The A-to-Z Guide to Preoperative Evaluation in Orthopedic Surgery

Streamlining the preoperative evaluation for orthopedic surgery can improve patient experience, streamline communication, and boost surgical outcomes. 

The demand for surgery in the U.S. is proliferating, with a 31.5% increase in surgery volume between 2000 and 2020 despite the population only growing by 18%. The preoperative evaluation process is a vital stage in every one of those surgeries, and optimizing the pre-op process could substantially impact the efficiency and income of orthopedic surgery providers. Understanding every aspect of the pre-op evaluation empowers you to streamline the process for your clinical team and offer every patient the best possible experience and outcome.

Key Takeaways

• Preoperative evaluation is essential to reduce the risk of surgical complications.
• Every preoperative evaluation consists of a pre-op history, examination, and testing.
• The information gathered during the preoperative evaluation helps your clinical team evaluate and prepare for potential risks.
• Establishing a smooth preoperative evaluation process sets every surgery up for success.

What is the Importance of Preoperative Evaluation in Orthopedic Surgery?

In the growing shift toward patient-centered healthcare, preoperative evaluation is an important stage in any patient’s surgical journey. Orthopedic surgery is no exception.

A preoperative orthopedic evaluation is designed to do more than simply “clear” the patient for their surgery. Instead, the goal of the pre-op evaluation is to minimize the risk of complications by identifying potential risk factors and creating a personalized surgical plan for each patient.

Thorough preoperative evaluations benefit both the patient and clinical team by:

• Allowing ample time to anticipate and mitigate the risk of complications
• Communicating the patient’s individual needs clearly in advance to all members of the clinical team
• Reducing last-minute cancellations due to unforeseen issues
• Lowering costs associated with those cancellations or delays
• Ensuring that the patient is thoroughly educated and understands their pre-op prep plan, which results in better health outcomes

Effective and streamlined preoperative evaluation is the key to improved surgical outcomes and reduced costs for your patients and clinical team.

Components of the Preoperative Evaluation for Orthopedic Surgery

A preoperative evaluation consists of three main components: the pre-op history, the pre-op examination, and pre-op testing. The information gathered can then be used to assess the risks involved with each patient and create a customized surgical plan.

Collecting the Pre-Op History

Gathering a comprehensive medical history is an essential first stage of the pre-op evaluation. Your patient’s pre-op history will inform every clinical team member, from the anesthesiologist who may need to avoid certain drugs because of allergies to the receptionist who can offer additional reassurance to an anxious patient.

The pre-op history will include:

• History of the presenting complaint – the reason the patient is having orthopedic surgery, as well as the type, site, and which side the procedure was on.
• Past medical history – a complete medical history including cardiovascular disease, respiratory disease, kidney disease, endocrine disease, pregnancy, and sickle cell disease.
• Past surgical history – information from any prior procedures, including their reaction to anesthetics and any complications.
• Drug history – including allergies, adverse responses, and any current medications that may need to be stopped before the procedure.
• Family history – with particular attention to adverse anesthetic responses, which could be genetic.
• Social history – history of smoking, alcohol, and other recreational drug use. Other relevant social factors could also include their living situation or any language barriers.

Conducting the Pre-Op Examination

Physical examination is essential before any orthopedic surgery to assess the site of the operation and any other conditions that could complicate the procedure. The pre-op exam is comprised of two main examinations:

• General examination – used to identify any undiagnosed conditions present. You should pay close attention to any signs of cardiovascular, respiratory, and abdominal issues. It’s also important to note any preexisting cognitive dysfunction, especially with elderly patients, to avoid confusion for a post-operative complication.

Airway examination – used by the anesthesiologist to evaluate the patient’s mouth and neck and predict the difficulty of airway management, e.g., for intubation. Here the Mallampati classification is used to measure the opening of the mouth.

Completing Pre-Op Testing

The third stage of the preoperative evaluation is testing and should be individualized for each patient to avoid wasting time and resources on unnecessary labs. The exact testing and investigation required will differ depending on the type of orthopedic procedure the patient is undergoing and other risk factors discussed below.

Pre-op tests you might conduct include: 

• Complete blood count
• Urinalysis
• Measures of serum electrolytes, creatinine, and plasma glucose
• Liver tests
• Coagulation studies
• ECG
• Chest x-ray
• Pulmonary function testing

Determining Pre-Operative Risk

Pre-Operative Risk assessment is a critical step in any surgical evaluation. An assessment of risk aids your surgical team in anticipating and mitigating potential complications. Preoperative intervention resulting from this assessment can lead to better health outcomes and significant cost reductions.  

The information you gain from the pre-op evaluation should be used to determine your patient’s level of risk. 

Pre-Operative Risk Factors

The following factors can be used to determine a patient’s overall pre-operative risk:

• Age
• Type of surgery
• Duration of surgery
• Anesthesia planned
• The surgical team’s skillset
• Equipment available
• Blood products required
• Implants required
• Previous medications
• Anticipated postoperative care
• Frailty
• Level of deconditioning
• Physical status classification (using ASAPS)

Physical Status Classification with ASAPS

Physiological status is an essential indicator of operative risk. The American Society of Anesthesiologists (ASA) has developed a system designed to help you categorize each patient’s physiological status, called the ASA Physical Status Classification System (ASAPS). The goal of the ASAPS is “to assess and communicate a patient’s pre-anesthesia medical co-morbidities.” 

ASAPS divides patients into 6 categories using ASA-approved examples, which you may choose to supplement with examples specific to your practice to optimize internal communication. Those categories are:

• ASA 1 – “a normal healthy patient”
• ASA 2 – “A patient with mild systemic disease”
• ASA 3 – “A patient with severe systemic disease”
• ASA 4 – “A patient with severe systemic disease that is a constant threat to life”
• ASA 5 – “A moribund patient who is not expected to survive without the operation”
• ASA 6 – “A declared brain-dead patient whose organs are being removed for donor purposes”

An additional E (e.g., ASA 2E) denotes emergency surgery.

The ASAPS is a valuable tool to help guide the surgical team throughout the preoperative process. A patient’s ASA grade correlates with their risk of post-operative complications and absolute mortality.

Streamline the Pre-Op Experience with Wellbe

The information you gather during the preoperative evaluation is only valuable if your team can use it effectively. Communication amongst the entire medical team is crucial to good surgical outcomes and a positive patient journey. That’s why Wellbe offers personalized automation solutions to help streamline the entire pre-op experience for your patients, allowing them to provide their information, consume their education, and share their results with the staff, facilitating clear communication for the best possible outcomes. 

Find out how Wellbe can create a seamless pre-op experience for your patients.