ROTATION: Preoperative Evaluation Clinic Rotation (Shands Hospital) 
TYPE: Required
DURATION:  1 month
FACULTY:  Adam Wendling, MD,  Patricia McNally, PhD, ARNP   
PREREQUISITES: Completion of clinical base year and 3 months clinical anesthesia   

GENERAL GOALS:

• Learn to quickly, accurately and completely evaluate ASA I and II patients presenting to the preoperative clinic (time goal < 15 minutes) prior to non-complex surgery
• Learn to efficiently, accurately and completely evaluate medically complex patients presenting to the preoperative clinic,
• Be able to quickly and efficiently perform a preoperative evaluation on the inpatient presenting for surgery - elective, urgent, or emergent
• Be able to rapidly and effectively communicate anesthetic, medical and surgical concerns to other anestheisa providers and to others involved in the perioperative management of patients.
• Be able to rapidly and effectively communicate basic anesthetic techniques, options and the risks and advantages of each to lay patients. 
• Become a perioperative medical consultant to the surgical team or to the patient's primary care physician

SPECIFIC COMPETENCIES:  (General Competencies also apply)

PATIENT CARE SKILLS:

• With respect to the planned anesthetic and surgical procedure,  be able to rapidly elicit medically relevant information historical information from the ASA I and II patient
• Obtain complete, accurate historical information from the medically complex patient
• Perform and accurate and complete airway assessment including:
  • Mouth opening
  • Thyromental distance
  • Cervical spine range of motion
  • Mallampati Classification
  • Condition of dentition
• Perform relevant physical examination in each preoperative patient, but minimally:
  • Cardiovascular system examination:  BP, heart rate and regularity, presence / absence of bruits and murmurs, assessment of peripheral pulses and differential pressures as appropriate; Allen's test
  • Respiratory system examination:  Breath sounds, airway sounds (listening for obstruction)
  • Neurologic system examination:  Mental status examination
  • Be able to perform more detailed system exams as needed and appropriate

• Methods of evaluation - Direct observation, Simulated patient, feedback from faculty in the operating room taking care of evaluated patients

MEDICAL KNOWLEDGE:   (See also General Competencies)

• All basic medical knowledge regarding disease states obtained during the clinical base year (see clinical base year goals) with emphasis on:
  • Cardiovascular disease (see below) including hypertension
  • Pulmonary disease, especially asthma and chronic obstructive pulmonary disease
    • Indications for Pulmonary Function Testing
    • Interpretation of routine spirometry, flow-volume loops, arterial blood gas measurements
  • Gastrointestinal Diseases (especially hiatal hernia / reflux, ulcer disease, liver disease)
  • Diabetes
  • Musculoskeletal disorders including arthritis - osteoarthritis and rheumatoid arthritis
  • Renal diseases - especially renal insufficiency
• During the Preop Clinic Rotation, the resident will gain knowledge sufficient to deal with one of the most common and serious preoperative evaluation problems - the evaluation, workup, and preparation of the patient with cardiovascular disease presenting for non-cardiovascular surgery.   The resident will use the Guidelines for the Evaluation of Patients with Cardiovascular Disease Presenting for Non-Cardiac Surgery as the source for most of this information.
• Preoperative Clinic Manual
• Evaluation of the airway
• Current indications for laboratory, radiologic, or more advanced clinical testing (Current Protocol HERE)

• Methods of evaluation:  In-training examination, Anesthesia Knowledge test, Oral Examinations (q 6 months), direct observation of presentations to faculty

INTERPERSONAL AND COMMUNICATION SKILLS, PROFESSIONALISM

• See general competencies section
• Learn how to interact with the clinic staff and ARNPs to provide optimal care for the preoperative patient.  Treat all staff and patients with appropriate dignity.
• Learn appropriate interpersonal skills to interact with anxious patients and their families in a calm, caring, professional manner.
• Be able to communicate with the surgical team and /or the patient's primary care physician in order to obtain needed additional studies and plan appropriate timing for surgery

• Methods of evaluation:  Direct observation, 360 evaluation

PRACTICE-BASED LEARNING AND IMPROVEMENT

• See general competencies section
• Gain speed and efficiency for performance of preoperative evaluations.  Routine ASA I and II patients should be seen and appropriately counseled in 15 minutes or less (except for complex operations which may require a longer period of counseling).
• Learn to utilize medical records information systems (both computerized and non-computerized) to obtain information needed for the complete evaluation of complex patients.
• Learn to utilize our computerized preoperative evaluation system

• Method of evaluation:  Documentation of conference attendance, Direct Observation

SYSTEMS-BASED PRACTICE

• See general competencies section
• Learn indicated, appropriate uses of laboratory studies to assist in evaluation of preoperative patients.
  • Also recognize when laboratory information is NOT needed for preoperative patients.
  • Appropriately document need for preoperative studies to assure appropriate reimbursement for ordered studies
• Keep complete records of preoperative care,  including appropriate coding for subsequent billing
• Learn to interact with Medical Records Departments in other hospitals to quickly obtain needed information
  • Learn appropriate methods of obtain consent for information located in other hospital systems.
• Appropriately utilize consultants to prepare the medically complex patient for surgery.
• All residents will be required to participate in or complete a systems project related to the preoperative evaluation clinic process.  Examples of previous projects include:  revision of the Minimum Surgical Blood Order Supply, preoperative clinic brochure in other languages, development of protocols for management of patients with specific medications / illnesses.

EVALUATION:

You are evaluated weekly on-line by attendings who worked with you. In this case, the preop clinic medical director will complete your primary evaluations.  Clinic ARNPs who have worked closely with you will also be asked to provide their assessment of your skills and competencies.  Finally, the five attendings with the greatest volume of patients going through the preop clinic will also be asked to evaluate your performance.  The evaluation data are reviewed quarterly by the Clinical Competence Committee. Your advisor informs you of any problems identified, and serious problems will be discussed with you immediately after they occur.

A 360 degree evaluation product will be developed for the preoperative evaluation clinic in the academic year 2008-9

You will complete a Departmental Rotation Evaluation Form. 

The Program Director will evaluate the results of the In-Training Examination for the American Board of Anesthesiologists (ABA) in general and for areas of departmental weakness. Consistent weaknesses may result in adjustment of the above goals. 

 Teaching Resources to Accomplish Objectives

• Patients: ~10,000 patients annually, all ages, varying complexity of operations
• Teaching materials: On-line articles in the Preoperative section of the Classic Anesthesia Articles Library.  Stoelting and Dierdorf:  Anesthesia and Coexisting Diseases (main reference text for rotation).  Also, any major textbook of Anesthesiology (Miller, Barash)
• University of Florida Online Medical Textbook
• Faculty:  All anesthesiology faculty  
  • Adam Wendling, MD (Chief)
  •    

SPECIFIC READING CURRICULUM AND SUGGESTED ACTIVITIES FOR THE PREOP ROTATION:

Our goal for you in your first two-weeks of your assignment to the Preop Clinic is to gain judgement in the preoperative preparation of patients with the most common medical problems:  coronary artery disease, chronic obstructive pulmonary disease, renal failure, hepatic failure, and sickle cell disease.  Additionally, we want you to become accustomed to the use of modern electronic medical records systems.    Accordingly, you should pursue the following reading and presentation schedule:

Monday:  Read about Coronary Artery Disease.  Suggest   Coronary Artery Disease, Chapter 1, Anesthesia and Co-Existing Disease, Stoelting, Dierdorf & McCammon.    Review the :Eagle criteria.   Read how our clinic works, from our Clinic Manual.   How to get a HIS password.  

Tuesday:    Review how to use the computer resources within the clinic. Information on how to use the PREOP program   Learn how to use the HIS system his.htm Also read about privacy and patient rights' concerns.    Take a look at some of the links on http://www.epic.org/privacy/medical/      The skills that you need to master include

• Alternating between different running programs in a Win95 environment
• Copy, and Copy Append from HIS into PREOP

You need to understand the concept of multitasking in computer operating systems.

Wednesday:  Read about COPD.  Suggest "Obstructive Airways Disease" , Chapter 14, Anesthesia and Co-Existing Disease, Stoelting, Dierdorf & McCammon.

Thursday:  Learn how to use our bedside spirometry equipment.   To learn how to evaluate them, check out the spirometry module from the Virtual Hospital. 

Friday:    Present an interesting patient with a literature review appropriate to their problems.  Explain your planned anesthetic.

Week 2:

Monday:    Read about CHF.  Suggest "Congestive Heart Failure", Chapter 7, Anesthesia and Co-Existing Disease, Stoelting, Dierdorf & McCammon

Tuesday:    Read about Renal Disease.  Suggest Renal Disease, Chapter 21, Anesthesia and Co-Existing Disease, Stoelting, Dierdorf & McCammon

Wednesday:  Read about Liver Failure.  Suggest "Diseases of the Liver and Biliary Tract," Anesthesia and Co-Existing Disease, Stoelting, Dierdorf & McCammon

Thursday:  Read about Sickle Cell Disease.  Suggest:  The hemoglobinopathies module from our Electronic Textbook.

Friday  Present an interesting patient you have seen this week with a literature review appropriate to their problems.  Explain your planned anesthetic. 

Second Two weeks in the Preop Clinic

Week 3

Our goal for your second assignment in the preop clinic is to become competent for consultant status for complicated patients.

Monday:      Jehovah's Witnesses.  Review the notebook on their rights and patients, review our Electron Textbook page on pediatric patient understanginds page on pediatric patient understandings and review the literature for the use of Erythopoeitin in the preop management of these patients.   Our clinic's protocol.   Consider    Article on which patients are most likely to benefit

Tuesday:    Rheumatoid Arthritis.  Read the notebook in the preop clinic. Chapter on Rheumatoid from the Virtual Hospital

Wednesday:    Liver Failure:  Review the preoperative evalution of end stage liver disease patients, and the impact and risks of a TIPS procedure.

Thursday:    Study the risks of perioperative thrombosis (deep venous thrombosis, etc) to surgical patients.  Review the methods of protection utilized by modern orthopedic surgeons and construct a table listing which surgeons utilize which methods here at Shands, and what the recomendations for post op epidurals are, as a result.  ASRA Recommendations for low molecular weight heparin.

Friday:    Present an interesting patient you have seen this week with a literature review appropriate to their problems.  Explain your planned anesthetic.  

WEEK 4

Monday.  Review Malignant Hyperthermia.

Tuesday.  Review porphyria..

Wednesday.  Review myelopathies and the care of patients.

Thursday.  Read about the TURP Syndrome  and the advantages of spinal anesthesia for TURPs.  Review the newer procedures for TURPs and their impact on the risks.  Study the toxicity of glycine.

Friday:    Present an interesting patient you have seen this week with a literature review appropriate to their problems.  Explain your planned anesthetic.  

Dr. Wendling is the faculty member responsible for this rotation. 

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RETURN TO INDEX FOR GOALS AND OBJECTIVES
Revised 6/2008