Vancouver Acute Department of Anesthesia

Anesthesia Consult Clinic (ACC) Policy

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ACC is a busy and hectic day.  The major complaint from patients is excessive wait times.  Please consider calling the slating anesthesiologist if running late

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1. You are expected to dictate the consultations using the departmental template.  The telephone in ACC all have dictation services on speed dial.  Please ensure you have obtained a dictation number by calling (604) 806-9696.
    

2. Please fill out the Anesthesia Consult Clinic Orders.  The orders have several components.
   
   Suitable for UBC [  ] Yes   [  ] No.
   The surgeons are not able to override and this will cancel UBC surgeries if filled out No.  
   
   Special postop overnight: [  ] PACU   [  ] UBCH High Acuity Unit    [  ] OSA Unit
   These requests for monitored beds are tracked.  High clinical demand for monitored beds on any specific day will trigger a notification to nursing management.  Who initiate a process to uplift nursing staffing for the day of surgery.
   
   Notify OR Booking of: _________________
   OR Booking does not read your Anesthetic consult nor understand the clinical significance of medical terms like diabetes, OSA.  Thus please actively manage the OR slate and write “morning slate” for OSA, diabetics on insulin, UBC cases with potential for major bleeding.  To have patients done preferentially either early or late in the OR day a written physician order is required.  
   
   Investigations:
   The CAS, Choosing Wisely and CMPA have endorsed not ordering baseline laboratory studies in asymptomatic patients undergoing low risk surgery.
   
   Preoperative Medications:
   If consenting a patient for a neuraxial or peripheral nerve block please hold the heparin.
   
   If patient has delayed gastric emptying from diabetes, GERD, or obesity consider ordering ranitidine.
   
   Aprepitant is available for those patients with severe PONV refractory to multiple agents.  Aprepitant is currently non-formulary and to arrange please e-mail Nilu Partovi directly. Nilu.Partovi@vch.ca
   
   Anesthesia Instructions for Patients.
   For those patients seen in consultation in ACC, provide clear instructions regarding which medications to take or hold on the morning of surgery.  You may choose to write these instructions on the Physician order sheet but the nurses perform their nursing assessment prior to you seeing the patient.  Thus these orders are not actionable. Thus success or failure of preoperative medication advice is dependent on your clear communication with the patient.  Consider providing patients with written instructions as studies show verbal retention is poor.
   
   For those patients who do not receive a preoperative Anesthesiology consult, their medication instructions for the day of surgery are done using a medical directive.  These medical directive driven medical instructions are given both verbally by a nurse with a follow up e-mail instructions.  Only write specific medication instructions on the physician order sheet for those patients not having an Anesthetic consultation or if you wish to override the SOP. Any written orders will override the medical directive. This should not normally be required.  
   
   The only medication exception is for diabetic patients on insulin. Nursing professional practice will not allow a medical directive advising partial doses of medication.  Thus please write preoperative insulin orders and the nurses will implement at the time of their phone interview.
   
   In addition in an attempt to minimize pages into the operating room on the day of surgery if you could fill out the diabetic preoperative PPO in Preadmission this will trigger no carbohydrates the morning of surgery, an earlier admission to hospital, a dextrose containing intravenous solution in PCC, prewarming and more importantly an insulin sliding scale on the chart. This avoids PCC paging into the OR on the day of surgery.
    

3. Preadmssion has linkages and preferential access to:

   • Psychiatry: Dr. Chan and Azar are always available to see patients in Preadmission.

   • Thrombosis clinic: Does not do time sensitive matters.

     For urgent bleeding disorders please send Paul Yenson an e-mail. PYenson@bccancer.bc.ca

     For other Hematologic matters send a fax marked urgent with the OR date to 604-875-4763.

   • Perioperative Medicine: Are in Preadmission three half days a week and always available to come down to Preadmission to see a consultation.

   • Endocrinology will in less than 5 business days if HbA1c > 9.0 or insulin infusion pump.   Fax: 604-875-5995

   • Dobutamine stress echocardiograms.  They hold “empty” slots for Preadmission, will perform a baseline echocardiogram and if poor acoustic windows will arrange a persantium MIBI all without disturbing you.

   • Full time social worker: Elvira Kocsis
     
     Please use these hospital resources.
      

4. The hospital uses physician order sheets as “actionable items”.  If you would like something to happen please write it as a physician order.  No matter how detailed or well written your consult note is, without a written physician order it is not actionable and will not be performed.
    

5. If you decide to delay surgery.

   1. Notify the surgeon directly by telephone.

   2. Fill out the “Delay of Surgery Form” and indicate what actions are required for the patient to proceed to surgery. This form is extremely helpful for your colleagues who may be asked to interpret subsequent investigations and decide if the results are compatible or incompatible with surgery.
       

6. The screening nurses determine which OR Booking packages:

• do not require an anesthetic consult

• require an anesthetic paper triage

• require a preoperative anesthetic consult.  
  
  If you are unhappy because a patient received an Anesthesiology consultation without justification or alternatively did not receiving a preoperative consultation when a consultation should have occurred. Please send an e-mail to the Preadmission medical director with your complaint and the patients identifiers.  There are three possibilities in follow up:

  • The medical directive filters which the screening nurses use require updating.

  • The screening nurses made an error which should be addressed.

  • Or you are an outlier. 

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    7.Risk Calculator:

https://riskcalculator.facs.org/RiskCalculator/

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For those patients seen in Anesthesiology consultation, who are deemed medically unsuitable for surgery at UBC. These patients are expected to have a high perioperative complication rate.

 

Please:

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1) Use a risk calculator to clearly document and discuss with the patient their risk.  The  risk calculator that is currently favored is the SORT app.

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Surgical Outcome Risk Tool (SORT):

http://www.sortsurgery.com/

Or free App for your phone

 

2) If expected 30 day mortality >5% please call surgeon to ensure aware of risk and no reasonable less invasive surgical options. 

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3) Ensure patient has clear goals of care.

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Last updated: Nov 2019