PRE SURGICAL TESTING DEPARTMENT ADVOCATE LUTHERAN GENERAL HOSPITAL STANDARD FOR CHART REVIEW

Transcription

1 Purpose: To provide a standard action plan for chart review of pre-admission testing done for scheduled surgical patients. PST will follow these guidelines for review, taking into consideration the patient s health history, current medications, and previous test results. Surgeons, Primary Care Physicians and Specialists can review results and order any additional tests as needed or wanted, regardless of the guidelines listed below. COMPLETE BLOOD COUNT WBC WBC >12k OR <3k in adults (attention to implants) Hgb Hgb <10 gms Platelets Platelets < 100k or >600k in adults METABOLIC PANEL Sodium Sodium <132 or >145 Potassium Potassium <3.0 or >5.5 Elevated WBCs - Documented and/or known Steroid use, CLL or other Leukemias, known infection (when procedure is related to infection). Decreased WBCs Documented and/or know Neutropenia. Chronic Anemia, Iron Deficiency Anemia, bleeding (procedure is related to bleeding, e.g. Colon CA) Idiopathic Thrombocytopenia Purpura (notify surgeon), Liver Failure. Renal Failure (repeat on admit for

2 Dialysis patient s). BUN/Creatinine BUN >45 with normal Creatinine and/or BUN normal with Creatinine >1.7 Renal Failure or Insufficiency. Magnesium Magnesium >2.5 or <1.7 Glucose No history of diabetes Glucose >150 or <60 Diabetic Glucose >250 or <70 Or >175 and Hgb A1c >9 COAGULATION PROFILE Prothrombin Time Elevated over normal values (Request Clearance from Surgeon if significant elevation without explanation.) INR INR >1.3 (Request Clearance from Surgeon if significant Steroid use, also take into consideration fasting status at time of blood draw. INR within normal limits. For Dr. Khorsand patient s only if above Pt. taking Coumadin not stopped at time of blood draw, order repeat on admit. Patient taking Coumadin not stopped at time of blood draw, order repeat on admit.

3 elevation without explanation.) Platelet Function Study Elevated over normal values (Request Clearance from Surgeon if significant elevation without explanation.) LIVER ENZYMES Bilirubin Bilirubin 1.4 or greater GPT/ALT If on statins for cholesterol- >130 If not on statins- Female >57 Male >76 Alkaline Phosphatase Alk Phos >130 URINALYSIS If Protein > or = 100, OR Positive RBCs Liver Failure (should also have PT and PTT, order on admit if not done), patient having Cholecystectomy. Hematuria, Menstruating female.

4 If Positive Leukocyte Esterase OR Positive Nitrite OR WBCs >10 a Culture should be done If a Culture was not done request Clearance from PCP with further information (Was patient treated for a UTI?)., request Clearance from Surgeon if having implants and not treated. Patient having Urology procedure with documented and/or known infection, normal Culture. MRSA SWAB MRSA or MSSA Positive, request Clearance from Surgeon if not treated. PREGNANCY TEST Positive Request Clearance from Surgeon Known Pregnancy Please review all available information prior to requesting Clearance. If the surgeon has ordered labs, and the patient is not seeing the PCP prior to surgery, clearance can be requested from the surgeon.

5 Abnormal or Borderline EKGs showing the following: The following EKG findings do not require Clearance or need to be brought to Anesthesia Huddle in the absence of other Cardiac History: Acute Ischemic Changes MI (history of MI, age undetermined, cannot rule out MI) 2 nd, 3 rd or Complete Heart Blocks Intrafasicular Blocks ST and/or T Wave Elevation or Inversion Non-Specific ST and/or T Wave Changes Presence of Q Waves Left Bundle Branch Block Axis Deviation Atria Enlargement Accelerated AV Condition Early Repolarization Low Voltage LVH 1 st Degree AV Block Known Right Bundle Branch Block Pacemaker and/or Cardiologist (also request most recent H&P or Office Note, any previous EKGs for comparison from any year, and any other Cardiac Testing results from the past 5 years) All information should be reviewed by RN and determination made if chart needs to go to Anesthesia Huddle (or Dr. Loj), regardless if the PCP/Cardiologist is on staff at LGH. Request most recent H&P or Office Note, any previous EKGs for comparison from any year, and any other Cardiac Testing results from the past 5 years for patients with RBBB and Pacemaker (or ICD). Also request most recent interrogation report for Pacemaker. Patients having CABG, Valve Replacement, or ICD Placement Old MI requires a prior EKG more than 6 months old that shows the same findings.

6 Sinus Bradycardia (<50 and asymptomatic) The following CXR findings require Clearance: Note: CT of the Chest may be used in lieu of a CXR in the absence of recent respiratory symptoms. Infiltrates/Blebs Pleural Effusion Pulmonary Congestion Deviated Trachea Aneurysms Severe Cardiomegaly Severe Atelectasis Moderate to Large Blunting Emphysema/COPD changes (if functional status is impaired) Previous Lung Surgery Nodule or Defect not previously seen and/or Pulmonologist (if patient has one). May need additional testing such as PFTs or ABGs. Forward Clearance when received. Nodule or Defect previously seen. Known Emphysema/COPD without change in functional status. Note: CT of the Chest may be used in lieu of a CXR in the absence of recent respiratory symptoms. The following CXR findings do not require Clearance: Emphysema/COPD changes with clear lung fields Calcified Lymph Nodes Granulomatous Disease Atelectasis Tortuosity of Aorta Compression Fracture (old) Kyphosis

7 Osteophytes of Spine Basilar Interstitial Change consistent with scarring Pleural of Parenchymal Scarring