Eur J Anaesthesiol 2024; 41:813–820

ORIGINAL ARTICLE
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Pre-operative triAge proCedure to streaMline elective

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surgicAl patieNts (PACMAN) improves efficiency by

selecting patients eligible for phone consultation
A retrospective cohort study
Manuela Di Biase, Babette van der Zwaard, Fenne Aarts and Barbe Pieters

BACKGROUND Pre-operative screening is a high volume MAIN OUTCOME MEASURES Primary outcome was the
task consuming time and resource. Streamlining patient flow reduction in number of in-PCs. Secondary outcomes includ-
= on 10/10/2024

by gathering information in advance reduces costs, opti- ed reliability of PACMAN, peri-operative patient outcomes
mises resources and diminishes patient burden whilst main- and cost-effectiveness.
taining safety of care.
RESULTS Of 965 patients triaged by PACMAN, 705
OBJECTIVE To evaluate whether ‘Pre-operative triAge pro- (73.1%) were identified as suitable for a PhC. Of those,
Cedure to streaMline elective surgicAl patieNts’ (PACMAN) 688 (97.6%) were classified American Society of Anesthe-
is able to improve pre-operative screening by selecting siologists Physical Status (ASA-PS) I to II or III with stable
patients eligible for evaluation by telephone. comorbidities. Of the 260 in-PC patients, 47.4% were
classified ASA-PS III with unstable comorbidities or ASA-
DESIGN A single-centre, retrospective, observational cohort
PS IV. The overall incidence of unanticipated adverse peri-
analysis.
operative events was 1.3%. Finally, implementation of PAC-
SETTING A tertiary medical teaching hospital in ‘s-Herto- MAN led to a 20% increase in pre-operative department
genbosch, The Netherlands. efficiency due to better deployment of personnel and
resources.
PATIENTS AND METHODS Adults scheduled for clinical
interventions under procedural sedation and all types of CONCLUSION Implementation of PACMAN resulted in a
elective medium or low risk surgery with anaesthetic guid- 73.1% reduction in pre-operative in-PCs at our hospital.
ance were eligible. Patients answered a questionnaire to Given the increasing pressure on healthcare systems glob-
calculate the PACMAN score. This score combined with risk ally, we suggest developing further optimisation and integra-
factors related to surgery determines suitability for phone tion of smart triage solutions into the pre-operative process.
consultation (PhC) or the need for an in-person consultation
TRIAL REGISTRATION ClinicalTrials.gov Identifier:
(in-PC).
NCT06148701
INTERVENTION Evaluation of standard care. Published online 9 September 2024

From the Department of Anaesthesiology and Pain Medicine (MDB, FA, BP), Department of Orthopaedics (BVDZ), Jeroen Bosch Hospital, ‘s-Hertogenbosch, the
Netherlands
Correspondence to Barbe Pieters, MD, PhD, Department of Anaesthesiology and Pain Medicine, Jeroen Bosch Hospital, Henri Dunantstraat 1, 5223 GZ ’s-
Hertogenbosch, the Netherlands
Tel: +31 073 553 2000; e-mail: [email protected]
0265-0215 Copyright ! 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the European Society of Anaesthesiology and Intensive Care.
DOI:10.1097/EJA.0000000000002055
This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is
permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
 814 Di Biase et al.

number 2021.08.06.01). Earlier on the 6 September

KEY POINTS 2021, the Medical Ethical Committee Brabant (METC
Brabant reference number NW2021–83) had waived the
! Rising pressure on healthcare systems and scarcity of
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need for written informed consent. This study was regis-

medical resources push for an alternative to the tered at ClinicalTrials.gov (NCT06148701) and adheres
conventional anaesthesiologist-led in to the applicable Equator guidelines.
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person assessment.
! The PACMAN triage model, based on patient and
surgery risk factors, is suitable for identifying those Design and patients
patients who can be evaluated by phone and leads to The PACMAN triage procedure was developed for
a substantial reduction in the number of pre- patients aged at least 18 years, scheduled for clinical
operative visits. interventions under procedural sedation and all types
! Implementation of PACMAN led to an increase in of elective medium or low risk surgery with anaesthetic
effectiveness of the anaesthesiology pre-operative guidance, as defined by the European Society of Anaes-
outpatient clinic with a low incidence of unantici- thesiology and Intensive Care (ESAIC) guidelines.9
pated adverse events. Patients scheduled for emergency and high-risk surgery
! Additional research is needed to evaluate the accu- were excluded as the policy of our department dictates
racy of PACMAN after incorporation in the elec- that these patients must always be seen in person, accord-
tronic medical record (EMR) software and its ing to ESAIC guidelines.9
= on 10/10/2024

feasibility in other settings. PACMAN was designed by a team consisting of three

anaesthesiologists, three nurses certified with a Bache-
lor’s degree in Nursing in PreOperative Screening (POS),
one registered nurse and the pre-operative clinic depart-
Introduction
ment coordinator. Following an extensive literature
An anaesthesiologist-led in-person assessment has been
search on guidelines and risk assessment scores, we
shown to drastically improve clinical outcome, becoming
defined patient and surgery-related risk factors for post-
the standard of care over the past three decades.1 How-
operative complications and incorporated them in a de-
ever, rising pressure on healthcare systems and scarcity of
cision supporting algorithm.9–16
medical resources have increased interest in alternatives
to in-person evaluation, such as screening by phone and Our pre-operative clinic is staffed by one anaesthesiologist,
teleconsultations.2 Different strategies to streamline the one resident, four to five registered nurses and six POS
pre-operative process have been explored, including the nurses on a daily basis. Before implementation of PAC-
use of health questionnaires, computer-assisted prescre- MAN, all patients were screened in person by the POS
ening models and screening software.3–8 These nurses or a resident and reviewed by the attending anaes-
approaches have led to a reduction in the number of thesiologist. After implementation, triage interviews were
pre-operative visits, with a surgery cancellation rate com- conducted by phone by registered nurses as part of the
parable to the conventional screening method and a high routine nursing preadmission assessment. Beforehand, the
rate of patient satisfaction. We developed ‘Pre-operative patient’s age, any potential language barrier and the level
triAge proCedure to streaMline elective surgicAl of surgical invasiveness were acquired from the hospital
patieNts’ (PACMAN) as a stratification tool to determine electronic medical record (EMR). To obtain the triage
whether patients should undergo screening in person (in- information about a patient’s health, the patient was asked
PC) or by phone (PhC). We evaluated this newly to complete a brief questionnaire, together with the RN.
designed triage procedure that combines patient comor- This questionnaire includes 10 primary questions target-
bidities with risk factors related to surgery. We hypothe- ing the presence of patient-related risk factors, and eight
sised that the implementation of PACMAN in a follow-up questions to distinguish between stable and
comprehensive screening process would lead to a signifi- unstable comorbidities (SDC 1, http://links.lww.com/
cant reduction in the number of in-PCs. In addition, we EJA/B27).9–15 Comorbidities were judged stable when
evaluated the reliability of PACMAN and its impact on treated under medical supervision without symptoms re-
peri-operative patient outcomes. Finally, cost-effective- quiring frequent monitoring or adjustment of treatment.17
ness and efficiency are discussed. The registered nurse used the information acquired from
the questionnaire to calculate the PACMAN score in order
Materials and methods to determine which kind of screening should be performed
Ethics (Fig. 1). Patients aged at least 70 years and/or presenting
This single-centre, retrospective observational cohort with a Metabolic Equivalent of Task (MET) score 4 or less
study was approved by the Institutional Review Board were always scheduled for an in-PC, as we assumed that
(IRB) of the Jeroen Bosch Hospital, ‘s-Hertogenbosch, age at least 70 years or poor exercise tolerance is associated
The Netherlands on 23 September 2021 (reference with more severe comorbidities and increased risk of

Eur J Anaesthesiol 2024; 41:813–820

 Triage for pre-operative screening 815

Fig. 1 Triage decision tree.

Triage by PACMAN
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Age ≥ 70
Patient Request
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Language barrier

Or

Unstable conditions:
BMI > 40 kg m-2
MET ≤ 4 Yes In-person
Symptomatic heart disease consultation
Untreated hypertension
Symptomatic asthma/COPD
Untreated OSAS
CVA/TIA < 6 months
Unstable DM/Insulin use
Neuromuscular disease
Renal disorder
= on 10/10/2024

No

Risk Factors (RF):

Stable heart disease
Stable asthma/COPD 0-1RF Phone
CVA/TIA > 6 months consultation
Stable DM
Treated OSAS

≥ 2RF

Medium risk surgery Low risk surgery

In-person consultation Phone consultation

BMI, Body Mass Index (kg m-2)

Obstructive Pulmonary Disease; OSAS, Obstructive Sleep Apnoea Syndrome; CVA,
Cerebrovascular Accident; TIA, Transient Ischaemic Attack; DM, Diabetes Mellitus; RF, Risk
Factors.

postoperative complications.18,19 Regardless of the out- ECG, these tests were carried out on the day of surgery.
come of the triage procedure, patients were always able to These patients were not planned for the first time slot to
request an in-PC. Patients’ wish and either the presence of allow sufficient time for the additional examination. Test
a BMI at least 40 kg m"2 or a language barrier automatically outcomes were reviewed by the attending anaesthesiolo-
led to an in-PC. Further more, patients who presented with gists and changes in policy were left to their judgement.
one or more unstable comorbidities or with at least two risk
factors scheduled for medium risk surgery were always Outcome measures
planned for an in-PC. After the triage procedure, all PhCs Reliability of the triage procedure was evaluated by
and in-PCs were carried out by POS nurses or a resident. verifying the PACMAN outcome (PhC vs. in-PC) against
The attending anaesthesiologist reviewed all screening the assigned American Society of Anesthesiologists Phys-
records and could overturn the triage algorithm outcome, ical Status (ASA-PS) classification. Patients scheduled for
converting a PhC into an in-PC, if further medical evalua- a PhC were considered to be accurately triaged if classi-
tion was deemed necessary. In case a patient, scheduled for fied ASA-PS I to II or III with stable comorbidities.
a PhC, needed extra medical testing such as blood tests or Patients scheduled for an in-PC were considered to be

Eur J Anaesthesiol 2024; 41:813–820

 816 Di Biase et al.

accurately triaged if classified ASA-PS III with unstable were 33 (3.4%) cases of misclassification (Table 2), none of
comorbidities or ASA-PS IV. On the day of surgery, whom gave rise to complications. In four cases (0.4%), the
anaesthesiologists recorded whether screening related triage procedure was performed correctly, but due to
problems occurred or, if surgery was cancelled, the reason additional information provided by the patient during
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for cancellation. To measure the impact of PACMAN on the PhC, the attending anaesthesiologist decided to con-
patient outcomes, the occurrence of unanticipated ad- vert the PhC into an in-PC. A total of 111 (42.7%) in-PC
verse peri-operative events (UAE) was evaluated.20 An patients were at least 70 years old. Of those, 55 (49.5%)
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anaesthesia-related UAE was defined as an event causing were classified ASA-PS I to II, thus possibly attending the
mortality or morbidity, occurring during the peri-opera- pre-operative clinic unnecessarily. Of the 82 patients who
tive period or up to 7 days after surgery and requiring attended the pre-operative clinic due to a reported MET 4
special medical treatment or prolongation of hospitalisa- or less, 46 (56%) were classified ASA-PS III to IV.
tion beyond the expected length of stay. Data concerning
peri-operative UAE were collected by reviewing the Secondary outcomes data
EMR of patients who had undergone surgery. There were no day-of-surgery cancellations due to
screening-related problems. Of the 861 patients who
Finally, we assessed cost-effectiveness and efficiency by
underwent surgery, 11 experienced a peri-operative
examining the time taken by the screening staff for a
UAE (overall incidence 1.3%, 2.2% in-PC group versus
single PhC or in-PC. In addition, the average number of
0.9% PhC group). Of the five UAEs reported in the in-PC
patients screened before and after implementation of
group, two were major adverse cardiovascular events
= on 10/10/2024

PACMAN along with associated staff costs were evaluat-

requiring consultation by a cardiologist, treatment and
ed. These results were compared with institutional costs
prolongation of hospitalisation. No major adverse cardio-
of the conventional screening procedure in 2019, before
vascular events were reported in the PhC group. In total,
introduction of PACMAN.
10 patients had an unanticipated difficult intubation
(overall incidence 1.2%). The incidence was highest in
Statistical analysis the PhC-group (1.3 versus 0.9%) (Table 3).
Patient characteristics, health status characteristics and
level of surgical invasiveness are presented using descrip- Before implementation of PACMAN, 90 patients were
tive statistics using mean # SD, median [range] or num- evaluated in person daily. Each consultation required
ber (%) where appropriate. Accuracy of the triage approximately 31 min, with an average total of 465 min
procedure was verified. Misclassifications and their per POS nurse per day (15 in-PCs per POS-nurse per
causes were described both descriptively and qualitative- day). After implementation, each POS nurse was sched-
ly. All patients who completed the screening procedure uled to perform 13 PhCs per day, each PhC taking 20 min,
were included in the analysis. Statistical analyses were with an average of 260 min per POS nurse per day and a
performed using IBM SPSS Statistics for Windows, Ver- time saving of 205 min. Due to a 73.1% reduction in the
sion 27.0 (IBM Corp. Armonk, New York, USA). number of in-PCs, only 30 in-PCs are carried out every
day (five in-PCs per POS nurse per day), enabling the
Results POS nurses to devote 41 min to each in-PC (205 min per
Patients and descriptive data POS nurse per day). This accounts for a 20% increase in
Using the PACMAN triage procedure, 1019 elective efficiency and an annual decrease of almost 100 000 euros
surgical patients were triaged from October 1 to 31 in staff related costs.
October 2021. Surgery was cancelled in 54 cases before,
and in 35 after pre-operative screening. Sixty-nine were Discussion
lost to follow-up, as their surgical procedure was planned In this study, we assessed the efficacy of our newly
after the end of the study period. Ultimately, 965 were developed pre-operative triage system. We demonstrated
evaluated pre-operatively of whom 861 underwent sur- that PACMAN was able to identify low-risk patients, who
gery (Fig. 2). Characteristics of patients are depicted in were suitable for pre-operative assessment by phone,
Table 1. from those who needed an in-person medical evaluation
at the pre-operative clinic. We found that the implemen-
tation of PACMAN led to a significant 73.1% reduction in
Primary outcome data
the number of in-PCs.
Of 965 patients who were evaluated pre-operatively, 705
(73.1%) were eligible for PhC and 260 (26.9%) for in-PC. Previous studies investigated the feasibility of pre-operative
After comparison of the triage-outcome (PhC or in-PC) to triage and screening systems in order to streamline patient
the ASA-PS classification, 688 (97.6%) of all PhC patients flow before surgery.3–8 After introducing a pre-operative
had been accurately triaged; 654 classified ASA-PS I to II patient-centred triage system, Molin et al. 6 showed a 39%
(92.8%) and 34 (4.8%) ASA-PS III with stable comorbid- reduction in in-PCs. There are, however, several differences
ities. Of the 260 in-PC patients, 47.4% were classified ASA- between their triage system and PACMAN. Firstly, sur-
PS III with unstable comorbidities or ASA-PS IV. There gery-related risk factors were not included. Secondly, the 12

Eur J Anaesthesiol 2024; 41:813–820

 Triage for pre-operative screening 817

Fig. 2 Patient flow chart.

Included

Triage procedure by PACMAN

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(n = 1019)
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Triaged by PACMAN

Scheduled for PhC (n = 739) Scheduled for in-PC (n = 280)

Change surgical plan Change surgical plan

(n = 33) (n = 16)
Referred to other hospital Referred to other hospital
(n= 1) (n = 4)

Screened
= on 10/10/2024

Screened by PhC (n = 705) Screened by in-PC (n = 260)

Change surgical plan Change surgical plan

(n = 24) (n = 11)

Approved

Planned for surgery (n = 681) Planned for surgery (n = 249)

Surgery postponed Surgery postponed

(n = 49) (n = 20)

Surgery (n = 632) Surgery (n = 229)

criteria selected to identify high-risk patients were not

Table 1 Patient characteristics combined, thus the presence of any one of those criteria
Overall (n U 965) In-PC (n U 260) PhC (n U 705)
was deemed sufficient to warrant a pre-operative visit. Grant
Age (years) 51.9 # 16.3 63.05 # 14.7 47.7 # 14.8
et al. 4 studied the potential utility of a computer-guided
Sex (n) questionnaire as a pre-operative triage tool compared with
Female 550 (57.0) 155 (59.6) 395 (56.0) face-to-face evaluation and found that their prescreening
Male 415 (43.0) 105 (40.4) 310 (44.0)
"2
BMI (kg m ) 26.6 # 4.8 28.07 # 5.8 26.0 # 4.2
Surgery complexity (n)
Table 2 Causes for misclassification
Low 675 (69.9) 164 (63.1) 511 (72.5)
Misclassified consultation n (%)
Moderate 290 (30.1) 96 (36.9) 194 (27.5)
ASA-PS class (n) PhC (would have been in-PC) 25
I 198 (20.5) 14 (5.4) 184 (26.1) Incorrect use decision tree (nurse) 24 (96)
II 593 (61.5) 123 (47.3) 470 (66.7) Incorrect answer (patient) 1 (4)
III 167 (17.3) 116 (44.6) 51 (7.2) In-PC (would have been PhC) 8
IV 7 (0.7) 7 (2.7) 0 (0) Overruled by interviewer 7 (88)
Diagnosis not in questionnaire 1 (12)
Data presented as mean # SD or number (%). ASA-PS, American Society of
Anesthesiologists Physical Status; in-PC, in-person consultation; PhC, phone Total number of patients: 33. Data represented as number (%). in-PC, in-person
consultation. consultation; PhC, phone consultation.

Eur J Anaesthesiol 2024; 41:813–820

 818 Di Biase et al.

Table 3 Summary of unanticipated adverse events

ASA-PS Surgery Unanticipated adverse

Sex Age class complexity History events Additional treatment
PhC group
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M 66 I Moderate None Hypertensive crisis and LBBB No changes in policy,

under general anaesthesia postoperative cardiology
consultation
M 57 II Moderate Mitral regurgitation, ablation Postoperative chest pain
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therapy without ECG changes

M 57 II Low Thalassemia, one episode of Pre-operative atrial fibrillation No changes in policy,
amaurosis fugax with slow ventricular postoperative cardiology
response consultation
F 64 II Moderate Paroxysmal atrial fibrillation Postoperative fluid overload Cardiology consultation
and respiratory distress
syndrome
M 52 II Moderate Diaphragmatic hernia, Postoperative chest pain
BMI ¼ 33 without ECG changes
M 48 II Low Asthma Postoperative chest pain
without ECG changes
In-PC group
M 61 II Moderate Hypertension, moderate aortic Non-ST elevation myocardial Admission at Coronary Care
valve stenosis, coronary infarction (NSTEMI) Unit
atherosclerosis
M 57 I Low Patient exhibited a low exercise Non-ST elevation myocardial Admission at Coronary Care
= on 10/10/2024

tolerance; no additional infarction (NSTEMI) Unit, angioplasty and stent

medical investigation was placement
deemed necessary
F 73 I Low Mitochondrial myopathy Postoperative tremor hand and Neurology consultation
arm
F 50 II Low Functional neurological system Postoperative pseudo Neurology consultation
disorder nonepileptic seizures
(PNES)
F 28 II Moderate Congenital aortic valve stenosis Postoperative chest pain Cardiology consultation
without ECG changes

ASA-PS, American Society of Anesthesiologists Physical Status; in-PC, in person consultation; PhC, phone consultation.

tool could have reduced the number of in-PC by 60%. In patients scheduled for a PhC were accurately triaged. In
another study, the implementation of an outpatient pre- the in-PC group, slightly less than 50% of the patients were
operative assessment computer program, including a gen- classified ASA-PS III with unstable comorbidities or ASA-
eral internal medicine clinic designated specifically for pre- PS IV. When we developed PACMAN, we chose age as a
operative evaluation and medical optimisation, allowed triage criterion requiring an in-PC.22 However, only 50.5%
35.6% of all patients to be evaluated on the day of surgery.3 of our patients aged at least 70 were classified ASA-PS III to
Both the absence of details on screening criteria and the IV. This confirms that age as a sole triage criterion does not
organisation of the presented pre-operative screening, suitably identify all high-risk patients.5,6 In previous stud-
which differs significantly from our procedure, make a direct ies, poor exercise tolerance was a triage criterion frequently
comparison challenging. Most recently, van den Blink et al.8 justifying an in-PC.4,23,24 As a lower MET score is often
showed that new screening software using a questionnaire associated with severe underlying comorbidities, we as-
consisting of a maximum of 185 questions, allowed 29.2% of sumed that by assessing exercise tolerance, we would be
patients to be first screened on the day of surgery. Unlike our able to identify patients with a higher ASA-PS classifica-
triage, the application evaluated by the authors was not tion. In our cohort, we found that only 56% of patients
designed specifically as a triage tool, but rather as a com- scheduled for an in-PC due to a MET 4 or less, were
prehensive screening procedure. classified ASA-PS III to IV. Further examination revealed
that the lower functional capacity was often related to the
In order to check the reliability of our triage procedure, we condition requiring surgery rather than underlying comor-
used the ASA-PS classification.21 Whilst this tool is uni- bidities. This suggests that a more comprehensive assess-
versally accepted and validated to assess the pre-anaes- ment tool such as the Duke Activity Status Index (DASI)
thesia medical status, we opted to distinguish an ASA-PS may have provided a more reliable estimate of functional
III group with stable comorbidities from a group with capacity and a more objective measure to decide upon the
unstable comorbidities for the purpose of triage (SDC 1, need for an in-PC.25 Whilst MET is used as a reference
http://links.lww.com/EJA/B27).9–15 This was done be- threshold of absolute intensities, the DASI is a 12-item
cause the ASA-PS III grade comprises a broad category self-reported questionnaire assessing the usual physical
of patients and their physical condition may differ greatly, aspects of quality of life. Incorporation of DASI scores
with important implications. In our cohort, 97.6% of in the pre-operative assessment could improve the

Eur J Anaesthesiol 2024; 41:813–820

 Triage for pre-operative screening 819

identification of patients at intermediate or high risk of additional nurse would have been necessary to manage
postoperative cardiopulmonary complications requiring such an increase. Therefore, in current times of shortages
further evaluation.26 and rising pressure on healthcare systems, the use of a
pre-operative triage tool such as PACMAN could help
In a previous study comparing a screening questionnaire
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face these challenges by reducing costs whilst maintain-

with in-person evaluation, Lee et al.27 showed an UAE
ing good quality pre-operative care. Further, before im-
rate of 6% in the in-person evaluation group versus 3% in
plementation, our POS nurses were unaware of a
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the group evaluated by questionnaire. In our sample, we

patient’s multiple comorbidities and the number of ‘com-
found an overall UAE incidence of 1.3%. However, our
plex patients’ they might encounter in a day. In the
groups are not comparable regarding their comorbidities.
current situation, alternating PhCs and in-PCs helped
The higher incidence of overall UAE in the in-PC group
achieving a more balanced distribution of workload and
most probably reflects the higher prevalence of (unstable)
an increase in job satisfaction. Remote screening poses
comorbidities in this group. To be able to reliably evalu-
the risk of an increase in day-of-surgery cancellation rate
ate the incidence of UAE between the two groups,
due to undected comorbidities. At our hospital, day-of-
further research is necessary, using a larger sample size
surgery cancellations cause an estimated financial loss of
comparing two groups with similar comorbidities.
approximately 1800 euros per hour, suggesting that at
The incidence of unanticipated difficult intubation was least four case cancellations per month would be required
higher in the PhC group. When we decided to implement to exceed the financial benefit of our triage procedure. In
our triage procedure, we considered the use of video our study population, there were no day-of-surgery can-
= on 10/10/2024

consultation to gather additional information including cellations, but additional research with larger sample
airway assessment. Regrettably, we encountered both sizes is necessary to address this issue.
patient and staff related barriers such as lack of familiarity
The strength of our triage system is its ability to accu-
with technology, inability to perform procedures as well
rately identify patients who may be screened by phone,
as logistical and privacy issues. However, given physical
reducing workload, institutional expenses and patient
examination is an essential part of pre-operative anaes-
burden. There are however limitations to the current
thesia care, it is important to stress the need for the
study. Firstly, in 25 cases, patients were incorrectly
anaesthesiologist to complete the evaluation before in-
scheduled for a PhC. Of those, one case was due to
duction of anaesthesia, especially when patients are
the patient providing incorrect answers, whereas 24 cases
screened by phone. We are aware that a last-minute
resulted from the registered nurse incorrectly applying
airway evaluation could pose disadvantages such as un-
the algorithm. Whilst there is no standardised, acceptable
preparedness. However, a recent Cochrane review
‘miss rate’, our goal is to minimise misclassifications. In
advises caution when interpreting clinical airway exami-
this context, phone consultations act as a safety net,
nation tests such as the Mallampati score or upper lip bite
helping to identify patients who may still require an
test, owing to poor sensitivity.28 Shiga et al.29 reported an
in-PC. Secondly, data from registered nurse work logs
overall incidence of 5.8% unexpected difficult airways in
showed that the triage phone call required approximately
apparently normal patients. Some common features iden-
10 additional minutes per call. However, by shortening
tified as predictors of a difficult airway are: head and neck
the nursing preadmission assessment, the registered
disorder, obstructive sleep apnoea and morbid obesity.30
nurses were able to complete both the triage question-
Considering that extensive history taking is conducted in
naire and the assessment within the same timeframe,
both the PhC and in-PC group, a preliminary selection is
although this increased their overall workload. To ensure
already made. In this way, the attending anaesthesiologist
accuracy of the algorithm and reduce registered nurses
is aware of comorbidities with a higher risk for difficult
workload, we embedded the triage questionnaire and
intubation like obstructive sleep apnoea. Given the poor
algorithm into our EMR software. Thirdly, as this is a
sensitivity of predictive tests, we are uncertain whether
single-centre study, these findings cannot be generalised
the higher incidence of unanticipated difficult intuba-
to all centres. For example cultural differences and
tions in the PhC group can be attributed solely to the
variations in feasibility and availability of technology
fact that physical examination was performed on the day
may pose challenges for implementation elsewhere. Last-
of surgery. As the incidence of anaesthesia-related ad-
ly, no partner patient was included in the development
verse peri-operative events and unanticipated difficult
and implementation process and patient satisfaction was
intubations in our sample was low, a larger cohort would
not officially assessed. Given that only 2.2% of patients
be required. As mentioned earlier, it would be preferable
refused a PhC, one can safely assume, as already con-
for these two groups to be comparable in terms of
cluded by Kamdar et al. 31, that patients recognise the
comorbidities.
many benefits of a remote pre-operative evaluation.
Introduction of PACMAN allowed our POS nurses to The periodic evaluation of patient satisfaction at our
screen an additional 18 patients per day, leading to a 20% department revealed that out of 37 interviewed patients
efficiency increase. Before implementation, hiring an scheduled for a PhC, four (10.8%) would have favoured

Eur J Anaesthesiol 2024; 41:813–820

 820 Di Biase et al.

an in-PC. The main reason was a preference to speak to a 7 Milne-Ives M, Leyden J, Maramba I, et al. The potential impacts of a digital
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Z7eb0Mbm2ZdFdZ4LZ3AwCd4DgRjRPEr3vaa+IGEJJMpliGDJMEUkRoFdYHVxnRDVxDZ1fIORtrAIyx+OPOdWXAmnV1UB5hVSFp3I

provided interesting extra insights. However, the retro- 9 Dalby Kristensen S, Knuuti J, Saraste A, et al. ESC/ESA GUIDELINES
spective character of this study precluded such possibili- 2014 ESC/ESA Guidelines on noncardiac surgery: cardiovascular
assessment and management The Joint Task Force on noncardiac surgery:
ties. Finally, we conducted this study during the COVID-
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cardiovascular assessment and management of the European Society of

19 pandemic period when, despite the resumption of Cardiology (ESC) and the European. Eur J Anaesthesiol 2014; 10:517–
573.
clinical care, patient access to healthcare systems was still 10 Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA
limited. This might have increased likeliness of accep- guideline on perioperative cardiovascular evaluation and management of
tance by patients who agreed to a PhC despite a prefer- patients undergoing noncardiac surgery: a report of the American College
of Cardiology/American Heart Association Task Force on practice
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affecting clinical characteristics of our study cohort. Nev- management of severely obese patients undergoing surgery: a science advisory
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