Guidelines for preoperative investigations for elective surgery at Queen Elizabeth Hospital: effects on practices, outcomes and costs

OBJECTIVES: Patients who present for elective surgery are often subjected to routine preoperative investigations, which often lead to unnecessary costs, delays or cancellation of surgery. We assessed the current practices, and the impact of guidelines for preoperative investigations on outcomes, practices and costs. DESIGN AND METHODS: The patterns of preoperative testing were assessed by conducting an audit. Preoperative investigation guidelines developed were presented to all surgical departments. The audit was repeated post-intervention compared to the pre-guideline audit. RESULTS: A total of 304 patients (150 before and 154 after) was included. The mean number of tests per patient did not significantly change between the pre-guideline and post guideline groups. For younger patients (under 60 years), the mean number of tests decreased from 3.42 ñ 1.8 in the pre-guideline group to 2.89 ñ 1.98 in the post guideline group (p=0.042). The total number of Chest X-rays decreased by 14.8% (p=0.012) and of Full blood counts (FBC) by 7.6% (p=0.036). For the remainder of investigations, there was no difference. The implementation of changes lead to overall savings of $15,178 per 1000 patients ($81,491 BDS per annum). The most notable savings are due to decreased number of Chest X-Rays. CONCLUSIONS: This study demonstrated that preoperative investigations were performed as a routine even in the absence of any clinical indication. The introduction of guidelines for preoperative investigations significantly decreased costs to the institution without compromising the safety of patient care and without placing patients at risk.

Optical recording from respiratory pattern generator of fetal mouse brainstem reveals a distributed network.

Unfailing respiration depends on neural mechanisms already present in mammals before birth. Experiments were made to determine how inspiratory and expiratory neurons are grouped in the brainstem of fetal mice. A further aim was to assess whether rhythmicity arises from a single pacemaker or is generated by multiple sites in the brainstem. To measure neuronal firing, a fluorescent calcium indicator dye was applied to embryonic central nervous systems isolated from mice. While respiratory commands were monitored electrically from third to fifth cervical ventral roots, activity was measured optically over areas containing groups of respiratory neurones, or single neurones, along the medulla from the facial nucleus to the pre-Bötzinger complex. Large optical signals allowed recordings to be made during individual respiratory cycles. Inspiratory and expiratory neurones were intermingled. A novel finding was that bursts of activity arose in a discrete area intermittently, occurring during some breaths, but failing in others. Raised CO2 partial pressure or lowered pH increased the frequency of respiration; neurons then fired reliably with every cycle. Movies of activity revealed patterns of activation of inspiratory and expiratory neurones during successive respiratory cycles; there was no evidence for waves spreading systematically from region to region. Our results suggest that firing of neurons in immature respiratory circuits is a stochastic process, and that the rhythm does not depend on a single pacemaker. Respiratory circuits in fetal mouse brainstem appear to possess a high safety factor for generating rhythmicity, which may or may not persist as development proceeds.

Control of respiration in the isolated central nervous system of the neonatal opossum, Monodelphis domestica.

Respiration represents an unusual motor activity with respect to its development. As newly born mammals enter the world, their limb movements are not coordinated; time and experience are required for effective performance to be achieved. Yet the rhythm of respiration is of necessity functionally perfected and unfailing at birth. Inspiratory and expiratory motor neurons are already able to fire at appropriate rates, under the command of rhythmically active neurons in the medulla. In this review, we discuss refinements of control present in the newborn opossum, particularly with respect to mechanisms that allow adaptation of respiration to changes in the level of activity or in the outside environment. Our own studies have been aimed at analyzing respiration at the earliest stages, and at establishing the way in which important variables influence inspiration and expiration. To this end, we have used the central nervous system (CNS) of a neonatal opossum, isolated in its entirety and maintained in culture. Although the opossum is unable to walk and highly immature at birth, its respiration is regular and unfailing. The isolated CNS survives, undergoes development, and maintains its neural activity and fine structure in vitro. Moreover, fictive respiration persists for over a day or longer at rates similar to those of the intact pup. The effects of altered pH, of increased temperature, and of drugs known to alter respiratory rhythm in intact animals can be measured directly, by electrical recordings made from medullary neurons or ventral roots. As in a slice, fluids of different composition can be applied focally, through micropipettes to the surface of the ventral medulla, or diffusely to the brainstem, With highly localized application of procaine hydrochloride (2%) to selected areas of the ventral medulla, the respiratory rhythm is reduced or abolished. As in adult mammals, both the rate and the amplitude of respiration simultaneously increase in response to lowered pH (6.5-.7.1) or to topical application of 1.0 microM carbachol. Conversely, as expected, the rate and amplitude decrease in response to increased pH (pH 7.5-7.7), or 100 microM scopolamine. Two characteristic features of the control of respiration in the neonatal opossum are evident from such tests. First, changes in rate are achieved by changes in the duration of the expiratory phase of respiration. This result suggests that the timing of the respiratory cycle in the neonatal opossum is controlled by an expiratory instead of an inspiratory "off-switch". Second, the rate and the amplitude of the respiratory excursions can be controlled independently, depending on the stimulus. For example, an increase in temperature increases the rate of fictive respiration without changing its amplitude, whereas noradrenaline decreases the rate while increasing the amplitude. Thus, changes of timing and amplitude need not go hand in hand. The opossum CNS offers a favorable preparation for the analysis of neural mechanisms that generate and modulate a motor rhythm, as the animal develops from embryonic to adult stages.

Fine structure and development of dorsal root ganglion neurons and Schwann cells in the newborn opossum Monodelphis domestica.

The aim of these experiments was to determine the state of maturity of dorsal root ganglia and axons in opossums (Monodelphis domestica) at birth and to assess quantitatively changes that occur in early life. Counts made of dorsal root ganglion cells at cervical levels showed that the numbers were similar in newborn and adult animals, approximately 1,600 per ganglion. In cervical dorsal root ganglia of newborn animals, division of neuronal precursors cells had ceased. The number of axons in cervical dorsal roots was similar in newborn and adult animals (about 4,500). For each ganglion cell body, approximately three axons were counted in the dorsal root. At birth, dorsal roots contained several bundles about 30 microns in diameter consisting of small axons (0.05-2 microns in diameter). A few non-neural cells were identified as Schwann cell perikarya, each enclosing a number of neurites. Later, marked changes occurred in Schwann cells and in their relationship to axons in the roots. Thus, at 12 days, an increase occurred in the number of Schwann cells and fibroblasts, and the bundles had enlarged to about 80 microns with little increase in axon diameter (0.1-2 microns). By 18 days, the bundles were larger, and myelination had already started. At 23 days, the dorsal root contained more than 500 myelinated axons that could reach 5 microns in diameter. The adult dorsal root enclosed about 900 myelinated axons. Throughout this time, the relationship between the Schwann cells and axons changed. Together, these results indicate that the number of axons and cell bodies of sensory dorsal root ganglia in opossum do not show major changes after birth. In addition, these results set the stage for quantitative studies of regeneration of dorsal column fibers in injured neonatal opossum nervous system.