Correspondence  |   January 1997
Reply: Anesthesia Preoperative Evaluation Clinic
Author Notes
  • Assistant Professor of Anesthesia, Stanford University School of Medicine, Medical Director, Anesthesia, Preoperative Evaluation Clinic, Stanford University Hospital, Stanford, California 94305–5115.
Article Information
Correspondence   |   January 1997
Reply: Anesthesia Preoperative Evaluation Clinic
Anesthesiology 1 1997, Vol.86, 262-263. doi:
Anesthesiology 1 1997, Vol.86, 262-263. doi:
In Reply:-Several authors have addressed, in correspondence to Anesthesiology and in personal communications to the author, issues of support, concerns, and questions regarding my recent article. [1] The primary focus of this article was to communicate the imperative need at Stanford University Hospital to change the manner and focus of the anesthesia preoperative system, and to report the results of two cost-effective outcome studies.
National health care has entered an era of rapid change, transformation, and evolution. The competitiveness and complexity of these changes place an increasing emphasis on the importance of leadership and strategic decision making. As discussed in the 1994 Rovenstine lecture [2] by the then-editor of this Journal, the anesthesiologist's role is changing, with increased recognition that anesthesiologists are the perioperative medicine specialists.
Kempen's correspondence raises several valid concerns and questions regarding the architectural design and evolution of the Anesthesia Preoperative Evaluation Clinic (APEC). As would be expected, the implementation of an APEC is an active process that involves some degree of risk and uncertainty. Innovation and progress requires a program of action to solve problems and to create opportunities. Some questions do not have clear answers or outcomes. However, it is only through a systematic approach that we can begin to evaluate what is functional and that which can be discarded. The process of developing an APEC requires an awareness that not everyone will agree or encourage this endeavor. Norman Vincent Peale put it simply, “If you put off everything till you're sure of it, you'll get nothing done.” The APEC at Stanford University Hospital has become successful in redefining the anesthesiologist's leadership and position as the preoperative medicine specialist.
In response to Hannenberg, I agree that delegating certain aspects of the preoperative patient evaluation to the registered nurse practitioner (RNP) may infringe on an area of practice previously relegated only to the expertise of the anesthesiologist. A decade ago, when patients were admitted to the hospital a day before elective surgeries, the assigned anesthesiologist would preoperatively evaluate their patients and establish a personal rapport in a relaxed manner.
The dramatic shift to outpatients and same-day admissions has required a change in our practice, to accommodate large volumes of patients (currently 45–50 patients per day at Stanford) and facilitate the anesthesiologists' focus on intraoperative care. Ideally, I would prefer that several anesthesiologists attend the APEC full time, but, current resource allocation does not allow this diversion from operating room to APEC. The RNPs at Stanford are not nurse anesthetists, and their specific clinical duties are under the direct, on-site supervision of the attending anesthesiologist in the APEC. The RNPs evaluate patients for unstable medical conditions and present concerns to the anesthesia medical director. The assigned anesthesia team, on the day of surgery, evaluates and reconfirms their patient's status in the anesthesia holding area before entering the operating room. This establishes a personal rapport with the anesthesiologist who will be directly responsible for the patient's management.
Lee and Hillman report a preanesthesia clinic service in Australia with comparable and contrasting development from Stanford's APEC. The conceptual goals appear similar: to provide efficient quality services, increase productivity, and decrease cost. I agree that further studies are needed to define the APEC's role in patient-care outcomes.
Silverman discusses the expanding role of the anesthesiologist in today's practice and the increased visibility the APEC can provide. I concur with Silverman that, to expand our specialty into the future, anesthesiology must evolve beyond the traditional operating room/procedure role.
Recently at Stanford, the Department of Medicine proposed structuring a preoperative screening clinic staffed by an internist, pulmonologist, and cardiologist for evaluation of presurgical patients. The surgical leadership responded in a concise and congruent manner. They indicated that the anesthesiologists at Stanford are the primary preoperative and operating room medicine experts and that their patients would continue to attend the APEC for presurgical assessment.
Positive changes can occur and certain advantages can accrue to the anesthesiologist and department of anesthesia when an APEC is established.
Stephen P. Fischer, M.D., Assistant Professor of Anesthesia, Stanford University School of Medicine, Medical Director, Anesthesia, Preoperative Evaluation Clinic, Stanford University Hospital, Stanford, California 94305–5115.
(Accepted for publication October 10, 1996.)
Fischer SP: Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology 1996; 85:196-206.
Saidman LJ: The 33rd Rovenstine Lecture: What I have learned from 9 years and 9000 papers. Anesthesiology 1995; 83:191-7.