient tested p r i o r to being taken to the nursing unit) and concluded that length of stay i s dependent on h o s p i t a l e f f i c i e n c y rather than the form of p r e s u r g i c a l t e s t i n g used. In a l e t t e r to the New England Journal of Medicine, an administrator who was obviously an opponent to preadmission t e s t i n g (and the f i s c a l outcomes of PSRO), contended that PAT did reduce length of stay at the Medical Centre at Princeton. When used i n 52% of a l l the 1974 e l e c t i v e admissions, there was a 1.5 day reduction i n length of stay. This was not a p o s i t i v e outcome f o r h i s i n s t i t u t i o n however, because shorter length of stay t r a n s l a t e d i n t o l o s t revenue, i . e . , the same i n t e n s i t y of services was required by the patient over a shorter period of time. Recognizing t h i s p o t e n t i a l consequence f o r American h o s p i t a l s , one can see why, even though shorter length of stay might be a goal i n theory, r e a l i t y suggests i t i s u n l i k e l y to be an aggressively pursued option. In addition, an empty bed represents l o s t revenue. The New York Times, i n a 1970 a r t i c l e , quoted a Blue Cross Medical Review physician as saying that even when patients were tested before admission "... some h o s p i t a l s which often have empty beds on weekends, offe r e d p a t i e n t s space on these days or kept them waiting f o r weeks. 9. The issue of what a c t u a l l y determines length of stay i s a complex one. Eastaugh's study reviewed various other studies and l i s t e d numerous conclusions by researchers of what these determinants are f o r s u r g i c a l patients." 1' 4 He himself found f e d e r a l ownership to be a s i g n i f i c a n t f a c t o r i n determining length of stay. The diagram below summarizes several of these determinants (other than PAT) mentioned by Eastaugh as well as Boaz, and Dumbaugh and Neuhauser. "^ It i s easy to see why i t i s d i f f i c u l t to i s o l a t e a cause and e f f e c t r e l a t i o n s h i p between a p a r t i c u l a r program and length of stay. Figure 1: Determinants of Length of Stay Identified in the Literature INSTITUTIONAL CHARACTERISTICS Functioning of Nature of the Departments: Organization: - Admitting - profit/non - OR Scheduling profit - Operating Room - government-- Laboratory & owned Radiology - medical school - Nursing affi l iation Bed Occupancy Staffing Rates DISEASE CHARACTERISTICS - single/multiple diagnosis(es) - severity of symptoms - urgency of situation - perceived health status 7 SOCIO-ECONOMIC CHARACTERISTICS - insurance coverage - marital status - financial status - employment status - living arrangements REGIONAL CHARACTERISTICS - location of hospital PROVIDER CHARACTERISTICS - physician training - physician speciality - number of years since graduation 11. An occasional reference to preadmission testing was found in non American sources. As early as 1968, an Australian a r t i c l e discussed delay in patients' investigations and suggested that preadmission c l i n i c s should 16 be set up for patients scheduled for elective surgery. An English study by several medical staffmembers evaluated the impact on length of stay of a preadmission c l i n i c . They concluded that "a considerable reduction in subsequent bed occupancy was shown" in the group who were evaluated in the c l i n i c . The c l i n i c provided for examination by the resident, consultation with the surgeon and anesthetist and i f needed, referral to the medical social worker. The work-up was comprehensive and included a l l aspects of presurgical diagnostic work-up and screening."1"7 A Canadian survey of 125 orthopedic admissions, concluded that there could be a potential saving in inpatient days i f preadmission investigations were used when appropriate and given that suitable hostel accommodation was 18 available for the out-of-town patient. The literature on preadmission testing can be summarized as follows: there i s l i t t l e of i t , and what there i s , - i s predominantly American, - i s limited in scope, - focuses mainly on preadmission testing for surgical patients, and - i s overwhelmingly concerned with impact on length of stay. 12. When objectives or outcomes other than shorter length of stay are mentioned, they are always considered as secondary objectives or incidental findings. Feurig mentions the following potential benefits of a preadmission testing program: For the patient - shorter waiting on admission day. - avoidance of an unnecessary hospitalization. For the physician - an opportunity to have test results available earlier in the hospital stay. For the hospital - greater f lexibil ity in scheduling patients to coincide with optimal times in the ancillary 19 departments. Barbaro, Shuman and Swinkola indicated that of the various procedures identified in their study "PAT is the only one which can provide test results before admission and thus allow the option to cancel admission." They also state that PAT can have a positive effect on the workload of ancillary departments by giving them more control through scheduling tests 20 at the most convenient time. Dumbaugh and Neuhauser questioned the cost-effectiveness of preadmission testing for presurgical patients but in their summary conceded that: Ideally, a PAT program will not only decrease LOS, but i t will also redistribute workloads in the admitting and diagnostic departments. PAT could result in the elimination of untimely admissions, i.e., admissions that will be postponed after the preadmission tests show a change in the patient's health status, which makes surgery impossible at that time.21 13. Okelberry adds the side benefit of permitting therapy earlier in the hospital stay. Treatment can be started immediately after hospitalization 77 rather than 1-2 days later. Only the study by Feurig attempted to examine the responses of doctors and patients. Physicians and surgeons as a whole lacked commitment to preadmission testing, particularly physicians whose reimbursement in part depended on the patients length of stay. They cited inconvenience to patients (two or more trips to the hospital) and inconvenience to themselves (test results from laboratories outside the hospital were not accepted) as being significant disadvantages. Some patients also indicated that they found the additional trip(s) to be inconvenient. Because of the small numbers of patients actually admitted under this program, Feurig was unable to quantify the data obtained through his questionnaires. Occasionally problems may result i f preadmission testing leads to unnecessary duplication or more intensive testing. A local study done at the Lions Gate Hospital to determine whether there was generally much duplication of diagnostic tests when done both before and after admission concluded that there was no significant duplication. The study by Dumbaugh and Neuhauser, on the other hand, found that PAT patients had more preoperative tests done than patients who were tested after admission. They stated that for some reason (not identified), PAT patients "received a 25 more intensive work-up, regardless of health status." IA. CHAPTER III MAIN METHODOLOGY Objectives of the Study The objectives of t h i s study are: 1. To determine the extent to which preadmission t e s t i n g f o r s u r g i c a l patients r e s u l t s i n fewer inappropriate admissions due to unexpected or abnormal t e s t r e s u l t s compared with the standard method. 2. To determine the extent to which preadmission t e s t i n g f o r s u r g i c a l patients r e s u l t s i n fewer postponed or cancelled s u r g i c a l procedures due to unavailable, unexpected or abnormal t e s t r e s u l t s compared with the standard method. 3. To determine the extent to which preadmission t e s t i n g r e s u l t s i n fewer delayed s u r g i c a l procedures due to unavailable t e s t r e s u l t s compared with the standard method. A. To determine whether or not preadmission tested patients have more repeated p r e s u r g i c a l laboratory t e s t s than patients who have pr e s u r g i c a l t e s t i n g done a f t e r admission to h o s p i t a l . D e f i n i t i o n s 15. The following d e f i n i t i o n s were used and w i l l apply i n t h i s paper: E l e c t i v e s u r g i c a l admission - any patient admitted by a surgeon or any patient admitted by a physician where surgery i s booked p r i o r to admission. Presurgical t e s t i n g - a l l t e s t s required by h o s p i t a l p o l i c y plus the commonly ordered p r e s u r g i c a l t e s t s of e l e c t r o l y t e s , BUN, c r e a t i n i n e , blood sugar, EKG, and chest x-ray, plus screening and typing f o r possible blood transfusion. Inappropriate admission - the patient i s admitted to h o s p i t a l and because of findings on any of the above-mentioned p r e s u r g i c a l t e s t s or f o r some other reason, the.patient i s discharged without having surgery done. Preadmission t e s t i n g (PAT) - p r e s u r g i c a l t e s t i n g done before the patient i s admitted to h o s p i t a l ; ambulatory t e s t i n g ; outpatient t e s t i n g . Standard method (nonPAT) - p r e s u r g i c a l t e s t i n g done a f t e r the patient i s admitted to h o s p i t a l , e i t h e r on a prebed basis or a f t e r he a r r i v e s on the nursing u n i t . Unavailable t e s t r e s u l t - information not i n the patient's chart or already received by the operating room s t a f f , at the point the patient i s checked i n by the operating room nurse. 16. Unexpected t e s t r e s u l t - a t e s t r e s u l t that leads to prolonged or furthe r t e s t i n g , e.g. unusual antibodies found during screening f o r crossmatch purposes. Abnormal t e s t r e s u l t - a t e s t r e s u l t which i s abnormal by the hos p i t a l ' s d e f i n i t i o n and as a consequence, some action i s taken. Postponed s u r g i c a l procedure - surgery not done as scheduled but done l a t e r i n the same admission episode. Cancelled s u r g i c a l procedure - surgery neither done as scheduled nor done i n the same admission episode. Delayed s u r g i c a l procedure - e i t h e r an actual time delay or an inconvenience to the operating room s t a f f a f t e r the patient has ar r i v e d i n the operating room holding area. Actual time delay - based on time recorded by the operating room nurse on the Operating Room Nursing Record. The "Anaesthetic Commenced" time i s compared with the time scheduled on the operating room s l a t e . Inconvenience - a s i t u a t i o n where the surgery s t a r t s at the scheduled time but a missing t e s t r e s u l t leads to some action a f t e r the patient has a r r i v e d i n the operating room holding area. Contributing co-morbidity - any pre-existing condition or c h a r a c t e r i s t i c l i s t e d by the surgeon or the anesthetist which i s l i k e l y to have some bearing on the type and number of t e s t s that are ordered. These include: conditions with systemic consequences, e.g. diabetes; conditions with some bearing on the patient's f i t n e s s f o r anesthesia, e.g. upper respiratory i n f e c t i o n ; previous conditions, e.g. old M.I.; possible conditions, e.g. possible asthma; and l i f e s t y l e r e l a t e d f a c t o r s , e.g. heavy smoker. Study Set t i n g 17. Permission was obtained to undertake a study at the Acute Care Unit of the University of B r i t i s h Columbia Health Sciences Centre Hospital (ACU -HSCH). ACU - HSCH i s a new f a c i l i t y of 300 general medical and s u r g i c a l adult beds. In addition to being a h o s p i t a l f o r the c i t y , i t also functions as a t e r t i a r y h o s p i t a l f o r the province. Because of the l a t t e r function, i t has a higher than average percentage of referred p atients. Most physicians and surgeons on s t a f f have admitting p r i v i l e g e s at other h o s p i t a l s and so can be s e l e c t i v e i n the types of patients they bring to the h o s p i t a l . ACU - HSCH has offered a preadmission t e s t i n g s e rvice f o r e l e c t i v e s u r g i c a l patients since the h o s p i t a l opened i n September 1980. The following i n s t r u c t i o n s are contained i n an information sheet prepared by the h o s p i t a l and given out through the doctors' o f f i c e s : It i s requested that a l l routine analysis, blood work and x-rays be done p r i o r to admission. Patients may come to the Acute Care Unit within the seven day period preceding t h e i r admission, any weekday, Monday to Friday from 8 a.m. to 4 p.m. to have t h i s done. No appointment i s necessary. Should the patient act on t h i s request and come to the h o s p i t a l before admission, the Admitting Department prepares a l l necessary papers and then d i r e c t s him to the appropriate t e s t i n g area. Tests other than blood work and u r i n a l y s i s are r a r e l y done, even though the service covers t e s t i n g done by three areas (laboratory, cardiology, radiology). In the majority of cases, only a complete blood count (CBC) and u r i n a l y s i s (U/A) are done. 18. The admitting and laboratory s t a f f estimate that approximately one t h i r d of e l e c t i v e s u r g i c a l admissions have some laboratory t e s t s done p r i o r to h o s p i t a l i z a t i o n . If the patient does not come i n f o r PAT, t e s t i n g i s c a r r i e d out on the day of admission on a prebed basis, i . e . the patient i s escorted to the laboratory p r i o r to being taken to the nursing u n i t . At t h i s time, unless a d d i t i o n a l t e s t s are ordered, blood i s taken f o r CBC and a urine sample i s obtained f o r routine analysis. A specimen f o r blood type and screening i s taken i f the surgery scheduled f o r the following day i s l i k e l y to require blood. An extra c l o t t e d sample i s also obtained i n case chemistry t e s t s are ordered l a t e r i n the day. Once the patient has been seen by the resident (and occasionally a f t e r the anesthetist has v i s i t e d the p a t i e n t ) , f u r t h e r t e s t s may be ordered on e i t h e r category of patient. I f further specimens are needed, the blood i s c o l l e c t e d l a t e r that day or on the following morning. Reports of laboratory t e s t r e s u l t s are handled i n the following manner. A l l t e s t r e s u l t s are entered i n t o the hospital-wide computer system. Gross abnormalities are i d e n t i f i e d through programmed "panic l i m i t s " and the associate d i r e c t o r of the laboratory personally contacts the doctor involved i n such s i t u a t i o n s . For PAT patients, a coloured laboratory r e s u l t sheet i s sent to the admitting department within 24 hours of t e s t i n g . This sheet i s attached to the patient's admitting forms and goes to the nursing unit with the patient when he i s h o s p i t a l i z e d . A copy i s also mailed to the r e f e r r i n g doctor's o f f i c e . For nonPAT patients, a 19. computer print-out i s sent to the ward l a t e r that day or on the following morning. Should t e s t r e s u l t s be needed e a r l i e r , the information, provided i t has been entered, can be obtained v i a computer print-out. General Methodology A prospective c o n t r o l study was c a r r i e d out over an eight week period. Based on rough estimates of e l e c t i v e s u r g i c a l admissions and the r a t i o of PAT to nonPAT patients, i t was expected at f i r s t , that approximately 150 PAT and 300 nonPAT patients would be followed over a s i x week period. A f t e r c o l l e c t i n g data on a l l the e l e c t i v e s u r g i c a l admissions f o r four weeks, i t was found that 228 of these represented nonPAT patients while only 39 PAT patients (15% of the t o t a l e l e c t i v e s u r g i c a l admissions) were i n the study. At t h i s point i t was decided to extend the study by two weeks beyond the o r i g i n a l s i x weeks ( t o t a l = eight weeks), to continue to follow a l l PAT patients but to follow only one nonPAT patient f o r each PAT patient admitted. Each day that one or more PAT patients were admitted, an equivalent number of nonPAT patients were randomly picked from the appropriate admissions f o r that day. By the end of the second four week period, an a d d i t i o n a l 51 PAT patients were admitted f o r e l e c t i v e surgery and one PAT patient was cancelled f o r other than t e s t - r e l a t e d reasons. (Data on t h i s patient i s not included i n the study but the s i t u a t i o n w i l l be discussed i n the f i n a l chapter of the t h e s i s . ) During the second four week period, a t o t a l p o t e n t i a l sample of 230 nonPAT patients was a v a i l a b l e . The nonPAT sample resulted i n only 49 patients, however, 20. because one patient i n c o r r e c t l y l i s t e d as nonPAT i n the computer information, was moved to the PAT group when the e r r o r was discovered. During the eight weeks therefore, a t o t a l of 548 patients were admitted f o r e l e c t i v e surgery. Of these, 90 patients had some or a l l of t h e i r t e s t s done p r i o r to admission while 458 had a l l t h e i r t e s t s done a f t e r admission. Data was c o l l e c t e d on a l l 90 PAT patients admitted but on only 277 of the nonPAT patients admitted. (Figure 2 summarizes the i n i t i a l sampling method described above.) Throughout the study period, a diary was kept of pertinent observations and comments. In addition, a number of employees and s t a f f were interviewed-at the end of the study. Eight surgeons were asked why they did or did not use PAT; f i v e anesthetists and the head nurse of the operating room were asked about t h e i r experiences with delays or ca n c e l l a t i o n s of surgery; and the four s u r g i c a l head nurses and the s u r g i c a l nursing coordinator were asked about p r e s u r g i c a l t e s t i n g i n general. Patients were not interviewed but some information about t h e i r reactions to various aspects of p r e s u r g i c a l t e s t i n g was obtained from the nursing, admitting and laboratory s t a f f . 21. Figure 2: I l l u s t r a t i o n of How I n i t i a l Sampling Was Carried Out T 2nd 4 weeks of study 1st 4 weeks of study 1 PAT patients not admitted n=l a l l PAT admitted* n=51 a l l PAT patients n= 39 PAT p o t e n t i a l sample PAT sample n=90 | 1 • remaining nonPAT i patients admitted r n=181 one nonPAT patient f o r each PAT patient admitted* n=49 a l l nonPAT patients admitted n=228 nonPAT p o t e n t i a l sample nonPAT sample n=277 * These groups are uneven despite the 1-1 s e l e c t i o n because one patient o r i g i n a l l y l i s t e d as nonPAT, was found to have been preadmission tested. S p e c i f i c Methodology 22. Objective l ; To determine the extent to which preadmission t e s t i n g f o r s u r g i c a l patients r e s u l t s i n fewer inappropriate admissions due to unexpected or abnormal t e s t r e s u l t s compared with the standard method. Hypothesis 1; PAT r e s u l t s i n fewer inappropriate s u r g i c a l admissions due t o unexpected or abnormal t e s t r e s u l t s . Method: Each weekday morning f o r eight weeks, the names of a l l e l e c t i v e s u r g i c a l admissions were obtained from the d a i l y l i s t compiled by the admitting department s t a f f . Patients eliminated from the sample included the previously described patients entering p r i m a r i l y f o r diagnostic work-up and also, patients whose admission diagnosis implied a procedure which would be done i n a l o c a t i o n other than the operating room, e.g. d i u r n a l tension curve. Patients entering h o s p i t a l over the weekend were reviewed on Monday morning. The study status of the patient was determined by looking f o r laboratory t e s t r e s u l t s appended to the admitting s l i p s or documents and by checking f o r any record of preadmission t e s t i n g v i a the laboratory information a v a i l a b l e through the computer system. In the evening or on the following morning, each patient's chart was reviewed f o r the following information. (See Appendix I f o r a copy of the form used): 23. P a t i e n t - r e l a t e d : age, sex, marital status, occupation, address. Diagnosis-related: primary diagnosis and c o n t r i b u t i n g co-morbidity, doctor, consultations, s u r g i c a l procedure. Te s t - r e l a t e d : t e s t s ordered and date ordered; t e s t s done and date done. Each patient was followed through to surgery or c a n c e l l a t i o n of surgery to determine the impact of t e s t i n g . A l l charts of patients discharged without having surgery done were c l o s e l y examined to discover the reasons f o r c a n c e l l a t i o n and the subsequent actions taken. Objective 2: To determine the extent to which preadmission t e s t i n g f o r s u r g i c a l patients r e s u l t s i n fewer postponed or cancelled s u r g i c a l procedures due to unavailable, unexpected or abnormal t e s t r e s u l t s compared with the standard method. Hypothesis 2: PAT r e s u l t s i n fewer postponed or cancelled procedures due to unavailable, unexpected or abnormal t e s t r e s u l t s . Method: In addition to patients who might have surgery cancelled outright, i t was necessary to assess those s i t u a t i o n s where the s u r g i c a l procedure was postponed during the p a r t i c u l a r episode of h o s p i t a l i z a t i o n under study. During the afternoon, the operating room s l a t e was checked f o r the s u r g i c a l procedure and booked surgery time. A l i s t of the patients booked f o r the 24. following day was compiled. Information was c o l l e c t e d as previously described. A l l charts of patients whose surgery plans were changed i n any way, were c l o s e l y examined to discover the reasons f o r the change. Objective 3; To determine the extent to which preadmission t e s t i n g r e s u l t s i n fewer delayed s u r g i c a l procedures due to unavailable t e s t r e s u l t s compared with the standard method. Hypothesis 3: PAT r e s u l t s i n fewer delayed s u r g i c a l procedures due to unavailable t e s t r e s u l t s . Method: Each patient's chart was followed u n t i l the i d e n t i f i e d laboratory r e s u l t s , EKG t r a c i n g , and any t e s t s p e c i f i c a l l y designated "to OR" or "pre-op" was a c t u a l l y i n the chart. If any of these were missing, a v i s i t was made to the operating room to coincide with the patient's a r r i v a l and the subsequent action of the operating room s t a f f was observed. This was done i n a l l cases subsequently included i n the subsample described i n Chapter V and was done personally by the researcher i n a l l cases but one. (In t h i s case the information was obtained from the c l e r k . ) The a v a i l a b i l i t y of chest x-rays was not determined on an i n d i v i d u a l basis f o r two reasons — t h i s information was not accessible as laboratory r e s u l t s and EKG's (x-rays were usually sent d i r e c t l y to a s p e c i f i c operating theatre) and, more importantly, chest x-rays were r a r e l y consulted by the anesthetist. I f , however, a chest x-ray was s p e c i f i c a l l y ordered by the anesthetist, the same procedure was followed. A l l actual time delays and 2 5 . inconveniences were documented by the researcher. The time recorded on the Operating Room Nursing Record as "Anesthetic Commenced" time was used as the time surgery began. Objective ,4: To determine whether or not preadmission tested patients have more repeated p r e s u r g i c a l laboratory t e s t s than patients who have p r e s u r g i c a l t e s t i n g done a f t e r admission to h o s p i t a l . Hypothesis 4: PAT does not r e s u l t i n more repeated p r e s u r g i c a l laboratory t e s t s . Method: The laboratory information entered i n t o the computer was reviewed f o r the subsample of matched p a i r s described i n Chapter V. The date and time of specimen c o l l e c t i o n was r e a d i l y a v a i l a b l e e i t h e r v i a computer print-out or video d i s p l a y . Charts were also reviewed to see i f repeat blood work was s p e c i f i c a l l y ordered. Because orders are written a f t e r the patient a r r i v e s on the nursing unit and routine samples are c o l l e c t e d before t h i s time, the number of venipunctures per patient was also counted. 26. CHAPTER IV FINDINGS FROM MAIN METHODOLOGY Findings Related to Age, Scheduled Surgery, Contributing Co-morbidity and  Preoperative Length of Stay As mentioned i n the previous chapter, data was c o l l e c t e d on 90 PAT patients and 277 nonPAT patients. PAT patients represented only 16% of the t o t a l e l e c t i v e s u r g i c a l admissions during the eight week study period. Data on the two groups was more c l o s e l y examined to see how the PAT group d i f f e r e d from the nonPAT group. The variables of i n t e r e s t chosen f o r comparison were: age, scheduled surgery, cont r i b u t i n g co-morbidity, and preoperative length of stay. Each of these v a r i a b l e s i s discussed b r i e f l y . 27. Age: Patients i n c e r t a i n age c l u s t e r s were found to have p a r t i c u l a r t e s t s ordered f a i r l y r o u t i n e l y , i r r e s p e c t i v e of diagnosis, co-morbidity or preoperative length of stay. The patterns observed were: Under 40: 'CBC and U/A only. 40 - 49: CBC and U/A. Occasionally e l e c t r o l y t e s , EKG's and chest x-rays. 50 - 64: CBC and U/A. Increased frequency of e l e c t r o l y t e s and other chemistry t e s t s , and chest x-rays. EKG's in v a r i a b l y ordered. 65 and over: CBC, U/A, and EKG's. Chest x-rays, e l e c t r o l y t e s , blood sugar, BUN, cr e a t i n i n e almost always ordered. It was found also that patients i n the PAT group were younger than those i n the nonPAT group. The mean age of patients i n the PAT group was 47.1 years while the mean age of those i n the nonPAT group was 51.7. In both groups patients, whose preoperative length of stay was one day and who had no contr i b u t i n g co-morbidity, were the youngest subgroup while those whose preoperative length of stay was greater than one day and who had some contributing co-morbidity, were the oldest subgroup. On the whole, patients admitted f o r orthopedic surgery were younger; patients admitted f o r eye surgery, older. Scheduled Surgery: The s u r g i c a l procedures scheduled f o r each patient i n the sample were examined. The sample information was then c l a s s i f i e d under nine s u r g i c a l s p e c i a l t y groups. These groups were: orthopedics, dental 28. surgery, ophthalmology, general surgery, urology, gynaecology, vascular surgery, p l a s t i c surgery and chest surgery. The s i n g l e l a r g e s t group found under one s p e c i a l i t y were patients admitted f o r orthopedic surgery. Thirty-nine percent (39%) of these patients had some or a l l of t h e i r t e s t s done p r i o r to admission. Patients i n the ophthalmology, general surgery and urology groups also represented large numbers of e l e c t i v e s u r g i c a l admissions but fewer of these patients were preadmission tested - 22%, 24%, 9% r e s p e c t i v e l y . (See Table 2.) Contributing Co-morbidity; Among the PAT group, 29% of the patients had a condition which could influence the numbers and types of t e s t s ordered. Among the nonPAT group, the percentage was the same. There was a dif f e r e n c e , however, when preoperative length of stay was examined at the same time. Patients from t h i s group with a preoperative stay of one day represented 26% of the t o t a l PAT group and 20% of the t o t a l nonPAT group; while those with longer preoperative stays represented 3% and 9% res p e c t i v e l y . 29. TABLE 2: CLASSIFICATION OF PATIENTS RECEIVING AND NOT RECEIVING PREADMISSION TESTING BY SURGICAL SPECIALITY SPECIALITY GROUP PAT nonPAT TOTAL Orthopedics 37 (41%) 58 (21%) 95 (26%) Dental Surgery 11 (12%) 13 (5%) 24 (7%) Ophthalmology 15 (17%) 52 (19%) 67 (18%) General Surgery 15 (17%) 47 (17%) 62 (17%) Urology 5 (6%) 50 (18%) 55 (15%) Gynaecology 3 (3%) 18 (6%) 21 (6%) Vascular Surgery 4 (4%) 30 (11%) 34 (9%) P l a s t i c Surgery 0 5 (2%) 5 (1%) Chest Surgery 0 4 (1%) 4 (1%) Total 90 (100%) 277 (100%) 367 (100%) Preoperative Length of Stay: In the PAT group, 94% of the patients had a preoperative length of stay of one day while i n the nonPAT, 85% of the patients had a preoperative length of stay of one day. The f i v e PAT patients with prolonged preoperative stays were older patients (aged 55 -71 years) and included two patients i n the vascular surgery group, two patients i n the dental surgery group and one patient i n the ophthalmology group. Three of the patients had contributing co-morbidity and two did not. Of the 42 nonPAT patients who had a prolonged preoperative length of 30. stay, 17 patients (40%) were admitted f o r vascular surgery and 12 patients (29%) were admitted f o r general surgery, most of which was major abdominal surgery. The mean age of those patients with contributing co-morbidity (n=25) was 68.1 years and of those without secondary conditions (n=17), was 60.3 years. Use of the PAT Program by Physicians and Surgeons On examining the data c o l l e c t e d during the f i r s t four weeks of the study, i t was noted that 21 of the 41 physicians and surgeons who admitted patients f o r surgery during the period, made use of the PAT program. No doctor used the service f o r the majority of his patients. Only a small number of doctors used the service r e l a t i v e l y frequently. Observations and Findings from Interviews E l e c t i v e s u r g i c a l patients admitted to the ACU - HSCH can conceivably have laboratory or other t e s t s done on four or more separate occasions — before admission, on admission, i n the afternoon or evening of admission, and on succeeding preoperative days. Tests other than the CBC and U/A are rar e l y done before the patient a r r i v e s on the u n i t . Orders f o r t e s t s are written a f t e r the patient i s on the unit and has been examined by the surgeon, resident or medical student i n t e r n . Orders f o r the CBC and U/A are frequently not written. Additional laboratory t e s t s are often requested. 31. The s u r g i c a l head nurses and the s u r g i c a l nursing d i r e c t o r describe t h i s p r e s u r g i c a l t e s t i n g system as "fragmented". Two head nurses stated that the system often resulted i n t e s t d u p l i c a t i o n and repeated venipunctures f o r the patients. One head nurse said that the nursing s t a f f i s not always c e r t a i n i f an order f o r blood work represents a new order or i f i t r e f e r s to the specimen already taken before the patient's a r r i v a l on the u n i t . One head nurse stated that her unit had considerable d i f f i c u l t y getting chemistry and cross-match t e s t s completed i n time f o r surgery, p a r t i c u l a r l y f o r the early cases. When asked why they did or did not use PAT, surgeons generally said that they used the program i f convenient f o r themselves and the pati e n t s . Two surgeons s a i d they also used the service i f a patient's diagnosis was unclear or i f f i t n e s s f o r surgery was i n doubt. One surgeon stated he was not aware of the PAT program but said he would use i t f o r "patients over 40 with f a i r l y complex diseases i n addition to t h e i r s u r g i c a l problems". The f i v e anesthetists who were interviewed were asked about t h e i r experiences with unavailable or abnormal t e s t r e s u l t s and about delays i n the operating room. They generally stated that few problems occur with unavailable or abnormal laboratory r e s u l t s . EKG's were i n v a r i a b l y done as required. Problems with unavailable chest x-rays were rarer than problems with laboratory t e s t s , p a r t i c u l a r l y since chest f i l m s were seldom consulted. When asked to rank delays due to unavailable t e s t r e s u l t s with a l l other reasons f o r delays i n the operating room, a l l the anesthetists indicated that t e s t - r e l a t e d delays were a minor problem. 32. The head nurse of the operating room said that unavailable or abnormal t e s t r e s u l t s l e d to inconveniences or actual delays i n about 10% of t h e i r scheduled s u r g i c a l cases. Actual time delays were l e s s frequent than inconveniences to the nurse admitting the patient to the operating room. These inconveniences related mainly to unavailable t e s t r e s u l t s . In such s i t u a t i o n s , the nurse i s required to get the missing information or, f a i l i n g that, consult with the anesthetist about what he wants done about the missing information. Patients were not interviewed. Head nurses, admitting s t a f f and laboratory s t a f f were asked about comments made by patients about any aspect of p r e s u r g i c a l t e s t i n g . It appeared that patients coming i n f o r PAT did not seem to mind doing so. For patients of doctors with o f f i c e s i n the ho s p i t a l or on the campus grounds, there was l i t t l e or no inconvenience. The head nurses stated however, that patients occasionally complained about "being poked twice". They also indicated that repeat venipunctures were done on patients i n both groups. Objectives of the PAT Program at ACU - HSCH Written objectives of the PAT program at the ACU - HSCH were not av a i l a b l e but on interviewing key s t a f f members who had worked at the ho s p i t a l since i t opened, the following objectives emerged: 33. - to avoid delays i n operating room workflow due to unavailable t e s t r e s u l t s , - to allow f o r more e f f i c i e n t organization and s t a f f i n g i n the c l i n i c a l laboratory, and - to give patients an opportunity to become f a m i l i a r with the h o s p i t a l p r i o r to admission. The f i r s t objective coincides with one of the objectives of t h i s study and w i l l be discussed i n the next chapter. The second objective has been met s u c c e s s f u l l y according to the Associate Director of the C l i n i c a l Laboratory, i n that PAT allows more t e s t s to be handled on a routine basis during normal working hours rather than on an urgent basis. Whether or not the t h i r d o bjective was met was not investigated i n t h i s study. Decision to Develop a Subsample of Matched Patients As shown' i n t h i s chapter, patients who are sent to the h o s p i t a l f o r preadmission t e s t i n g , represent a s e l e c t group. On the whole PAT patients were found to be younger. This was l a r g e l y due to the f a c t that a s i g n i f i c a n t number of them (41.1%) were admitted f o r orthopedic surgery. Much of the orthopedic surgery at the h o s p i t a l i s done f o r s p o r t s - r e l a t e d i n j u r i e s and these patients are generally young and healthy. Of three other s p e c i a l i t y groups that represented s i g n i f i c a n t numbers of e l e c t i v e s u r g i c a l admissions — ophthalmology, urology and general surgery — fewer than 25% of the patients were preadmission tested. Patients admitted for vascular or gynaecological surgery were under-represented. No patients 34. admitted f o r p l a s t i c surgery or chest surgery had t e s t s done p r i o r to h o s p i t a l i z a t i o n . Patients with a preoperative length of stay of greater than one day were three times more prevalent i n the nonPAT group. Patterns of p r a c t i c e of physicians and surgeons showed that about h a l f of them used the PAT program and only a few of them used the program to any s i g n i f i c a n t extent. Patients were sent i n f o r preadmission t e s t i n g mainly i f i t was convenient f o r them or the doctors. Because of these preliminary findings, i t was decided to develop a subsample of appropriately matched PAT and nonPAT patients. The hypotheses would thus be tested using t h i s subsample. The matching process and a d e s c r i p t i o n of the subsample obtained i s found i n the next chapter. 35. CHAPTER V SECONDARY METHODOLOGY AND FINDINGS Methods Used to Obtain a Matched Subsample Data on the patients i n the PAT group was arranged according to the s u r g i c a l s p e c i a l t i e s previously described. Further subgrouping according to scheduled s u r g i c a l procedure was done i n some of these s p e c i a l t y groups. (Table 3 shows the groups, subgroups and numbers of PAT patients i n each.) Because preoperative length of stay and contributing co-morbidity can influence numbers and types of t e s t s ordered, patients with these c h a r a c t e r i s t i c s were eliminated. This process l e f t 62 PAT patients a v a i l a b l e f o r matching with s i m i l a r nonPAT pat i e n t s . As described i n the previous chapter, a patient's age was found to influence, i n a r e l a t i v e l y p redictable manner, the number and type of t e s t s that are ordered. Age c l u s t e r s were therefore selected on the basis of the patterns observed. These age c l u s t e r s were: 14-39 years; 40-49 years; 50-64 years; and, 65 + years. The p r o f i l e sheets (see Appendix I) of the nonPAT patients were placed i n order of admission. A match was f i r s t attempted i n the same s p e c i a l t y subgroup and age c l u s t e r . I f no match was found i n the same week of admission, a match was sought i n the previous week, then the following week, 36. TABLE 3: SURGICAL SPECIALITY CHARACTERISTICS OF PAT PATIENTS AND NUMBERS OF PATIENTS IN THE GROUPS AND SUBGROUPS SUBGROUP GROUP % NUMBER (n=90) SUBGROUPS: Trauma-related knee surgery 25 Foot procedures 8 Other lower limb 2 Arm and shoulder _2 ORTHOPEDICS GROUP TOTAL 37 41.1 DENTAL GROUP TOTAL 11 12.2 SUBGROUPS: Intraoccular 13 Extrsocculsr 2 OPHTHALMOLOGY GROUP TOTAL 15 16.7 SUBGROUPS: Cholecystectomy (no CBE) 5 Inguinal hernia 5 Umbilical/Ventral hernia 1 P e r i a n a l / P i l o n i d a l 4 GENERAL SURGERY GROUP TOTAL 15 16.7 SUBGROUPS: TUR 1 Hydrocelectomy 1 Minor bladder procedures 2 UROLOGY GROUP TOTAL 5 5.6 SUBGROUPS: Breast lump (malignant or non malignant) 2 D & C 1 GYNAECOLOGY GROUP TOTAL 3 3.3 SUBGROUPS: Varicose veins 1 Vein g r a f t 2 VASCULAR GROUP TOTAL 4 4.4 TOTAL PAT PATIENTS 90 100.0% 37. continuing backward and forward i n t h i s manner u n t i l a l l the nonPAT p o t e n t i a l samples were exhausted. Forty-eight (48) matched p a i r s were achieved at t h i s point leaving 14 unmatched PAT p a t i e n t s . A second matching was then done i n the following manner. F i r s t , i f no corresponding age group match f o r a PAT patient could be found i n a p a r t i c u l a r subgroup, the nonPAT patient c l o s e s t i n age with the same surgery was sought i n the next lower age c l u s t e r . This process resulted i n an a d d i t i o n a l f i v e matched p a i r s . In the remaining nine cases, patients were matched i n the same age group but across the e n t i r e s u r g i c a l s p e c i a l t y group. Five orthopedic lower limb surgery matches, one ophthalmology match and three general surgery matches were achieved i n t h i s manner. Patients were not matched according to sex but representativeness f o r sex was looked f o r i n the matched samples. At the end of the matching process, the subsample was examined i n terms of age and sex c h a r a c t e r i s t i c s . The mean age i n each of the two groups was 41 years (compared with the mean age of 47.1 years f o r the e n t i r e PAT sample and 51.7 years f o r the e n t i r e nonPAT sample). The PAT subsample consisted of 35 male patients and 27 female p a t i e n t s ; the nonPAT subsample, 38 and 24 r e s p e c t i v e l y . This male/female r a t i o coincided with the sex d i s t r i b u t i o n i n the e n t i r e sample. (Table 4 shows the age and sex d i s t r i b u t i o n within the subsample.) 38. TABLE 4: AGE AND SEX DISTRIBUTION WITHIN THE MATCHED SAMPLES Age and Sex Age (yrs) 14 -- 39 40 - 49 50 -• 64 65 + Tot a l T o t a l Sex M F M F M F M F M F Both Sexes PAT 15 17 5 4 8 2 7 4 35 27 62 nonPAT 21 15 5 1 7 3 5 5 38 24 62 124 Findings Hypothesis 1: PAT r e s u l t s i n fewer inappropriate s u r g i c a l admissions due to unexpected or abnormal t e s t r e s u l t s . Only one patient i n the matched sample was found to be inappropriately admitted due to a pr e s u r g i c a l t e s t - r e l a t e d cause. Intere s t i n g l y enough, t h i s was a PAT patient whose potassium l e v e l was found to be low when she came i n f o r her preadmission t e s t i n g . Rather than postpone the admission and surgery, the surgeon attempted to t r e a t the hypokalemia and bring the patient i n t o h o s p i t a l as scheduled. On admission the patient was found to be s t i l l hypokalemic and was discharged subsequent to the preoperative v i s i t by the anesth e t i s t . (See Table 5.) 39. TABLE 5: INAPPROPRIATE SURGICAL ADMISSIONS DUE TO ALL REASONS n Patients discharged due to pre s u r g i c a l t e s t - r e l a t e d causes Patients discharged due to other reasons PAT 62 1 0 nonPAT 62 0 1 Total 124 1 1 Hypothesis 2: PAT r e s u l t s i n fewer postponed or cancelled s u r g i c a l procedures due to unavailable, unexpected or abnormal t e s t r e s u l t s . No s u r g i c a l procedures were postponed due to pr e s u r g i c a l t e s t - r e l a t e d causes. The previously discussed inappropriate admission was the only cancelled surgery due to t e s t r e s u l t s . Hypothesis 3: PAT r e s u l t s i n fewer delayed s u r g i c a l procedures due to unavailable t e s t r e s u l t s . Only one recorded time delay was found and t h i s was i n the nonPAT group. An unusually long delay (37 minutes) occurred because the e l e c t r o l y t e r e s u l t s , requested by the anesthetist, were not i n the patient's chart when he arri v e d i n the operating room holding area. Inconveniences that did not r e s u l t i n an actual time delay occurred on two occasions i n each group. In the PAT group, one inconvenience involved a patient whose surgery had been moved ahead and the other involved a patient already i n the operating theatre who had blood taken during surgery f o r crossmatch a f t e r i t was discovered that none had been taken previously. In the nonPAT group, one inconvenience re l a t e d to an absent EKG while the other involved CBC and U/A r e s u l t s missing from the chart 40. but a v a i l a b l e through the operating room's computer. In the former s i t u a t i o n , the anesthetist accepted an EKG s t r i p done by an outside laboratory which was i n the patient's chart. (See Table 6.) TABLE 6: DELAYS AND INCONVENIENCES DUE TO UNAVAILABLE PRESURGICAL LABORATORY TESTS  n Recorded Delays Inconveniences Total PAT nonPAT Tot a l 62 0 2 2 62 1 2 3 124 1 4 5 Delays f o r other reasons were also noted. These reasons included: s u r g i c a l procedures that took longer than anticipated to complete, l a t e s t a r t i n g time f o r the f i r s t case, s t a f f i n g shortages, turnaround time and surgeons who were l a t e . It was found that delays due to t e s t - r e l a t e d reasons were i n s i g n i f i c a n t compared with delays due to other reasons. (See Table 7.) TABLE 7: REASONS FOR AND NUMBERS OF ALL DELAYS IN STARTING SURGERY Delays due to unavailable Delays due to a l l n p r e s u r g i c a l t e s t r e s u l t s other reasons PAT nonPAT Total 62 62 124 0 1 1 23 25 48 41. Hypothesis 4: PAT r e s u l t s i n more repeated p r e s u r g i c a l laboratory t e s t s . The a n a l y s i s indicated that there were more repeated t e s t s i n the preadmission tested group than the non preadmission tested group. The most commonly repeated screening t e s t was the CBC. Eighteen patients had a CBC done twice and one patient had a t h i r d repeat (Hemoglobin only), compared with seven patients i n the nonPAT group who had CBC done twice. Table 8 shows the numbers of patients who had some of t h e i r p r e s u r g i c a l t e s t s repeated. TABLE 8: TOTAL NUMBERS OF PATIENTS WHO HAD REPEATED TESTS BY CATEGORY OF PATIENT Numbers of patients who Numbers of patients who Total n had t e s t s repeated had no t e s t s repeated PAT 27 35 62 nonPAT 9 53 62 Total 36 88 124 P(x 2 = 27.84) < .001 PAT patients were three times as l i k e l y to have some t e s t repeated a f t e r admission. This outcome was found to be s t a t i s t i c a l l y s i g n i f i c a n t (p < .001) and i s l i k e l y to be s i g n i f i c a n t from a p r a c t i c a l point of view as w e l l . 42. An an a l y s i s was also done to determine how many venipunctures were repeated. As shown i n Table 9, a s i g n i f i c a n t l y greater number of venipunctures were repeated i n the PAT group compared with the nonPAT group (p < .001). TABLE 9: REPEATED VENIPUNCTURES BY CATEGORY OF PATIENT One venipuncture More than one Total only venipuncture venipunctures PAT 26 36* 62 nonPAT 51 11 62 Tot a l 77 47 124 * Represents 34 patients who had 2 venipunctures done and 2 patients who had 3 venipunctures done. P(x 2 = 27.92) < .001 A3. Discussion Inappropriate S u r g i c a l Admissions: Surgery Cancellations, Postponements  and Delays At the ACU - HSCH, the form of p r e s u r g i c a l t e s t i n g does not appear to have a s i g n i f i c a n t e f f e c t on appropriateness of admission. Even when a l l the study patients were considered (N=367), only one a d d i t i o n a l inappropriate admission related to p r e s u r g i c a l t e s t i n g was found among the 26 nonPAT group. Again, there was no s i g n i f i c a n t d i f f e r e n c e i n the two groups when i t came to e f f e c t on postponement or c a n c e l l a t i o n of surgery. In questioning f i v e a n esthetists on t h i s subject, generally i t emerged that, based on t h e i r perception, surgery was r a r e l y cancelled or postponed because of unavailable or abnormal t e s t r e s u l t s . In the t o t a l sample (N=367) only one a d d i t i o n a l case was found where surgery was cancelled due to t e s t s and i n t h i s case, the i n t e n t of the p a r t i c u l a r t e s t was diagnostic rather than screening. No s i g n i f i c a n t d i f f e r e n c e was found i n terms of e i t h e r a c t u a l time delays or inconveniences due to t e s t s being unavailable on the patient's a r r i v a l i n the operating room. A f t e r interviewing the anesthetists, i t became apparent that they considered delays or inconviences due to unavailable t e s t r e s u l t s to be a r e l a t i v e l y small problem. It should be 44. recognized, however, that from an anesthetist's point of view, a delay due to unavailable t e s t r e s u l t s r a r e l y poses a d d i t i o n a l workload while from the nursing s t a f f point of view, i t generally does. The nursing s t a f f i n the operating room are charged with r e c t i f y i n g the omission or seeking out the anesthetists to make a dec i s i o n on missing t e s t r e s u l t s . In r e l a t i o n to the issue of delays i n general, i t should be stressed that what was being examined was time delays and inconveniences at the operating room l e v e l . Problems p r i o r to t h i s point have not been examined, though one head nurse had mentioned that her unit experienced considerable d i f f i c u l t i e s g e t t i n g some t e s t r e s u l t s before surgery. Repeated Laboratory Tests PAT patients had s i g n i f i c a n t l y more t e s t s repeated than nonPAT patient s ; i n f a c t two and one h a l f times as many patients had t h e i r CBC t e s t s repeated. In reviewing the charts, repeated t e s t s could r a r e l y be interpreted as i n t e n t i o n a l . Almost i n v a r i a b l y , t e s t s were found to have been repeated because routine t e s t s could be done on e i t h e r a PAT or prebed basis without a s p e c i f i c order and other t e s t s were generally not ordered u n t i l a f t e r the patient had been examined by the resident. The nursing s t a f f consequently e i t h e r were not sure i f the order meant a t e s t was to be repeated and chose to 'commit rather than omit', or d i d not check to see what had been done and ordered a l l the t e s t s l i s t e d . The nonPAT group was l e s s l i k e l y to have repeat orders c a r r i e d out because the data supervisor i n the laboratory checked f o r possible duplicate orders before repeating a 45. t e s t . Since a c l o t t e d specimen was taken f o r these patients i n a n t i c i p a t i o n of further t e s t s , fewer venipunctures were needed provided enough blood was a v a i l a b l e f o r the requested t e s t s and the q u a l i t y of the specimen was acceptable. In general, one would expect more repeated t e s t s i n a teaching h o s p i t a l as compared with a non teaching h o s p i t a l p a r t i c u l a r l y when some t e s t s are ordered by the admitting doctor and others are ordered by residents and medical students. Findings Related to the Objectives of the PAT Program at ACU - HSCH The data suggests that preadmission t e s t i n g f o r p r e s u r g i c a l patients i n i t s e l f , has l i t t l e e f f e c t on one of the h o s p i t a l ' s objectives — avoiding t e s t - r e l a t e d delays i n the operating room. In addition, the p o s i t i v e impact on laboratory workflow may not be as great as perceived since venipunctures and t e s t s are more often repeated f o r PAT p a t i e n t s . Since patients are sent f o r preadmission t e s t i n g mainly i f convenient, i t i s understandable that they are generally accepting of t h i s form of p r e s u r g i c a l t e s t i n g . However, they might consider PAT l e s s 'convenient' i f they r e a l i z e d that repeat venipunctures are often required. The f l e x i b i l i t y i n p r e s u r g i c a l t e s t i n g methods i s desirable from a doctor's point of view but i t causes d i f f i c u l t i e s f o r the nursing s t a f f . There i s some 'confusion of systems' with regard to laboratory t e s t i n g and 27 t h i s often leads d i r e c t l y to some r e p e t i t i o n of t e s t s . 46. Answering the Questions Considered at the Outset At the beginning of the project, four questions were considered. The findings of t h i s study suggest the following answers to these questions: ( i ) Does preadmission t e s t i n g (PAT) lead to fewer inappropriate s u r g i c a l admissions since more evaluation and screening i s done p r i o r to h o s p i t a l i z a t i o n ? No ( i i ) Are there fewer postponed or cancelled s u r g i c a l procedures a f t e r p a tients enter the h o s p i t a l i n the preadmission tested group, that are due to unavailable, unexpected or abnormal t e s t r e s u l t s ? No ( i i i ) Does preadmission t e s t i n g (PAT) improve the workflow i n the operating room since delays due to unavailable, unexpected or abnormal t e s t r e s u l t s are more l i k e l y to be avoided by early t e s t i n g ? No (iv) Is there an adverse e f f e c t i n that i t may be more l i k e l y that t e s t s are repeated a f t e r admission? Yes 47. CHAPTER VI POLICY CONSIDERATIONS In providing a service to a patient within the health care system, a l t e r n a t i v e means are often a v a i l a b l e f o r the d e l i v e r y of that s e r v i c e . For the service of p r e s u r g i c a l t e s t i n g , three such a l t e r n a t i v e approaches have been mentioned — before the patient i s admitted (PAT), at the time the patient i s admitted (PBT), or l a t e r i n the preoperative period. It has also been i d e n t i f i e d that several i n t e r e s t s could be considered when determining the objectives of a program f o r carrying out p r e s u r g i c a l t e s t i n g . Each i n d i v i d u a l or group involved may have a d i f f e r e n t idea of what the goal of that program should be. The insurance c a r r i e r (private or government), the h o s p i t a l and the provider a l l may have d i f f e r e n t targets i n mind. The patient, as the r e c i p i e n t of the ser v i c e , may have d i f f e r e n t goals as well. Goals may e i t h e r s t r e s s e f f i c i e n c y or e f f e c t i v e n e s s . Ideally they should do both. According to the l i t e r a t u r e , the primary goal f o r PAT programs i n the past has been to decrease the length of h o s p i t a l stay. Considerable controversy e x i s t s as to whether or not t h i s goal has been s u c c e s s f u l l y achieved to any s i g n i f i c a n t extent. Hospitals that are reimbursed on an occupancy basis have no incentive to reduce length of stay. Leaving a bed empty and providing the same amount of care over a shorter period of time 48. represents l o s t revenue to them. Doctors who are l i k e l y to receive lower fees i f t h e i r patients stay i n h o s p i t a l shorter periods of time or are l i k e l y to have t h e i r patients or themselves inconvenienced, are u n l i k e l y to cooperate f u l l y with a preadmission t e s t i n g program. Patients who are f u l l y insured and whose h o s p i t a l stay does not represent l o s t wages are also u n l i k e l y to be tempted with repeat v i s i t s to a h o s p i t a l p r i o r to h o s p i t a l i z a t i o n i n order to save inpatient time. It i s not s u r p r i s i n g therefore, that past PAT programs which were aimed at reducing length of stay have met with questionable success. U n t i l some incentives are b u i l t i n , or at l e a s t u n t i l some of these d i s i n c e n t i v e s are removed, i t i s improbable that future PAT programs w i l l be successful on a voluntary basis. In a d d i t i o n to a questionable commitment to the goal of reducing length of stay, previous programs can be c r i t i c i z e d f o r t h e i r narrow a p p l i c a t i o n . Insurance companies often did not cover prehospital t e s t s i f the patient was not subsequently admitted and surgery was done. In s i t u a t i o n s where insurance c a r r i e r s expanded t h e i r coverage to a l l outpatient diagnostic services, a higher degree of success could be expected. In a recent American a r t i c l e describing such a s i t u a t i o n , Sr. P a t r i c i a Clare writes that, contrary to some e a r l i e r fears, t h e i r outpatient diagnostic program did not jeopardize q u a l i t y , place unwelcome burdens on the patient nor r e s u l t i n decreased revenue to the h o s p i t a l because of empty beds or to the physicians because of l o s t fees. The key element i n t h e i r approach was cooperative planning. She s t a t e s : Although the physicians, the insurance companies, and the h o s p i t a l have had d i f f e r e n c e s of opinion, they were able to cooperate to develop and implement the program.28 49. In B r i t i s h Columbia, t e s t s done f o r diagnostic and screening purposes are covered by insurance regardless of where they are c a r r i e d out. Lo c a l l y , the programs to date have been directed mainly at goals other than shorter lengths of stay. The Vancouver General Hospital, by allowing physicians to submit t e s t s from outside l a b o r a t o r i e s , hopes to avoid unnecessary delays and needless d u p l i c a t i o n . In addition, the h o s p i t a l has recently opened a preadmission c l i n i c where patients who may be at r i s k from anesthesia and surgery, can be evaluated by an anesthetist before entering h o s p i t a l . The goals of Shaughnessy Hospital and ACU - HSCH are aimed at preventing delays i n surgery due to unavailable t e s t r e s u l t s and improving e f f i c i e n c y within the laboratory s e r v i c e . It appears the l a t t e r goal has met with mixed success. Whether t h i s i s a r e s u l t of PAT or PBT or ei t h e r program, i s yet to be determined. Both PAT and PBT f o r pres u r g i c a l t e s t i n g have introduced added complexity f o r the nursing s t a f f and have resulted i n a c e r t a i n amount of repeated blood t e s t s and repeated venipunctures. In designing a p r e s u r g i c a l t e s t i n g system with a view to saving resources therefore, one must set up a c l e a r communication system and a p r a c t i c a l method of avoiding repeated t e s t s . In terms of the effec t i v e n e s s outcomes studied i n t h i s t h e s i s , PAT was not found to be s i g n i f i c a n t i n avoiding delays, postponements, or c a n c e l l a t i o n s of surgery nor inappropriate s u r g i c a l admissions. The reason f o r t h i s may be o v e r a l l h o s p i t a l e f f i c i e n c y which, as suggested by Barbaro, Shuman and Swinkola, makes the argument f o r the effectiveness of a p a r t i c u l a r program merely academic. 2 9 On the other hand, the find i n g s i n t h i s study could r e s u l t from other h o s p i t a l c h a r a c t e r i s t i c s . The h o s p i t a l i s small, new and very 50. sophisticated i n terms of technological aids to communication. The patients represent a s e l e c t group and i n some cases have been well investigated p r i o r to t h e i r r e f e r r a l to the doctors who p r a c t i c e at the h o s p i t a l . A high percentage of the patients are young, healthy patients who are referred to the Sports Medicine C l i n i c f o r i n j u r y - r e l a t e d reasons. Even when looking at the e n t i r e sample (N=367), p r e s u r g i c a l t e s t i n g done p r i o r to h o s p i t a l i z a t i o n , whether f o r purposes of screening or diagnosis, does not appear to o f f e r s i g n i f i c a n t p o t e n t i a l benefits f o r the patients or the nursing s t a f f . On the other hand, h o s p i t a l s , where the f a c i l i t i e s are l e s s t e c h n o l o g i c a l l y advanced or where p o t e n t i a l patients are more l i k e l y to benefit from preadmission screening, may f i n d that p r e s u r g i c a l t e s t i n g on an outpatient basis i s an appropriate option. Where a pressure f o r beds e x i s t s , there s t i l l i s a very r e a l p o t e n t i a l f o r shortening length of stay when PAT i s used f o r both diagnostic and screening purposes provided the d i s i n c e n t i v e s do not overshadow the incentives. Patients who are not at r i s k f o r anesthesia and also require l i t t l e preoperative i n - h o s p i t a l preparation, can be admitted on the morning of surgery rather than on the previous day. The Vancouver General Hospital has such a system i n the Urology s e r v i c e . Some patients who are expected to be discharged on the f i r s t postoperative day, are admitted on an extended day care basis. Such a program requires a change i n system f o r preoperative preparation — more patient teaching i s required and a p r a c t i c a l way f o r the anesthetist to do his preoperative assessment on the day of surgery (rather than the night before) must be found. A second p o t e n t i a l approach to reducing 51. preoperative length of stay would be to do more p r e s u r g i c a l diagnostic t e s t i n g on an outpatient basis f o r those "patients with f a i r l y complex diseases i n addition to t h e i r s u r g i c a l problems". Further studies would need to be done to investigate the f e a s i b i l i t y of e i t h e r of these approaches i n a p a r t i c u l a r h o s p i t a l . The patient's point of view was not formally examined i n t h i s study. It i s conceivable that, provided a system i s convenient and/or appears to be b e n e f i c i a l , i t i s acceptable to the patient. On the other hand, i f a patient was aware of the l i k e l i h o o d of repeated venipunctures, t h i s might have a deterrent e f f e c t on h i s w i l l i n g n e s s to be preadmission tested. Only one patient i n t h i s study who was sent f o r preadmission t e s t i n g was not admitted. If preadmission t e s t i n g was a requirement rather than an option, one might f i n d that more patients would f a l l i n t o t h i s category. With reference to the screening function of p r e s u r g i c a l t e s t i n g , the push f o r screening healthy people has taken a change i n d i r e c t i o n over the past few years. Studies, including the comprehensive one done by the Canadian Task Force on the Periodic Health Examination, now question the appropriateness of general s c r e e n i n g . 3 0 Other studies as well have maintained there i s "overscreening" of p r e s u r g i c a l p a t i e n t s . ^ In addition, the question of how much att e n t i o n i s paid to routine screening t e s t s was raised by three l o c a l laboratory physicians. They found that a s i g n i f i c a n t number of physicians did not respond to abnormal "3? u r i n a l y s i s r e s u l t s . During the study at the ACU - HSCH, i t was noted that r e s u l t s of chest x-rays routinely ordered f o r preoperative evaluation were r a r e l y i n the patients' charts at the time of discharge. In only one 52. u n i t was there any i n d i c a t i o n (the urology resident i n i t i a l l e d a l l x-ray reports) that these r e s u l t s had been noted. In f a c t , some comments made i n the discharge summary were i n d i r e c t c o n t r a d i c t i o n to the radiology report and few follow-up studies that were recommended were a c t u a l l y done. The v a l i d i t y of p r e s u r g i c a l screening and the question of who pays at t e n t i o n to t e s t r e s u l t s was not an objective of t h i s study, although questions i n t h i s regard arose during the research period. In the planning f o r any p r e s u r g i c a l t e s t i n g program, however, these issues should a l s o be considered. SUMMARY The fi n d i n g s of t h i s study i n d i c a t e that PAT does not have a s i g n i f i c a n t impact on operating room workflow nor inappropriate admissions at the ACU - HSCH. Because of the s p e c i a l c h a r a c t e r i s t i c s of the h o s p i t a l , generalizations are not necessarily appropriate. The f i n d i n g s also suggest that when more than one form of p r e s u r g i c a l t e s t i n g program i s i n e f f e c t simultaneously, be n e f i t s occur f o r some while problems r e s u l t f o r others. Cost-effectiveness of PAT and patient s a t i s f a c t i o n was not examined i n t h i s study, although some information about the l a t t e r outcome was obtained from h o s p i t a l personnel. In planning a p r e s u r g i c a l t e s t i n g program, one must recognize the various i n t e r e s t s that e x i s t and the p o t e n t i a l f o r c o n f l i c t i n g goals. The type of program that i s therefore most l i k e l y to promise success f o r a l l 53. i n t e r e s t e d p a r t i e s , i s the one that involves as many of them as possible i n the planning of the program. 54. NOTES 1 Thomas L, Feurig, Development of an Evaluation Model f o r the  Analysis of a Pre-jAdmission Testing Program at Harper Hospital, D e t r o i t ,  Michigan, Diss. (Ann Arbor; The University of Michigan, May 6, 1974), (University Microfilms International 12309 AM). 2 Casmir P. Czapski, "Surgical Preadmission Testing," Project MD-SB-34a, c i t e d i n "An Evaluation of Various Pre-Surgical Testing Procedures," Donna Maria Barbaro, Larry J. Shuman, and Robert B. Swinkola, Inquiry, (December 16, 1977), 369. 3 James E. Mebs and John W. Brewer, "Preadmission Testing," Hospitals, J.A.H.A., (January 16, 1971), 48. 4 The insurance c a r r i e r s provided reimbursement only f o r t e s t s performed on patients who were subsequently admitted to h o s p i t a l f o r e l e c t i v e surgery. 5 L. N e i l Fogel, "Outpatient Presurgical Care Conserves Inpatient Days," Hospitals, J.A.H.A., 43 (January 1, 1969), 51-54. 6 C a r l R. Okelberry, "Preadmission Testing Shortens Preoperative Length of Stay," Hospitals, J.A.H.A., 49 (September 16, 1975), 71-74. 7 Rachel Floersheim Boaz, " U t i l i z a t i o n Review and Containment of Hospital U t i l i z a t i o n , " Medical Care, 17 (1979), 315-330. 8 Feurig, p. 17. 9 Karin Dumbaugh and Duncan Neuhauser, "The E f f e c t of Pre-Admission Testing on Length of Stay," Organizational Research i n Hospitals, ed. Stephen M. S h o r t e l l and Montague Brown (Chicago: Blue Cross Association, 1976) , 15. 1° Dumbaugh and Neuhauser, p. 16. 11 Donna Maria Barbaro, Larry J. Shuman and Robert B. Swinkola, "An Evalution of Various Presurgical Testing Procedures," Inquiry, 16 (December 1977) , 369. 12 Robert J. Kreb, "PSRO - A F i s c a l Nightmare," l e t t e r , N.E.J.M., 292 (May 15, 1975), 1083. 13 Robert J. Cole, "Personal Finance: Pre-Hospital Tests," The New  York Times (May 25, 1970), 56. 14 Steven R. Eastaugh, "Organizational Determinants of S u r g i c a l Lengths of Stay," Inquiry, 17 (Spring 1980), 85-96. 55. 1 5 Eastaugh, pp. 85-96, Boaz, pp. 315-330, Dumbaugh and Neuhauser, pp. 13-28. 16 Roderick McEwin, "Delay i n Patients' Investigations," The Medical  Journal of A u s t r a l i a (July 6, 1968), 30-33. 1 7 D.L. Crosby, et a l . "General S u r g i c a l Pre-Admission C l i n i c , " B r i t i s h Medical Journal (July 15, 1972), 157-159. 18 Bharrat S. Latchman, "Alternative Modes of Care Reduce Costs," Dimensions (June, 1977) 27-31. 15 Feurig, p. 10. 20 Barbaro, Shuman and Swinkola, pp. 382 and 380. 21 Dumbaugh and Neuhauser, p. 26. 2 2 Okelberry, p. 74. 23 Feurig, pp 44-59. 24 D.B. Rix and Gregory Stump, "Is There Duplication of Diagnostic Test Results?" CMA Journal, 112 (January 25, 1975), 237-242. 2 5 Dumbaugh and Neuhauser, p. 18. 26 This was a patient whose surgery was cancelled 2 1/4 hours before the scheduled time due to glucosuria, hypertension, and an elevated blood digoxin l e v e l . 27 "Confusion of systems" was a d e s c r i p t i v e term used by one of the head nurses during an interview. 28 Sr. P a t r i c i a Clare, "Outpatient Diagnostic Program Encourages Appropriate U t i l i z a t i o n , " Hospitals, J.A.H.A., 54 (June 16, 1980), 71-73. 29 Barbaro, Shuman and Swinkola, p. 383. 30 I r e f e r t o : Canadian Task Force on the Periodic Health Examination, "The Periodic Health Examination," CMA Journal,121, (November 3, 1979), 1193-1203, and to Gerald Sandler, "The Importance of the History i n the Medical C l i n i c and the Cost of Unnecessary Tests," American Heart Journal, 100, No. 6 (December 1980), 928-931. 31 I r e f e r t o : John A. Robbins and A l v i n I. Mushlin, "Preoperative Evaluation of the Healthy Patient," Medical C l i n i c s of North America, 63, No. 6 (November 1979), 1145-1155, and B. Delahunt and P.R.G. Turnbull, "How Cost E f f e c t i v e are Routine Preoperative Investigations?" New Zealand  Medical Journal (December 10, 1980), 431-432. 56. 32 G. A l l e n Heimann, J i r i F r o h l l c h and Melvyn Bernstein, "Physicians" Response to Abnormal Results of Routine U r i n a l y s i s , " CMA Journal, 115 (December 4, 1976), 1094-1095. BIBLIOGRAPHY 57. Barbaro, Donna Maria; Larry J. Shuman and Robert B. Swinkola. "An Evaluation of Various Presurgical Testing Procedures." Inquiry, 16, December 1977, 369-383. Boaz, Rachel Floersheim. " U t i l i z a t i o n Review and Containment of Hospital U t i l i z a t i o n . " Medical Care, 17, 1979, 315-330. Canadian Task Force on the Periodic Health Examination. "The Periodic Health Examination." CMA Journal, 121, November 3, 1979, 1193-1203. Clare, Sr. P a t r i c i a . "Outpatient Diagnostic Program Encourages Appropriate U t i l i z a t i o n . " Hospitals, J.A.H.A., 54, June 16, 1980, 71-73. Cole, Robert J. "Personal Finance: Pre-Hospital Tests." The New York  Times, 25, May 1970, p. 56. Crosby, D.L. et a l . "General S u r g i c a l Pre-Admission C l i n i c . " B r i t i s h  Medical Journal, July 15, 1972, 157-159. Czapski, Casmir P. "Surgical Preadmission Testing," (Project MD-SB-34a). Cited i n "An Evaluation of Various Presurgical Testing Procedures." Donna Maria Barbaro, Larry J. Shuman and Robert B. Swinkola. Inquiry, 16, December 1977, 369-383. Delahunt, B. and P.R.G. Turnbull. "How Cost E f f e c t i v e are Routine Preoperative Investigations?" New Zealand Medical Journal, December 10, 1980, 431-432. Dumbaugh, Karin and Duncan Neuhauser. "The E f f e c t of Pre-Admission Testing on Length of Stay." Organizational Research i n Hospitals. Ed. Stephen M. S h o r t e l l and Montague Brown. Chicago: Blue Cross Association, 1976, 13-28. Eastaugh, Steven R. "Organizational Determinants of S u r g i c a l Lengths of Stay." Inquiry, 17, Spring 1980, 85-96. Feurig, Thomas L. Development of an Evaluation Model f o r the Analysis of a  Pre-Admission Testing Program at Harper Hospital, D e t r o i t , Michigan. Diss. Ann Arbor: The University of Michigan, May 6, 1974 (University Microfilms Internation 12309 AM). Fogel, L. N e i l . "Outpatient Presurgical Care Conserves Inpatient Days." Hospitals, J.A.H.A., 43, January 1, 1969, 51-54. G i b a l d i , Joseph and Walter S. Achtert. MLA Handbook f o r Writers of Research Papers, Theses, and D i s s e r t a t i o n s . New York: Modern Language Association, 1980. 58. Heimann, G. A l l e n ; J i r i F r o h l i c h and Melvyn Bernstein. "Physicians' Response to Abnormal Results of Routine U r i n a l y s i s . " CMA Journal, 115, December 4, 1976, 1094-1095. Kreb, Robert J. "PSRO - A F i s c a l Nightmare." Letter. N.E.J.M., 292, May 15, 1975, 1083. Latchman, Bharrat S. "Alternative Modes of Care Reduce Costs." Dimensions, June 1977, 27-31. McEwin, Roderick. "Delay i n Patients' Investigations." The Medical Journal  of A u s t r a l i a , July 6, 1968, 30-33. Mebs, James E. and John W. Brewer. "Preadmission Testing." Hospitals,  J.A.H.A., 45, January 16, 1971, 48-51. Okelberry, C a r l R. "Preadmission Testing Shortens Preoperative Length of Stay." Hospitals, J.A.H.A., 49, September 16, 1975, 71-74. Rix, D.B. and Gregory Stump. "Is there Duplication of Diagnostic Test Results?" CMA Journal, 112, January 25, 1975, 237-242. Robbins, John A. and A l v i n I. Mushlin. "Preoperative Evaluation of the Healthy Patient." Medical C l i n i c s of North America, 63, No. 6, November 1979, 1145-1155. Sandler, Gerald. "The Importance of the History i n the Medical C l i n i c and the Cost of Unnecessary Tests." American Heart Journal, 100, No. 6, December 1980, 928-931. 5 9 . APPENDIX I STUDY NUMBER STUDY STATUS DATA COLLECTION-SHEET: PREADMISSION TESTING STUDY PATIENT'S NAME UNIT # WARD ADDRESS AGE SEX [ MARITAL STATUS OCCUPATION DIAGNOSIS CONTRIBUTING CO-MORBIDITY SURGEON CONSULTATIONS PROCEDURE SCHEDULED - ADMISSION: DATE SCHEDULED TIME SCHEDULED ACTUAL DATE ACTUAL TIME COMMENTS IbSIS: TEST DATE & TIME DATE & TIME COMMENTS SURGERY: DATE SCHEDULED TIME SCHEDULED ACTUAL DATE ACTUAL TIME COMMENTS GENERAL COMMENTS U A I L 

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