Anaesthesia clinics: the Canadian experience

We would like to comment on the recent editorials and correspondence regarding anaesthesia consultation clinics [1-6]. As British trained anaesthetists working in Canada we would like to submit our experiences of working in an anaesthesia clinic. We agree with Professor Webster [2] that advantages are gained in enhanced training opportunities and perception of the physician anaesthetist's role but also feel that significant benefits come from reduction in late cancellations with a subsequent reduction in patient inconvenience and wasted operating time. At our institution, no patients admitted on the day of surgery were cancelled due to inadequate pre-operative preparation in the latest 3-month period. During this time, 98% of elective surgical patients (total 3161 cases) arrived in hospital on the day of surgery and 77% were discharged the same day. We do not agree with Dr Davies' assertion that it will be difficult to show clinics to be cost effective [5]. At Toronto Western Hospital, the cost of an hour lost in the operating room is $CDN200 (£93) excluding the salaries of medical staff, and an overnight stay costs $CDN3000 (£1400). By combining ‘same day-admit’ for inpatient elective surgery with anaesthesia clinics, savings are made not only in reduced hotel costs but also from a reduction in wasted operating time. The practice of admitting patients on the day of surgery offers little opportunity to ensure that patients with complex comorbidity are adequately investigated or counselled. Our experience, in line with the literature [7], is that the anaesthesia clinic plays a major role in reducing cancellations and gives more time for patient assessment. A consultant-led clinic can therefore lead to an improvement in quality as well as cost savings. We would share Dr Baines' concerns [6] if clinics were delegated to unsupervised trainees. At Toronto Western, all consultations are undertaken by, or with direct supervision from, fully trained anaesthetists. An argument against clinics is that individual anaesthetists may feel that pre-operative investigation or counselling differs from that which they themselves would recommend. In our experience, open dialogue with colleagues leads to an improved awareness of other clinical viewpoints and can be educational. We find that the presence of the anaesthesia clinic encourages teamwork in this department. Having seen a patient where a complex anaesthesia plan is required, a note is made and stored in a file of difficult patients. This file is of use both to the anaesthetist in charge of the case and to trainees, both to direct them to challenging cases, and for case study teaching. Clearly the anaesthetist giving the anaesthetic will also wish to see the patient on the day of surgery. Such a visit is considerably facilitated with all information to hand. The anaesthesia clinic at Toronto Western has been a valuable tool for improving operating room efficiency whilst enhancing our public profile and offering valuable educational opportunities for anaesthesia trainees and consultants alike. We arrived in Toronto with a sceptical view of the benefit of anaesthesia clinics, but now see that there are clear advantages to be gained from a well-organised, well-staffed clinic.

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