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Locally Agreed Guidelines May Reduce Inappropriate Preoperative Echocardiography Requests

Locally Agreed Guidelines May Reduce Inappropriate Preoperative Echocardiography Requests. Dr Sheila Carey Anaesthetic SpR Northern Deanery. Background: Preoperative Echocardiography. Assessment of perioperative cardiac risk is part of anaesthetic preoperative assessment.

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Locally Agreed Guidelines May Reduce Inappropriate Preoperative Echocardiography Requests

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  1. Locally Agreed Guidelines May Reduce Inappropriate Preoperative Echocardiography Requests Dr Sheila Carey Anaesthetic SpR Northern Deanery

  2. Background:Preoperative Echocardiography • Assessment of perioperative cardiac risk is part of anaesthetic preoperative assessment. • Echocardiography can give useful information on cardiac function but has its limitations.

  3. Background:Sunderland Experience • Disquiet from cardiology regarding quality and appropriateness of echo requests. • Uncertainty about indications for pre-operative echo amongst PAAC staff and junior surgical medical staff.

  4. Aims • Audit all preoperative echocardiogram requests • Produce local guidelines • Survey local consultant opinion regarding pre operative echo • Literature review • Evaluate impact of guidelines

  5. Preoperative Echo Survey: Who needs investigating? • New murmur with other indicators of AS • New murmur with no suggestive features of AS • Stable angina • Decompensated heart failure • Known AS. No change in symptoms , no recent echo ( >1 year )

  6. Published Literature / Guidance • ACC/ AHA Guideline • Recommendations for pre-op non-invasive evaluation LV Function • Patients with current or poorly controlled HF* ( Class I) • Patients with prior HF / patients with dyspnoea unknown origin ( Class II) • Valvular heart disease • If a murmur is present, the clinician will need to decide whether or not it represents significant valvular disease • AS poses the greatest risk

  7. Published Literature / Guidance • NCEPOD • 1994/5 • Patient with ESM in association with LVH or myocardial ischaemia should be referred for assessment • 2001 • Patients can be asymptomatic despite mod – severe AS and hence an asymptomatic cardiac murmur should be investigated preoperatively by echocardiography • NCEPOD recognises the spiralling increase in workload this causes but echocardiography services should be accorded an appropriate priority with regards funding

  8. Published Literature / Guidance • Appropriateness Criteria for TTE and TOE (ACCF / ASE / ACEP et al) • Symptoms due to suspected cardiac aetiology (not previously investigated) (9) • Initial investigation of murmur where there is reasonable suspicion of valvular or structural disease (9) • Re-evaluation of a patient with known valvular heart disease with a change in clinical status (9) • Routine ( yearly) evaluation of an asymptomatic patient with severe stenosis (7)

  9. Published Literature / Guidance • Pandit (2004) • Maximising the benefit from pre-operative cardiac evaluation • The uninvestigated murmur • NCEPOD guidelines extremely cautious • Implementation would increase demand greatly on echo services • Local guidelines should be jointly developed

  10. Review of Echocardiogram requests • Preoperative requests collected over a 6 week period. • Reviewed by Consultant Cardiologist to determine appropriateness. • Inappropriate requests – patient note review. • Indications compared against new guidelines

  11. Results • Twenty eight requests for preoperative echocardiography • 7/28 ( 25%) deemed as acceptable by Cardiology • 21 (75%) unacceptable requests • 14 murmurs / added sounds • 4 Left ventricular Function • 3 nature of surgery

  12. Analysis of Unacceptable Requests • 16 Unacceptable requests from Trauma & Orthopaedic Department • 12 sets of notes reviewed • 9 requests could have been prevented (75%) using guidelines

  13. Conclusions 1 • No consensus amongst senior medical staff regarding who requires investigation • Personal preference probably dictates choice except when clear cut suspicion of AS • Advice given to other staff, (e.g. trainees, PAAC nurses) likely to be inconsistent • Guidelines may improved this

  14. Sunderland echocardiogram request

  15. Conclusions 2 • A significant proportion preoperative echocardiogram requests are unacceptable • Retrospective application of guidelines suggests inappropriate requests could be reduced • Potential for a rise in number of requests if patients selected more appropriately

  16. Limitations • Cardiology review subjective • Retrospective analysis • Prospective Audit needed to clarify the effect of introducing guidelines

  17. Recommendations • Investigation should only be considered if management will be affected • Information given on request form has to be relevant and detailed • Local guidelines can help direct appropriate use of resources

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