Preoperative Assessments, Annotated Bibliography Example

Erdogan, D., Balci, O., Karaman, A., Karaman, I., and Cavusoglu, H. (2013). Value of preoperative laboratory tests in elective pediatric outpatient surgery. Pediatrics Research International Journal, 2013, DOI: 10.5171/2013.589490

This article addresses the significance of preoperative laboratory testing for children who require outpatient surgery. One of the critical components of preoperative assessments such as laboratory testing is to identify any possible challenges that may lead to negative surgical outcomes for all patients, including children (Erdogan et.al, 2013). The article considers a patient’s medical history and possible congenital conditions or defects that could lead to complications in the post-surgical state (Erdogan et.al, 2013). The study evaluated the utilization of preoperative testing for over 3,500 children who underwent outpatient elective surgery, and the results demonstrate that 5.2 percent of all patients presented a value that required further evaluation, with 3.1 percent of patients diagnosed with low hemoglobin and anemia based upon these tests (Erdogan et.al, 2013). Furthermore, 1.9 percent of patients had their surgeries postponed as a result of abnormal test results because normal results were essential to the completion of a successful surgery (Erdogan et.al, 2013).

This article is relevant because it conveys the importance of preoperative laboratory testing as recommended by many physicians in order to determine if there are any abnormalities that could lead to complications during or after surgery (Erdogan et.al, 2013). Tests such as complete blood counts and hemoglobin levels are particularly critical for pediatric patients in order to identify an anemic state and the potential need for blood transfusions (Erdogan et.al, 2013). It is necessary for some tests to be performed; however, other tests such as liver function for pediatric patients may not be necessary and could be considered wasteful and cost ineffective (Erdogan et.al, 2013). Therefore, for the pediatric population, a careful examination of these tests must be performed in order to achieve improved patient care outcomes in the postoperative state.

Benarroch-Gampel, J., Sheffield, K.M., Duncan, C.B., Brown, K.M., Han, Y., Townsend Jr., C.M., and Riall, T.S. (2012). Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Annals of Surgery, 256(3), 518-528.

This article addresses the importance of preoperative laboratory tests as a component of the assessment process prior to surgery. The study examined the implementation and impact of these tests for patients who required hernia repair, which is a low-risk procedure (Benarroch-Gampel et.al, 2012). For this patient population, there is likely to be a low risk associated with the surgery in question; therefore, the necessity for laboratory testing at the preoperative stage is low (Benarroch-Gampel et.al, 2012). The article notes that guidelines regarding the standards and recommendations for preoperative surgery are not consistent with technological and surgical advancements; therefore, there is disconnect between these guidelines and current trends in treatment and surgical interventions (Benarroch-Gampel et.al, 2012). Furthermore, the opinions presented in recommendations are not always based upon clinical evidence; therefore, they do not always align with the medical needs of patients (Benarroch-Gampel et.al, 2012).  Based upon the results extracted from the NSQIP study, it was determined that the use of preoperative laboratory testing is not an efficient use of resources reflects weak guidelines and does not ultimately consider individual patient characteristics (Benarroch-Gampel et.al, 2012). These elements must be considered in future studies because the use of these tests does not have any significant or lasting impact on patient outcomes for low-risk candidates for surgery (Benarroch-Gampel et.al, 2012). It is believed that factors such as tradition, possible complications, and other factors may play a role in the utilization of preoperative laboratory testing as common practice for low-risk patients, in spite of the cost and unnecessary nature of these tests (Benarroch-Gampel et.al, 2012). Therefore, it is necessary to reconsider the widespread use of these tests for future patients (Benarroch-Gampel et.al, 2012).

Gregoratos, G. (2008). Controversies in Cardiovascular Medicine: Current Guideline-Based Preoperative Evaluation Provides the Best Management of Patients Undergoing Noncardiac Surgery. Circulation, 117, 3134-3144.

This article addresses the importance of considering cardiac preoperative assessments for non-cardiac patients and to determine their efficacy. This approach was examined in detail with a combined effort from the American Heart Association and the American College of Cardiology in order to determine if these assessments are essential and their favorability for non-cardiac patient populations (Gregoratos, 2008). The rationale behind these evaluations is based upon the reality of cardiovascular disease in much of the patient population, which indicates the necessity determine risks of cardiovascular events in conjunction with non-cardiac surgical procedures (Gregoratos, 2008). Therefore, it is important to identify patients who are at risk of developing a cardiovascular event and to establish whether or not these assessments are critical for this patient population (Gregoratos, 2008). As a result, patients requiring surgeries that are of low risk are not likely to experience any significant cardiac events as a result of these surgeries and therefore, are not likely to require significant and potentially costly preoperative assessment testing (Gregoratos, 2008). These factors are critical because they support a greater understanding of cardiac risk for patients requiring surgeries that are non-cardiac and of low risk so that resources are used wisely and testing is appropriate for this group of patients (Gregoratos, 2008). However, for patients who face higher cardiac risks even with low-risk non-cardiac surgeries, the benefits of preoperative testing are likely to be demonstrated and supported by the expanded use of these tests (Gregoratos, 2008). It is the responsibility of clinicians to make effective and practical decisions regarding the need for preoperative assessments for patients who face greater cardiac risks and to demonstrate their willingness to be effective communicators regarding these assessments on a case-by-case basis (Gregoratos, 2008).

Hepner, D.L. (2009). The role of testing in the preoperative evaluation. Cleveland Clinic Journal of Medicine, 76(Suppl 4), S22-S27.

This article considers the significance of preoperative assessment testing and whether or not it is necessary for patients requiring outpatient surgeries. The article supports the belief that there are significant factors that must be considered when making decisions regarding preoperative testing because there are a number of factors to consider that have a significant impact on patient outcomes (Hepner, 2009). For some patients, these tests are not only unnecessary, but they are also very expensive and do not provide any real benefits to patients prior to low-risk surgery (Hepner, 2009). Therefore, it is important to identify and distinguish between patients who require testing versus those for whom testing is not necessary (Hepner, 2009). Furthermore, tests should not be determined based upon age because this factor does not provide any significant benefit to clinicians when a physical examination is available (Hepner, 2009). In addition, many of these tests which are considered routine will not be approved and paid by insurance, thereby leading to an unnecessary out-of-pocket expense (Hepner, 2009). These elements are critical to the discussion of preoperative testing because they convey the importance of discussing each patient case individually so that there are sufficient opportunities to address whether or not preoperative assessments must include additional tests (Hepner, 2009). It is likely that patients will benefit from sound and reasonable clinical advice and will be provided with a framework that will reduce their risk of complications and improve their chance of recovery (Hepner, 2009). The article conveys the importance of collaborative discussions between clinicians and other personnel in order to determine whether or not patients require additional or extensive testing and evaluation during the preoperative phase so that the most appropriate strategy is chosen for patients who require surgery that is low risk in the outpatient setting (Hepner, 2009).

Brown, S.R., and Brown, J. (2011). Why Do Physicians Order Unnecessary Preoperative Tests? A Qualitative Study. Family Medicine, 43(5), 338-343.

This article considers an important question that is common throughout healthcare facilities in regards to preoperative testing and its level of necessity for patient populations. To be specific, the article addresses the high cost and inefficiency associated with many preoperative tests, thereby creating an environment whereby these tests are ordered without just cause (Brown and Brown, 2011). However, physicians possess varied opinions regarding the use of preoperative tests, with some experts supporting the need for these tests on a frequent basis and others expressing a lack of support for these tests (Brown and Brown, 2011). Therefore, it is important to identify evidentiary support for these tests and whether or not it is sufficient to make decisions regarding preoperative testing for patients (Brown and Brown, 2011). For many physicians, ordering preoperative testing even if unnecessary is a routine practice method, and it also conveys a level of worry regarding what might be missed in a patient’s medical status if these tests are not conducted (Brown and Brown, 2011). Therefore, it is important for physicians to discuss the necessity of these tests and the role of expanded education in enabling physicians to make these decisions in an intelligent and thoughtful manner (Brown and Brown, 2011). These efforts will provide a greater understanding of the challenges and limitations of preoperative testing and its role in low-risk outpatient surgeries, particularly when patients are otherwise healthy and do not appear to be at high risk of developing a more serious condition (Brown and Brown, 2011). The results derived from these tests are not likely to make any real difference for some patients; therefore, physicians must question whether or not their need is warranted and appropriate (Brown and Brown, 2011). These factors are critical in order to support a greater understanding of the challenges related to quality of care and safety for patients in these settings (Brown and Brown, 2011).

Smetana, G.W. (2010). Preoperative medical evaluation of the healthy patient. UpToDate, 18(2), retrieved from http://www.vtcardsfellows.com/pdf/Guidelines/Pre-operativeManagement/Preop_Medical_Evaluation_of_the_Healthy_Patient.pdf

This article identifies the importance of specific factors that are associated with preoperative assessments and their role in adequately preparing patients for surgical procedures, particularly in the outpatient setting.  It is important to identify the potential for selectivity in determining whether or not testing is required, thereby creating an environment whereby important questions are raised regarding the value of these tests for patients who are deemed healthy (Smetana, 2010). From this perspective, it may be argued that there are significant factors associated with the value of these tests in determining whether or not there will be a greater risk during the outpatient surgical event (Smetana, 2010). When conducting a preoperative assessment, it is necessary to determine the level of risk for a given patient and whether or not preoperative testing is warranted and necessary (Smetana, 2010). These factors play a critical role in determining whether or not patients require preoperative assessments that involve testing and if it is essential to their cases (Smetana, 2010). Most importantly, it is necessary to determine if other factors may pose a risk to patients that could warrant preoperative testing (Smetana, 2010). These factors are critical because they reflect the importance of factors such as age, prior medical history, and exercise potential as part of the assessment process in determining if additional testing is necessary (Smetana, 2010). For patients who might face these risks, it is important to develop new strategies to evaluate patients that are cost effective and that have a positive impact on patients prior to surgery (Smetana, 2010). These factors will support a greater understanding of the critical issues that are relevant to physicians as they examine patient needs and overall status before they have surgery in the outpatient setting, even at low risk (Smetana, 2010).

Practice Advisory for Preanesthesia Evaluation: An Updated Report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology, 116(3), 1-17.

This article addresses the significance of different factors that are associated with obtaining an assessment prior to the administration of anesthesia. This framework mandates that the role of preoperative testing is completed with the best interests of patients in mind and with a prior understanding of a patient’s medical history (American Society of Anesthesiologists, 2012). For patients who require anesthesia in the outpatient setting, the assessment process is particularly relevant because it supports a detailed understanding of a patient’s history and the potential risks that are involved when receiving anesthesia (ASA, 2012). These factors are critical because they are likely to determine the need for additional testing that could contribute to unnecessary costs and time (ASA, 2012). The practice guidelines indicate that there are a number of factors to consider that play a role in determining whether or not individual patients might benefit from preoperative testing and to evaluate the means by which these decisions are made (ASA, 2012). It is important to note that preoperative testing should not be considered as a routine process and that there are other factors that must be considered before determining if these tests are warranted (ASA, 2012). Tests should also be considered in conjunction with the timing of any medical events that have been recorded in patient histories, because this process will enable physicians to determine if preoperative testing is worth the additional time and expense (ASA, 2012). These factors are instrumental in determining whether or not the clinical presentation of evidence within a patient’s chart, coupled with age and other factors, are sufficient to warrant further testing (ASA, 2012). It is believed that the guidelines regarding preoperative assessments must be considered on a continuous basis in order to determine if additional testing is warranted for some patients requiring anesthesia in the outpatient setting (ASA, 2012).

Chow, W.B., Ki, C.Y., Rosenthal, R.A., and Esnaola, N.F. acs nsqip®/ags best Practice guidelines: Optimal Preoperative Assessment of the Geriatric Surgical Patient. American College of Surgeons, 1-49.

These guidelines were established by the American College of Surgeons (ACS) in order to provide a summary of questions to ask and recommended approaches to evaluate patients prior to surgery. In older patients, for example, it may be necessary to evaluate their needs based upon cognitive assessments so that patients are able to make effective decisions for themselves, particularly when surgery is required (Chow et.al). Furthermore, it may be necessary to conduct a depression screening for some patients to determine if there may be an additional risk associated with surgery (Chow et.al). Factors such as delirium and alcohol use must also be considered and provide a basis for examining patients who require surgery (Chow et.al). Patients should be considered for expanded cardiac and/or pulmonary assessments, depending upon their medical histories and any other factors that might contribute to increased risks (Chow et.al). The ability to function and move about in patients who are ambulatory is essential because it may determine whether or not a patient is able to manage surgery and improve quality of life (Chow et.al). Clinicians must consider the different perspectives of older patients and determine whether or not they require additional tests prior to surgery (Chow et.al). Patients with nutritional concerns should also be considered because there is a potentially greater risk, depending on the nature of the surgery and other factors that may contribute to negative outcomes (Chow et.al). For older patients, regardless of the circumstances, there is a higher level of risk associated with surgery; therefore, additional measures must be considered that will provide a basis for evaluating this population group differently than other populations that may be deemed lower risk (Chow et.al). These efforts are critical to the continued development of guidelines that govern the geriatric population.

Patient Safety Authority (2009). Patient screening and assessment in ambulatory surgical facilities. Pennsylvania Patient Safety Advisory, 6(1), 3-9.

This article addresses the importance of ambulatory surgical facilities (ASFs) and their importance to patients requiring surgery that does not require hospitalization (PSA, 2009). Many procedures are performed in these facilities; however, the level of risk for patients is highly individual and must be addressed on a case-by-case basis (PSA, 2009). Clinicians must identify the level of need for preoperative testing and the conditions that are most common and that should be examined if testing is deemed necessary (PSA, 2009). However, some of the criteria that are used to determine whether or not testing is required may not be effective in determining if patients are ready for surgery (PSA, 2009). Furthermore, a set of risk factors have been identified that are important in determining when to conduct additional preoperative testing procedures (PSA, 2009). From a clinical perspective, patients must be screened so that they are deemed sufficiently healthy to undergo a surgical procedure, and this is best accomplished by using a complex set of criteria that have a significant impact on patient care and wellbeing for surgical candidates (PSA, 2009). A number of steps are described in the article that summarize the requirements prior to admission for a given surgical procedure, including nurse assessment and patient follow up so that all checklists are complete and are completed in a timely manner (PSA, 2009). Patient histories are a critical component of the preoperative process because they support a greater understanding of the issues that may pose a risk to patients or that could interfere with surgical outcomes (PSA, 2009). Therefore, it is expected that additional resources will be utilized to ensure that patient outcomes are timely and appropriate for the patient’s medical history and recovery, including the preoperative process and any required testing (PSA, 2009).

Johansson, T., Fritsch, G., Flamm, M., Hansbauer, B., Bachofner, N., Mann, E., Bock, M., and Sonnichsen, C. (2013). Effectiveness of non-cardiac preoperative testing in non-cardiac elective surgery: a systematic review. British Journal of Anaesthesia, doi: 10.1093/bja/aet071

This article addresses the importance of new perspectives regarding non-cardiac surgery and the issues that are most relevant in the development of new approaches to preoperative testing methods. The article demonstrates that the implementation of preoperative testing and evaluation is designed for a specific purpose; however, it does not always provide any realized benefits to patients who face surgery (Johansson et.al, 2013). Most importantly, the article conveys that “There is no evidence derived from high-quality studies that supports routine preoperative testing in healthy adults undergoing non-cardiac surgery” (Johansson et.al, 2013). From this perspective, it is critical for clinicians to recognize that in cases where non-cardiac elective surgery is required, there is a potentially greater risk of obtaining preoperative testing when it is not really necessary and is not cost effective (Johansson et.al, 2013). This perspective supports the belief that many preoperative tests and assessments are far too excessive and do not provide clinicians with any useful information that will enable them to make decisions regarding the risks associated with surgery (Johansson et.al, 2013). However, there is a longstanding belief that preoperative testing is necessary prior to almost every form of surgery, including non-cardiac forms (Johansson et.al, 2013). These factors demonstrate that there are a number of misconceptions regarding preoperative testing that play a critical role in determining whether or not patients will benefit from these tests and if the results will have any real bearing on surgical outcomes (Johansson et.al, 2013). The article supports the belief that in order to make effective decisions regarding preoperative testing, additional resources and evaluations must be conducted using existing evidence in order to demonstrate the lack of effectiveness of these tests from a clinical perspective (Johansson et.al, 2013).

Feely, M.A., Collins, C.S., Daniels, P.R., Kedebe, E.B., Jatoi, A., and Mauck, U.F. (2013). Preoperative testing before noncardiac surgery: guidelines and recommendations. American Family Physician, 87(6).

This article provides a number of frameworks under which clinicians make important decisions regarding patients undergoing surgery and the decision to have preoperative testing. This process is complex and multifaceted and requires an effective understanding of the issues that are most relevant in supporting positive surgical outcomes (Feely et.al, 2013). The guidelines for patients requiring noncardiac surgery include the following: “Patients undergoing low-risk surgery do not require electrocardiography. Chest radiography is reasonable for patients at risk of postoperative pulmonary complications if the results would change perioperative management” (Feely et.al, 2013). The efforts that are made by physicians to determine the necessity for preoperative testing require their full understanding of the consequences of ordering unnecessary tests and the implications for insurance coverage under these conditions (Feely et.al, 2013). Furthermore, it is possible that there might be additional challenges to consider that are indicative of an increased risk for patients who have undergone testing, or that if testing is abnormal, surgery will not take place (Feely et.al, 2013). There is also a risk that patients with abnormal test results might be cleared for surgery yet experience unforeseen and preventable complications (Feely et.al, 2013). Therefore, additional methods must be considered that emphasize the importance of evaluating all patients carefully so that the decisions made regarding their pending surgery are appropriate and timely (Feely et.al, 2013). Furthermore, testing must be deemed necessary so that patients are provided with the best possible scenarios, given the possible risks associated with surgery and the potential outcomes that may occur under some conditions (Feely et.al, 2013).

Siriussawakul, A., Nimmannit, A., Rattanaarpa, S., Chatrattanakulchai, S., Saengtawan, P., and Wangdee, A. (2013). Evaluating compliance with institutional preoperative testing guidelines for minimal-risk patients undergoing elective surgery. BioMed Research International, 2013, http://dx.doi.org/10.1155/2013/835426

This article addresses the significance of preoperative testing for patients who are deemed low-risk. It has been determined that these tests are not for all patients and that some patients are sufficiently healthy so that they do not require additional preoperative testing (Siriussawakul, 2013). Therefore, it is necessary for clinicians to consider these differences and to demonstrate the importance of physical examinations as a routine component of the preoperative process because they are likely to answer some of the most important questions that should be considered in the preoperative setting (Siriussawakul, 2013). Patients facing surgery are often at risk of complications; however, when they are deemed low risk, it is likely that they will face additional challenges and cost if they are unnecessarily tested for conditions that they are not likely to have (Siriussawakul, 2013). In this context, only those patients who are at the greatest risk should be examined with greater depth and with various types of preoperative tests (Siriussawakul, 2013). Clinicians must learn to use the physical examination and other evaluation tools in an effective manner so that they are able to distinguish between low and high risk patients without hesitation or delays (Siriussawakul, 2013). This process will enable clinicians to focus their efforts on patients who require preoperative testing rather than those who do not (Siriussawakul, 2013). Most importantly, making decisions regarding preoperative testing is essential to a patient’s wellbeing and recovery (Siriussawakul, 2013). The use of existing guidelines is critical in the decision-making process regarding preoperative testing and assessment methods in order to ensure that the desired tests and evaluations are conducted only when deemed necessary (Siriussawakul, 2013).

Chung, F., Yuan, H., Vairavanathan, S., and Wong, D.T. (2009). Elimination of preoperative testing in ambulatory surgery. Ambulatory Anesthesiology, 108(2), 467-475.

This article demonstrates the belief that preoperative testing is ineffective and does not have any real benefit for patients, particularly in low risk settings. A number of factors must be considered that have a significant impact on patient care and wellbeing for ambulatory surgical patients, including the elimination of preoperative testing for most patients (Chung et.al, 2009). Patients who require surgery and who are not considered to be high risk should not be required to have preoperative testing because it is unnecessary and wasteful (Chung et.al, 2009). However, an evaluation of any possible events associated with eliminating preoperative testing must also be considered (Chung et.al, 2009). The study sought to determine this risk; therefore, two groups were examined: one who received preoperative testing and one who did not (Chung et.al, 2009). The study results indicate that there is no additional risk associated with reducing or eliminating preoperative testing for patients who are deemed low risk (Chung et.al, 2009). It is important to identify this risk because if there are additional complications when these tests are eliminated, then there would appear to be a direct correlation between these two events (Chung et.al, 2009). When these tests are not utilized on a consistent basis, healthcare evaluations are likely to be more cost effective and appropriate for the needs of patients who otherwise are healthy and do not meet specific criteria (Chung et.al, 2009). Most importantly, it is necessary to conduct additional studies using a larger population group in order to determine if this risk is indeed minimal (Chung et.al, 2009). These efforts will provide a greater understanding of the challenges associated with outpatient surgery and the need for preoperative testing for some patients who might be at risk for complications (Chung et.al, 2009).

Agency for Healthcare Research and Quality (2010). Evidence-based patient safety advisory: patient selection and procedures in ambulatory surgery. Retrieved from http://www.guideline.gov/content.aspx?id=15334

This set of guidelines provides a framework in order to better understand the selection process for patients who require ambulatory surgery. It is necessary for clinicians to determine a patient’s individual risk if surgery is performed and to address the possible complications that might occur (AHRQ, 2010). Some of the basic preoperative assessments are critical such as blood pressure and heart rate, because these are part of the intake process and basic medical history (AHRQ, 2010). Most importantly, patients should be evaluated in accordance with the established regulations set forth so that all possible complications are minimized (AHRQ, 2010). Within this context, it is important to identify areas where additional attention must be paid during the preoperative process, such as cardiovascular concerns, prior risk factors, and stress, amongst others (AHRQ, 2010). Each of these areas is essential because it conveys the importance of evaluating patients prior to surgery in a thorough yet cost effective manner (AHRQ, 2010). These elements are essential to the discovery of new techniques and approaches that will generate positive results and enable clinicians to make responsible decisions regarding surgical patients (AHRQ, 2010). These guidelines are based upon existing evidence; therefore, the nature of this evidence is critical and the recommendations provided to clinicians must be comprehensive, insightful, and appropriate for the population group in question (AHRQ, 2010). These elements will play a significant role in determining whether or not the preoperative assessment phase should include additional testing or if this is not required (AHRQ, 2010). These guidelines are indicative of a comprehensive framework that will provide clinicians with the resources that are necessary to achieve the desired outcomes (AHRQ, 2010).

Kumar, A., and Srivastava, U. (2011). Role of routine laboratory investigations in preoperative evaluation. Journal of Anesthesia Clinical Pharmacology, 27(2), 174-179.

This article addresses the utilization of standard laboratory tests in order to determine their effectiveness in preoperative assessments. There are several different types of laboratory tests; however, routine tests are often performed prior to surgery and are not associated with a specific health condition or event (Kumar and Srivastava, 2011). When tests are required to determine a specific diagnosis, they are likely to be more cost effective and appropriate for patients so that a diagnosis is determined (Kumar and Srivastava, 2011). However, routine testing is not typically cost effective and does not provide any realized benefits to patients requiring low-risk noncardiac surgery (Kumar and Srivastava, 2011). There have been a number of arguments against routine testing prior to low-risk outpatient surgeries because they are not positive predictors of any possible complications or other concerns (Kumar and Srivastava, 2011). Therefore, additional measures must be considered to ensure that these tests are not conducted without good reason (Kumar and Srivastava, 2011). It is expected that patient safety must be a critical priority in reducing the risk of poor outcomes and complications related to outpatient surgery; therefore, it is expected that routine tests should not be performed because they may actually lead to unnecessary complications in some cases (Kumar and Srivastava, 2011). Therefore, clinicians must evaluate all patients thoroughly during the preoperative stage so that they are able to understand the possible complications that might occur, given personal health histories and other factors (Kumar and Srivastava, 2011). These contributions will support the continued growth and development of new perspectives in order to ensure that patients are treated according to standard that also support their health and wellbeing at all times (Kumar and Srivastava, 2011).

References

Agency for Healthcare Research and Quality (2010). Evidence-based patient safety advisory: patient selection and procedures in ambulatory surgery. Retrieved from http://www.guideline.gov/content.aspx?id=15334

Benarroch-Gampel, J., Sheffield, K.M., Duncan, C.B., Brown, K.M., Han, Y., Townsend Jr., C.M., and Riall, T.S. (2012). Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Annals of Surgery, 256(3), 518-528.

Brown, S.R., and Brown, J. (2011). Why Do Physicians Order Unnecessary Preoperative Tests? A Qualitative Study. Family Medicine, 43(5), 338-343.

Chow, W.B., Ki, C.Y., Rosenthal, R.A., and Esnaola, N.F. acs nsqip®/ags best Practice guidelines: Optimal Preoperative Assessment of the Geriatric Surgical Patient. American College of Surgeons, 1-49.

Chung, F., Yuan, H., Vairavanathan, S., and Wong, D.T. (2009). Elimination of preoperative testing in ambulatory surgery. Ambulatory Anesthesiology, 108(2), 467-475.

Erdogan, D., Balci, O., Karaman, A., Karaman, I., and Cavusoglu, H. (2013). Value of preoperative laboratory tests in elective pediatric outpatient surgery. Pediatrics Research International Journal, 2013, DOI: 10.5171/2013.589490

Feely, M.A., Collins, C.S., Daniels, P.R., Kedebe, E.B., Jatoi, A., and Mauck, U.F. (2013). Preoperative testing before noncardiac surgery: guidelines and recommendations. American Family Physician, 87(6).

Gregoratos, G. (2008). Controversies in Cardiovascular Medicine: Current Guideline-Based Preoperative Evaluation Provides the Best Management of Patients Undergoing Noncardiac Surgery. Circulation, 117, 3134-3144.

Hepner, D.L. (2009). The role of testing in the preoperative evaluation. Cleveland Clinic Journal of Medicine, 76(Suppl 4), S22-S27.

Johansson, T., Fritsch, G., Flamm, M., Hansbauer, B., Bachofner, N., Mann, E., Bock, M., and Sonnichsen, C. (2013). Effectiveness of non-cardiac preoperative testing in non-cardiac elective surgery: a systematic review. British Journal of Anaesthesia, doi: 10.1093/bja/aet071

Kumar, A., and Srivastava, U. (2011). Role of routine laboratory investigations in preoperative evaluation. Journal of Anesthesia Clinical Pharmacology, 27(2), 174-179.

Patient Safety Authority (2009). Patient screening and assessment in ambulatory surgical facilities. Pennsylvania Patient Safety Advisory, 6(1), 3-9.

Practice Advisory for Preanesthesia Evaluation: An Updated Report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology, 116(3), 1-17.

Siriussawakul, A., Nimmannit, A., Rattanaarpa, S., Chatrattanakulchai, S., Saengtawan, P., and Wangdee, A. (2013). Evaluating compliance with institutional preoperative testing guidelines for minimal-risk patients undergoing elective surgery. BioMed Research International, 2013, http://dx.doi.org/10.1155/2013/835426

Smetana, G.W. (2010). Preoperative medical evaluation of the healthy patient. UpToDate, 18(2), retrieved from http://www.vtcardsfellows.com/pdf/Guidelines/Pre-operativeManagement/Preop_Medical_Evaluation_of_the_Healthy_Patient.pdf