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In recent years, the increase in the complexity of patients, the shortage of staff, poor planning, and defensive medicine have in many cases transformed the Preoperative evaluation outpatient clinic (in Italy defined “Prericovero”) into a bottleneck. In Italy, the need to reduce waiting lists led the Conference between the State and the Regions in 2020 to issue the “guidelines for the governance of the planned surgical patient path” in which Prericovero represents a phase of the process.1 These guidelines, in the application phase, could be integrated by the use of digital health and telemedicine technologies which, based on literature data, increase the efficiency and effectiveness of the process. The facility’s surgeon has the task of ensuring the care and timing of inclusion in the list. The entry date represents the start of the waiting time calculation. Various digital tools can be useful for “prericovero” planning and the timing of the face-to-face evaluation by the anesthetist. Their development, in the digital age, is disruptive. Considering that they precede the preoperative anesthetic evaluation, they can be defined as Preassessment. Depending on the active or passive participation performed by the Patient or his caregivers, the Preassessment can be schematically divided into Self, Nonself, or Hybrid. Furthermore, participation can be synchronous or asynchronous.
SELF PREASSESSMENTIt includes various digital activities performed directly by the patient, including filling out electronic questionnaires via the web and using smartphone applications. For example, the ePAQ can be completed by patients asynchronously via computer or tablet. On this way, patient information is available before you arrive.2
NON–SELF ASSESSMENTUse of documents shared between health care professionals via the web in asynchronous mode. This way of accessing data offers many advantages. The information is exhaustive and can be used at any time by the specialist outside of appointments with the patient or the medical doctor who feeds the data. In 2018, an observational study was conducted on eConsult in departments in the Veterans Affairs New England Healthcare System (VANEHS). The number of face-to-face appointments is mainly reduced by preoperative evaluation led by Anesthesiology e-consults. Travel burden and timing manner are partially resolved, thus potentially expediting surgical scheduling.3 A particular form of nonself methodology is One-Stop Anesthesia in which the surgeon is deputized to provide medical history data. The surgeon fills out an anesthetic questionnaire and sends it to the anesthesiologists. Having read this, they decide the timing of their visit which can take place the same morning of the surgical operation (One-Stop) or in “prericovero.” The methodology was implemented to reduce pediatric patient access. It is applied in day surgery operations in patients for whom routine preoperative tests are not necessary. This methodology has a high diagnostic accuracy, is applied in approximately 90% of cases, and determines a reduction of direct, indirect, and intangible costs.4 The Electronic Health Record (Fascicolo Sanitario Elettronico [FSE] in Italy) was established in Italy by the Ministry of Health.5 FSE data useful for the Preassessment are the emergency room reports, discharge letters, the summary health profile, specialist and pharmaceutical prescriptions, medical records, and the patient’s personal notebook, the latter being similar to a self-assessment. The use of nonself assessment may be favored by the natural language processing.
THE HYBRID ASSESSMENTHybrid methods are those that take place synchronously between the patient and health care workers. Telephone screenings, performed above all as part of nurse-led preoperative evaluation, belong to this category and became widespread before the digital age. In this area, telemedicine plays a fundamental role. In Italy, telemedicine health care services are reported in specific guidelines.6 The anesthetic televisit was used in the pandemic period with positive results and is a type of service that can also be used by consultants, when requested, thus avoiding the patient’s further access to the hospital.
GOVERNANCE AND CONCLUSIONSGovernance is ensured at various levels. In some Regions, for example, Tuscany, the Hospital Medical Directorates, through the “Surgical Planning Offices—UPC,” perform the role of planning “prericovero” and hospitalization.
The use of management methods, based on literature data, increases the effectiveness of the surgical process and the quality perceived by patients. Hospital Medical Directorates could encourage the adoption of digital technologies by all health care professionals involved and perform efficient management of UPC agendas. Surgeons could guarantee adequate management and establish the timing of inclusion on the list. Anesthesiologists could have reliable medical history data available before the patient’s access and guarantee adequate preparation for the intervention of clinically complex patients (Prerehabilitation). Furthermore, patients at low perioperative risk who, according to the Guidelines, do not require the execution of preoperative tests could be subjected to a televisit and subsequently directly accessed the hospital on the day of the operation (Figure).
Figure.: Flowchart of preassessment processes.
The face-to-face anesthetic visit can be performed in dedicated clinics before entering the operating room. The expected indicators can measure the process and induce quality improvement cycles.1 It is hoped that subsequent studies will provide data relating to the use of the reported tools.
Giovanni Mangia, MD
Orbetello Hospital (GR)
ASL South East Tuscany
Orbetello, Italy
[email protected]
Massimiliano Angelucci, MD
San Camillo de Lellis Hospital ASL
Rieti, Italy
Cesare Golia
ASL South East Tuscany
Orbetello, Italy
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