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Clinical Guidelines for Patient Surgery Updated

In its ongoing effort to provide high-value care, Cedars-Sinai has significantly updated its clinical guidelines for patient testing before surgical procedures.

The new policy, which will impact thousands of procedures performed each year throughout the health system, aims to eliminate unnecessary care that exposes a patient to needless risk or wastes time and money.

Under the new guidelines, healthy patients undergoing low-risk procedures should avoid undergoing unnecessary testing. For example, the latest medical evidence shows that previously routine preoperative chest X-rays are unlikely to change treatment plans for patients who have no symptoms or history of heart or lung disease. Therefore, if an otherwise healthy patient is getting a hip replacement, the patient should no longer receive a chest X-ray to be cleared for surgery. This simple change will reduce radiation exposure to patients, save time and reduce unnecessary costs.

The updated guidelines were overseen by the Ambulatory High-Value Care Committee. This diverse group of physicians and executive leaders promotes the practice of evidence-based medicine by translating guidelines from professional medical societies and Choosing Wisely into everyday practice.

"This is a very significant update," said urologist Karyn Eilber, MD, co-chair of the Ambulatory High-Value Care Committee and co-leader of the pre-op guidelines project. "We worked closely with key clinicians in multiple departments to ensure that changes to these guidelines were based on current professional society recommendations and driven by the people it affects."

Some physicians continue ordering unnecessary tests out of an abundance of caution, or just plain habit.

"Change is really hard," said orthopaedic surgeon Robert Klapper, MD.

He worked with the committee on another high-value care initiative—reducing unnecessary pre-op tests that check a patient’s blood type in case they need a blood transfusion (known as a "type and screen"). Klapper explained that when he became an orthopaedic surgeon 30 years ago, joint replacement surgeries were very different.

"We were working with the surgical equivalents of rotary phones compared to today’s iPhones," he said. "When I started in 1989, we made big incisions, cut through muscle and put everyone to sleep. Surgery took a significant amount of time and there was blood loss."

Flash forward to today, and a hip or knee replacement looks totally different. Patients get lighter sedation, a drug helps reduce bleeding and the risk of blood clots, incisions are smaller and there's no need to cut through muscle.

Now that low-risk joint replacement patients normally lose less blood, blood type testing that was once routine is no longer necessary in most patients. Medical societies have changed their guidelines to reflect this progress.

A lightbulb went off for Klapper when Eilber showed him data on how much blood type testing he'd been doing for hundreds of low-risk surgeries each year, versus the number of transfusions needed. Once he was convinced, it didn’t take too much effort to change his pre-op process.

"It was painless," Klapper said.