Conducting Preoperative Planning

Documents to Request

• Complete H&P (within 30 days per CMS requirements, updated within 24 hours of surgery)
• Relevant imaging studies with radiology reports
• Cardiology clearance (if indicated by RCRI score or active cardiac conditions)
• Pulmonary function tests (if thoracic surgery or significant pulmonary disease)
• Current medication list with last doses of anticoagulants
• Prior operative reports (for revision or re-operative cases)
• Laboratory results: CBC, BMP, coagulation studies, type and screen/crossmatch
• Anesthesia pre-assessment documentation

Step 1: Patient Risk Stratification

Apply standardized risk assessment tools:

For each tool applied, record:

• Score and interpretation
• Whether the score triggers additional workup (e.g., RCRI ≥3 → consider cardiology consultation)
• Patient-specific modifying factors not captured by the tool

Step 2: Imaging Review and Anatomic Planning

Structure the imaging review as follows:

1. Modality and date — List each study reviewed (CT, MRI, ultrasound, plain film, angiography) with date obtained.
2. Key anatomic findings — Describe relevant anatomy that will affect the surgical approach (e.g., aberrant hepatic artery, renal vein anomaly, extent of tumor involvement).
3. Measurements — Record sizes of lesions, distances from critical structures, vessel diameters.
4. Approach implications — Document how imaging findings influence port placement, incision planning, or need for vascular control.
5. Additional imaging needed — Flag gaps (e.g., "CT angiography recommended to delineate mesenteric vascular anatomy prior to pancreaticoduodenectomy").

For complex cases, include annotated imaging screenshots or 3D reconstruction references.

Step 3: Equipment, Instrumentation, and Team Requirements

Build the OR resource checklist:

• Instrumentation trays: List specific trays by name (e.g., major laparotomy set, vascular set, thoracotomy tray)
• Energy devices: Harmonic scalpel, LigaSure, argon beam coagulator, monopolar/bipolar
• Specialized equipment: Robotic system (which platform, arm count), C-arm fluoroscopy, intraoperative ultrasound, neuromonitoring, cell saver
• Implants and prosthetics: Mesh type and size, stents, vascular grafts — have alternates available
• Blood products: Type and screen vs. crossmatch; number of units to have available
• Positioning aids: Bean bag, Allen stirrups, shoulder roll, Mayfield head clamp
• Team composition: Surgeon, first assistant, scrub tech vs. scrub nurse, circulating nurse, anesthesia team, additional specialties on standby (e.g., vascular surgery, interventional radiology)

Step 4: Anticoagulation and Medication Management

Create a preoperative medication plan:

Document bridging anticoagulation plan if indicated (e.g., LMWH bridge for mechanical valve patients).

Step 5: Preoperative Optimization Checklist

Before confirming the surgery date, verify:

• Hemoglobin A1c < 8% for elective cases (ACS and Endocrine Society guidance)
• Smoking cessation ≥4 weeks (reduces wound complications per Cochrane evidence)
• Nutritional status assessed; albumin ≥3.0 g/dL (ACS NSQIP predictor)
• Dental clearance obtained (if cardiac surgery or implant placement)
• MRSA screening completed (if institutional protocol requires)
• Bowel prep ordered (if colorectal surgery per ERAS guidelines)
• Preoperative surgical site marking completed by operating surgeon
• Consent form signed with correct procedure, laterality, and surgeon name

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Are all risk scores calculated and documented with implications?
2. Has imaging been reviewed and anatomic concerns addressed in the surgical plan?
3. Is the anticoagulation management plan explicit with hold/resume dates?
4. Does the equipment list match the planned procedure and any contingencies?
5. Are all preoperative optimization criteria met or exceptions documented?

Quality Audit

• ASA classification assigned and documented
• RCRI score calculated for patients ≥45 years or with cardiac history
• ACS NSQIP risk calculator completed for major surgery
• Caprini VTE score calculated with prophylaxis plan
• All relevant imaging listed with dates and key findings summarized
• Equipment and instrumentation checklist generated
• Blood product plan documented (type and screen vs. crossmatch with units)
• Medication management plan documented with hold/resume dates
• Preoperative labs reviewed and within acceptable ranges
• H&P completed within 30 days and updated within 24 hours of surgery
• Surgical consent signed with correct laterality
• Operating surgeon has marked the surgical site
• Anesthesia pre-assessment completed

Guidelines

1. The H&P must be completed within 30 days of surgery per CMS CoP and updated within 24 hours — no exceptions for elective cases.
2. Never proceed with a planned case if the type and screen is expired; repeat if older than 72 hours per institutional blood bank policy.
3. For patients on anticoagulation, always document the indication for anticoagulation and the rationale for the hold/bridge decision.
4. Involve anesthesia early for patients with ASA ≥ III, anticipated difficult airway, or significant cardiac/pulmonary disease.
5. For re-operative cases, obtain and review all prior operative reports — adhesion density and altered anatomy significantly affect planning.
6. Document a contingency plan for the most likely intraoperative complication (e.g., "if unable to achieve laparoscopic access due to adhesions, will convert to midline laparotomy").
7. Ensure SCIP/CMS core measures compliance: appropriate antibiotic selection and timing, VTE prophylaxis plan, and normothermia maintenance plan.