Transcript Locally Agreed Guidelines May Reduce Inappropriate

Locally Agreed Guidelines May
Reduce Inappropriate Preoperative
Echocardiography Requests
Dr Sheila Carey
Anaesthetic SpR
Northern Deanery
Background:
Preoperative Echocardiography
• Assessment of perioperative cardiac risk is
part of anaesthetic preoperative assessment.
• Echocardiography can give useful information
on cardiac function but has its limitations.
Background:
Sunderland Experience
• Disquiet from cardiology regarding quality and
appropriateness of echo requests.
• Uncertainty about indications for preoperative echo amongst PAAC staff and junior
surgical medical staff.
Aims
• Audit all preoperative echocardiogram
requests
• Produce local guidelines
– Survey local consultant opinion regarding pre
operative echo
– Literature review
• Evaluate impact of guidelines
Preoperative Echo Survey: Who needs
investigating?
• New murmur with other indicators of AS
• New murmur with no suggestive features of
AS
• Stable angina
• Decompensated heart failure
• Known AS. No change in symptoms , no
recent echo ( >1 year )
Published Literature / Guidance
• ACC/ AHA Guideline
– Recommendations for pre-op non-invasive
evaluation LV Function
• Patients with current or poorly controlled HF* ( Class I)
• Patients with prior HF / patients with dyspnoea
unknown origin ( Class II)
– Valvular heart disease
• If a murmur is present, the clinician will need to decide
whether or not it represents significant valvular disease
• AS poses the greatest risk
Published Literature / Guidance
• NCEPOD
– 1994/5
• Patient with ESM in association with LVH or myocardial
ischaemia should be referred for assessment
– 2001
• Patients can be asymptomatic despite mod – severe AS
and hence an asymptomatic cardiac murmur should be
investigated preoperatively by echocardiography
• NCEPOD recognises the spiralling increase in workload
this causes but echocardiography services should be
accorded an appropriate priority with regards funding
Published Literature / Guidance
• Appropriateness Criteria for TTE and TOE (ACCF /
ASE / ACEP et al)
– Symptoms due to suspected cardiac aetiology (not
previously investigated) (9)
– Initial investigation of murmur where there is
reasonable suspicion of valvular or structural disease (9)
– Re-evaluation of a patient with known valvular heart
disease with a change in clinical status (9)
– Routine ( yearly) evaluation of an asymptomatic patient
with severe stenosis (7)
Published Literature / Guidance
• Pandit (2004)
– Maximising the benefit from pre-operative cardiac
evaluation
– The uninvestigated murmur
• NCEPOD guidelines extremely cautious
• Implementation would increase demand greatly on
echo services
• Local guidelines should be jointly developed
Proposed Guidelines for Preoperative
Echocardiography
1) Dyspnoea of unknown origin where there is suspicion of cardiac component or
known IHD with poor functional capacity.
2) Previously undiagnosed systolic murmur with elements suggestive of aortic
stenosis, ECG abnormalities or symptoms.
3) Known aortic stenosis with a change in symptoms since last echo , or if due for
routine follow-up echo
4) Patients with current / poorly controlled heart failure (NYHA grade III-IV) and no
echo in past two years confirming moderate - severe LV dysfunction.
Review of Echocardiogram requests
• Preoperative requests collected over a 6 week
period.
• Reviewed by Consultant Cardiologist to
determine appropriateness.
• Inappropriate requests – patient note review.
• Indications compared against new guidelines
Results
• Twenty eight requests for preoperative
echocardiography
• 7/28 ( 25%) deemed as acceptable by Cardiology
• 21 (75%) unacceptable requests
– 14 murmurs / added sounds
– 4 Left ventricular Function
– 3 nature of surgery
Analysis of Unacceptable Requests
• 16 Unacceptable requests from Trauma &
Orthopaedic Department
• 12 sets of notes reviewed
• 9 requests could have been prevented (75%)
using guidelines
Conclusions 1
• No consensus amongst senior medical staff
regarding who requires investigation
• Personal preference probably dictates choice
except when clear cut suspicion of AS
• Advice given to other staff, (e.g. trainees, PAAC
nurses) likely to be inconsistent
• Guidelines may improved this
Sunderland echocardiogram request
Conclusions 2
• A significant proportion preoperative
echocardiogram requests are unacceptable
• Retrospective application of guidelines
suggests inappropriate requests could be
reduced
• Potential for a rise in number of requests if
patients selected more appropriately
Limitations
• Cardiology review subjective
• Retrospective analysis
• Prospective Audit needed to clarify the effect
of introducing guidelines
Recommendations
• Investigation should only be considered if
management will be affected
• Information given on request form has to be
relevant and detailed
• Local guidelines can help direct appropriate
use of resources