The present study shows that there has been an inadequate utilization of the preanaesthetic clinic by the surgical specialties associated with a very high rate of cancellation of 30%.
There are many possible reasons for the high cancellation rate. The 'miscellaneous' category of reasons for cancellation in the present study was a high proportion of cancellations (Table 1) and this consisted of reasons such as unavailability of equipment, breakdown of equipment, lack of linen due to either shortage of linen or breakdown of the central sterilization equipment, unavailability of anaesthetic technicians, unavailability of resources to clean the operating rooms from the day before, etc. This is a typical 'third world' phenomenon and because of the lack of coordination of different departments involved in the functioning of operating rooms and lack of efficient management of operating theatre floor, many surgical procedures were cancelled. Although a similar finding has been reported by earlier studies both from the developed world as well as from the Caribbean, the reported rate of cancellations was not as high as the present study [6, 7]. Cancellations of this nature, despite patients attending the preanaesthetic clinics may dissuade the surgical specialties referring their patients to the clinics on a regular basis.
As mentioned earlier two of the three functioning operating rooms in our hospital are exclusively dedicated to ambulatory surgery. Many of these patients belong to physical status of American Society of Anesthesiologists (ASA) physical status I and II, and many surgeons do not feel the need of referring such patients to the preanaesthetic clinics. Since the clinics operate only once a week, many surgical specialties having out-patient clinics on different days find it difficult to ask the patient to return on a different day for preanaesthetic evaluation.
Additionally because our hospital predominantly caters service to paediatric patients, there were cancellations due to sudden unexpected upper respiratory symptoms in children on the day of surgery. Cancellation due to this reason has been well documented and may not be influenced upon by evaluation in the preanaesthetic clinic [8].
There have been many published reports highlighting the importance of preanaesthetic clinics and their beneficial effects [9–11]. Most importantly the clinics play a part in evaluating surgical patients with co-morbid illnesses and assist in preoperative optimization. Improper preoperative preparation has been reported as one of the major reasons for cancellations of surgical procedures [12]. This issue could be addressed by implementing early warning parameters, and in complicated cases this could be easily done in an outpatient environment such as the anaesthetic clinic [13]. Disagreements between the surgeons and anaesthetists in many issues such as the amount of banked blood available for a particular procedure may well be addressed by a preanaesthetic evaluation in the clinic. In the present study all patients whose procedures were cancelled because of improper preoperative preparation belonged to the group who did not attend the preanaesthetic clinic (Table 1).
Despite clear advantages, there have been controversies regarding the establishment and utility of these clinics [14]. The major dissident view is that in many settings it is impossible to spare anaesthetic staff exclusively for these clinics due to shortage of both material and human resources [15]. In a developing country such as ours, establishing exclusive anaesthesia clinics may be defied by cost factor. However, many studies have shown that these clinics are cost effective not only with respect to avoiding unnecessary investigations but also for the hospital administration in allocating resources for such a clinic [4, 16, 17]. In our situation, although the hospital has staff shortages, this is the only hospital in the Caribbean to establish and run two clinics – one each for adult and paediatric, without interruption for the past ten years.
Another controversy is that the surgical patient may be assessed by a different anaesthetist who may not actually conduct the anaesthesia for the given patient [18]. Although this may be true, there can be no doubt that complicated cases who require detailed evaluation need not wait until the day before surgery for evaluation and any anaesthetist in a particular setting could evaluate and offer advise in general. The specific anaesthetic techniques may vary but the common perioperative implications may be easily addressed. In our situation, we do respect the views of a colleague consultant anaesthetist regarding a patient's general assessment and the so-called 'fitness' for anaesthesia.
There is a suggestion that patients should undergo a preanaesthetic evaluation by questionnaire administration which would be scrutinized by staff in the clinic who will then decide if the patient needs to be further evaluated by an anaesthetist [19]. A nurse led questionnaire evaluation has shown to impact on the cancellation rate of surgical procedure [20]. Presently, our preanaesthetic clinic requires the patient to fill an initial questionnaire administered which form and all patients are assessed by residents who seek the consultant's opinion for major cases. We suggest that a future prospective study in our setting to triage patients and compare the effect of questionnaire evaluation alone and complete evaluation in the clinic may throw some more light on the impact of these clinics on cancellation rates.
There were some limitations to the present study. We could not clearly establish the beneficial impact of the clinic probably due to the duration of the study. Although we had a reasonable sample size, if the study would have been continued for a longer period, the advantages of the preanaesthetic clinic could have been found better.
