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LocallyAgreedGuidelinesMayReduceInappropriatePreoperativeEchocardiographyRequests

DrSheilaCareyAnaestheticSpRNorthernDeaneryLocallyAgreedGuidelinesMayBackground:

PreoperativeEchocardiographyAssessmentofperioperativecardiacriskispartofanaestheticpreoperativeassessment.Echocardiographycangiveusefulinformationoncardiacfunctionbuthasitslimitations.Background:

PreoperativeEchocBackground:

SunderlandExperienceDisquietfromcardiologyregardingqualityandappropriatenessofechorequests.Uncertaintyaboutindicationsforpre-operativeechoamongstPAACstaffandjuniorsurgicalmedicalstaff.Background:

SunderlandExperieAims

AuditallpreoperativeechocardiogramrequestsProducelocalguidelinesSurveylocalconsultantopinionregardingpreoperativeechoLiteraturereviewEvaluateimpactofguidelinesAimsAuditallpreoperativeecPreoperativeEchoSurvey:Whoneedsinvestigating?NewmurmurwithotherindicatorsofASNewmurmurwithnosuggestivefeaturesofASStableanginaDecompensatedheartfailureKnownAS.Nochangeinsymptoms,norecentecho(>1year)PreoperativeEchoSurvey:Who

PublishedLiterature/GuidanceACC/AHAGuidelineRecommendationsforpre-opnon-invasiveevaluationLVFunctionPatientswithcurrentorpoorlycontrolledHF*(ClassI)PatientswithpriorHF/patientswithdyspnoeaunknownorigin(ClassII)ValvularheartdiseaseIfamurmurispresent,theclinicianwillneedtodecidewhetherornotitrepresentssignificantvalvulardiseaseASposesthegreatestriskPublishedLiterature/GuidanPublishedLiterature/GuidanceNCEPOD1994/5PatientwithESMinassociationwithLVHormyocardialischaemiashouldbereferredforassessment2001Patientscanbeasymptomaticdespitemod–severeASandhenceanasymptomaticcardiacmurmurshouldbeinvestigatedpreoperativelybyechocardiographyNCEPODrecognisesthespirallingincreaseinworkloadthiscausesbutechocardiographyservicesshouldbeaccordedanappropriateprioritywithregardsfundingPublishedLiterature/GuidancPublishedLiterature/GuidanceAppropriatenessCriteriaforTTEandTOE(ACCF/ASE/ACEPetal)Symptomsduetosuspectedcardiacaetiology(notpreviouslyinvestigated)(9)Initialinvestigationofmurmurwherethereisreasonablesuspicionofvalvularorstructuraldisease(9)Re-evaluationofapatientwithknownvalvularheartdiseasewithachangeinclinicalstatus(9)Routine(yearly)evaluationofanasymptomaticpatientwithseverestenosis(7)PublishedLiterature/GuidancPublishedLiterature/GuidancePandit(2004)Maximisingthebenefitfrompre-operativecardiacevaluationTheuninvestigatedmurmurNCEPODguidelinesextremelycautiousImplementationwouldincreasedemandgreatlyonechoservicesLocalguidelinesshouldbejointlydevelopedPublishedLiterature/GuidancProposedGuidelinesforPreoperativeEchocardiography1)Dyspnoeaofunknownoriginwherethereissuspicionof

cardiaccomponent

orknownIHDwithpoorfunctionalcapacity.2)Previouslyundiagnosedsystolicmurmurwithelementssuggestiveofaorticstenosis,ECGabnormalitiesorsymptoms.3)Knownaorticstenosiswithachangeinsymptomssincelastecho,orifdueforroutinefollow-upecho4)Patientswithcurrent/poorlycontrolledheartfailure(NYHAgradeIII-IV)

andnoechoinpasttwoyearsconfirmingmoderate-severeLVdysfunction.ProposedGuidelinesforPreopeReviewofEchocardiogramrequestsPreoperativerequestscollectedovera6weekperiod.ReviewedbyConsultantCardiologisttodetermineappropriateness.Inappropriaterequests–patientnotereview.IndicationscomparedagainstnewguidelinesReviewofEchocardiogramrequeResultsTwentyeightrequestsforpreoperativeechocardiography7/28(25%)deemedasacceptablebyCardiology21(75%)unacceptablerequests14murmurs/addedsounds4LeftventricularFunction3natureofsurgeryResultsTwentyeightrequestsfAnalysisofUnacceptableRequests16UnacceptablerequestsfromTrauma&OrthopaedicDepartment12setsofnotesreviewed9requestscouldhavebeenprevented(75%)usingguidelinesAnalysisofUnacceptableRequeConclusions1NoconsensusamongstseniormedicalstaffregardingwhorequiresinvestigationPersonalpreferenceprobablydictateschoiceexceptwhenclearcutsuspicionofASAdvicegiventootherstaff,(e.g.trainees,PAACnurses)likelytobeinconsistentGuidelinesmayimprovedthisConclusions1NoconsensusamonSunderlandechocardiogramrequestSunderlandechocardiogramrequConclusions2AsignificantproportionpreoperativeechocardiogramrequestsareunacceptableRetrospectiveapplicationofguidelinessuggestsinappropriaterequestscouldbereducedPotentialforariseinnumberofrequestsifpatientsselectedmoreappropriatelyConclusions2AsignificantproLimitationsCardiologyreviewsubjectiveRetrospectiveanalysisProspectiveAuditneededtoclarifytheeffectofintroducingguidelinesLimitationsCardiologyreviewsRecommendationsInvestigationshouldonlybeconsideredifmanagementwillbeaffectedInformationgivenonrequestformhastoberelevantanddetailedLocalguidelinescanhelpdirectappropriateuseofresourcesRecommendationsInvestigationsLocallyAgreedGuidelinesMayReduceInappropriatePreoperativeEchocardiographyRequests

DrSheilaCareyAnaestheticSpRNorthernDeaneryLocallyAgreedGuidelinesMayBackground:

PreoperativeEchocardiographyAssessmentofperioperativecardiacriskispartofanaestheticpreoperativeassessment.Echocardiographycangiveusefulinformationoncardiacfunctionbuthasitslimitations.Background:

PreoperativeEchocBackground:

SunderlandExperienceDisquietfromcardiologyregardingqualityandappropriatenessofechorequests.Uncertaintyaboutindicationsforpre-operativeechoamongstPAACstaffandjuniorsurgicalmedicalstaff.Background:

SunderlandExperieAims

AuditallpreoperativeechocardiogramrequestsProducelocalguidelinesSurveylocalconsultantopinionregardingpreoperativeechoLiteraturereviewEvaluateimpactofguidelinesAimsAuditallpreoperativeecPreoperativeEchoSurvey:Whoneedsinvestigating?NewmurmurwithotherindicatorsofASNewmurmurwithnosuggestivefeaturesofASStableanginaDecompensatedheartfailureKnownAS.Nochangeinsymptoms,norecentecho(>1year)PreoperativeEchoSurvey:Who

PublishedLiterature/GuidanceACC/AHAGuidelineRecommendationsforpre-opnon-invasiveevaluationLVFunctionPatientswithcurrentorpoorlycontrolledHF*(ClassI)PatientswithpriorHF/patientswithdyspnoeaunknownorigin(ClassII)ValvularheartdiseaseIfamurmurispresent,theclinicianwillneedtodecidewhetherornotitrepresentssignificantvalvulardiseaseASposesthegreatestriskPublishedLiterature/GuidanPublishedLiterature/GuidanceNCEPOD1994/5PatientwithESMinassociationwithLVHormyocardialischaemiashouldbereferredforassessment2001Patientscanbeasymptomaticdespitemod–severeASandhenceanasymptomaticcardiacmurmurshouldbeinvestigatedpreoperativelybyechocardiographyNCEPODrecognisesthespirallingincreaseinworkloadthiscausesbutechocardiographyservicesshouldbeaccordedanappropriateprioritywithregardsfundingPublishedLiterature/GuidancPublishedLiterature/GuidanceAppropriatenessCriteriaforTTEandTOE(ACCF/ASE/ACEPetal)Symptomsduetosuspectedcardiacaetiology(notpreviouslyinvestigated)(9)Initialinvestigationofmurmurwherethereisreasonablesuspicionofvalvularorstructuraldisease(9)Re-evaluationofapatientwithknownvalvularheartdiseasewithachangeinclinicalstatus(9)Routine(yearly)evaluationofanasymptomaticpatientwithseverestenosis(7)PublishedLiterature/GuidancPublishedLiterature/GuidancePandit(2004)Maximisingthebenefitfrompre-operativecardiacevaluationTheuninvestigatedmurmurNCEPODguidelinesextremelycautiousImplementationwouldincreasedemandgreatlyonechoservicesLocalguidelinesshouldbejointlydevelopedPublishedLiterature/GuidancProposedGuidelinesforPreoperativeEchocardiography1)Dyspnoeaofunknownoriginwherethereissuspicionof

cardiaccomponent

orknownIHDwithpoorfunctionalcapacity.2)Previouslyundiagnosedsystolicmurmurwithelementssuggestiveofaorticstenosis,ECGabnormalitiesorsymptoms.3)Knownaorticstenosiswithachangeinsymptomssincelastecho,orifdueforroutinefollow-upecho4)Patientswithcurrent/poorlycontrolledheartfailure(NYHAgradeIII-IV)

andnoechoinpasttwoyearsconfirmingmoderate-severeLVdysfunction.ProposedGuidelinesforPreopeReviewofEchocardiogramrequestsPreoperativerequestscollectedovera6weekperiod.ReviewedbyConsultantCardiologisttodetermineappropriateness.Inappropriaterequests–patientnotereview.IndicationscomparedagainstnewguidelinesReviewofEchocardiogramrequeResultsTwentyeightrequestsforpreoperativeechocardiography7/28(25%)deemedasacceptablebyCardiology21(75%)unacceptablerequests14murmurs/addedsounds4LeftventricularFunction3natureofsurgeryResultsTwentyeightrequestsfAnalysisofUnacceptableRequests16UnacceptablerequestsfromTrauma&OrthopaedicDepartment12setsofnotesreviewed9requestscouldhavebeenprevented(75%)usingguidelinesAnalysisofUnacceptableRequeConclusions1Noconsensusamong

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