29 October 2000
At the last MAB Meeting, Dr. Ngun was asked to draft new recommendations on routine pre-anaesthetic investigations for inpatients undergoing surgery.
Currently, the Rules & Regulations of the Medical Staff of SJMC stipulate that
Dr. Ngun tried to look for recommendations or guidelines from various national anaesthetic associations but the only one he found was that from our very own Chapter of Anaesthesiologists, Academy of Medicine, Malaysia (April 1998). A copy of the relevant page has been included for your perusal. As no one else has submitted any other recommendations, Dr. Ngun took it that these are the only ones that we know of.
Based on this, Dr. Ngun would therefore like to make the following proposed changes to items 11 and 12 of the Rules and Regulations.
11)
Ensure that all patients admitted for an invasive procedure or delivery
have a Hb, TWC and urinalysis done, if not done within the last 30 days,
12)
Ensure that for patients admitted for an invasive procedure, and if the
following investigations have not been done within the last 6 months,
a)
Patients 50 years and older have an electrocardiogram, and
b)
Patients 60 years and older have a chest X-ray, renal profile (II) and
random blood sugar.
Note, however, that the patient’s clinical condition may indicate the requirement for the above or other investigations even though they may not satisfy the above criteria.
ECG for males > 40 and females > 50
CXR for all > 50
Hb, TWC, urinalysis : O.K.
Renal profile II + RBS : > 40 yrs for all
Pat 40 yr and over require ECG.
A platelet count should be included along with the Hb, inpatient > 40 or 60 yrs.
I think you should include the recommendations made by the Academy for the relevant type of cases.
Our existing guide-line are safety net to out practice in a private hospital.
They are taken from 2 large private centres in USA by the Steering Committee and Mr. Rob Manson to help us prevent litigations.
By all means add these,
FBS/RBS should be part of Renal profile; Liver profile and not as separate request.
TWDC should include platelet count (PC) (vital test from our point of view e.g. TURP) & not separate tests.
DO NOT upset our contract (Investigations & Preop tests)
Add words e.g. ECG in 50 yr or younger if pt. has CVS disease, diabetes, renal disease, i.e. specify condition as in the appendix recommended so that there is less misunderstanding.
Agrees with footnote at bottom of the Recommendations by the Academy of Medicine.
The votes went as follows:-
[ 2 ] I fully agree with the proposed guidelines.
[ 3 ] I agree with the proposed guidelines with modifications (given above).
[ 1 ] I disagree with the proposed guidelines.
Although the votes asked for certain changes to be included, the suggestions given were too disparate to be consolidated into any coherent proposal.
Also, the footnote to the proposal was deliberately left open ended so that,
Surgeons could not turn round and say, "Look, this disease wasn't stated in your guidelines and so I didn't order the extra investigations."
It is rather unrealistic to expect the surgeons to memorise a whole list of conditions under which they were obliged to do the investigations. If it is too complicated, no one will follow the guidelines at all.
Dr. Ngun pondered for quite a while as to whether to include platelet count and TWDC but finally decided against it because it was already difficult enough to try to get them to do these few basic investigations. Adding even more, may antagonise too many surgeons, thereby jeopardising our chance of getting the other proposals passed.
Hence the proposal to be presented to the MAB was left unchanged.
