[On preoperative risk evaluation of adult patients before elective non-cardiac surgery: results of a survey on clinical practice in the Federal State of Hessen].

BACKGROUND: The German Societies of Anesthesiology and Intensive Care Medicine, Internal Medicine and Surgery have recently published for the first time joint recommendations for the evaluation of adult patients prior to elective non-cardiac surgery. In these recommendations indications for preoperative diagnostic procedures were critically revised and updated. It was unclear to what extent these recommendations were known among German anesthesiologists, how the recommendations were perceived and to what extent they were put into practice. The indications of five common diagnostic procedures in the context of the preoperative evaluation were also unknown.
METHODS: Three months after publication of the recommendations, all anesthesiologists employed at hospitals in the state of Hessen were requested to take part in an online survey (OS). In the first part of the OS participants were asked about familiarity with the recommendations, opinions concerning the utility of the recommendations and to what extent they were implemented. In the second part of the OS participants were questioned in general and in the context of two common case scenarios about indications for electrocardiograms (ECG), chest radiographs (chest x-ray), echocardiograms, spirometry and extended cardiac diagnostics, such as stress ECG. In addition, participants of the OS were requested to take part in an interview survey (IS) addressing the same topics. The purpose of the IS was to detect any bias caused by the anonymous character of the OS which could lead to an overestimated self-assessment. Answers of the IS were not compared to the results of the corresponding answers given online by the same anesthesiologist but only analyzed together with the other results of the IS for comparison with the results of the OS.
RESULTS: Of the contacted anesthesiologists 396 (29 %) took part in the OS of which 100 took part in the IS. According to the OS 30 % were familiar and 34 % were partially familiar with the recommendations, 20 % just knew that recommendations had been published and 16 % did not even know about the publication. The corresponding results of the IS were 16 %, 36 %, 28 % and 20 %, respectively. Of the participants 90 % (OS) and 89 % (IS) considered the recommendations at least to be predominantly reasonable and useful and 66 % (OS) of the participants tried to implement or at least to partially implement the recommendations (IS only 33 %). Concerning the indications for the different diagnostic procedures, the results of the OS showed that hospital guidelines (44 %) and patient age (32 %) were the most frequent indications for a preoperative ECG. Hospital guidelines (40 %) and own judgement (39 %) were the most common indications for a preoperative chest x-ray and patient age still accounted for 18 % of the indications. In contrast, echocardiography (67 %), spirometry (61 %) and extended cardiac diagnostics (70 %) were primarily indicated based on own judgement. However, reasons given in this context were frequently (77 %) not in agreement with the recommendations. Comparing the results of the OS to those of the IS with respect to the indications of the different diagnostic procedures for the common case scenarios showed a varying degree of consistency with the recommendations. In both cases responses to the IS concerning the indications for the different diagnostic procedures were mostly in accordance with the recommendations compared to answers obtained in the OS. Indications for the chest x-ray showed the worst degree of consistency with the recommendations.
CONCLUSIONS: Corresponding to the high significance of local standards for the decision of indicating preoperative diagnostic procedures, the development of local standards that are in agreement with the recommendations seems to be a reasonable way to facilitate the implementation of the recommendations.