Surgical Clearance

Neuro Guy NP, DNP, PhD, APRN · Jun 18, 2015

Yes, I don't see why not, particularly if you work for a surgical group. Most often, a surgeon will ask pulmonology or cardiology to clear a patient from their standpoint if the patient in question has such a disease process. So if you work in either of those roles you may have the opportunity to clear someone as well.

What is the patient's cardiac function as determined by EKG and recent echo?

What about their pulmonary function as determined by recent PFT/spirometry and chest xray?

These are since of the considerations that must be accounted for

snoflak25 · Jun 19, 2015

That's pretty much what I thought. I do work in Cardiology - so I will have to take into account the specific disease process and the indications of that disease. I just wanted to confirm that it was within our scope of practice!

Thank you!!

Trauma Columnist · Jun 19, 2015

I'm an APN in IL also and it actually is dependent on the hospital system. One of the hospital systems allows me to renal clearance while another requires it to be an MD.

So, while in our scope of practice, it still is dependent on the hospital doing the surgery - lol.

bugya90, ASN, BSN, LVN, RN · Jun 19, 2015

I'm not a NP so I apologize in advance if this doesn't help answer your question. I work for a large multi hospital system in Texas. Our PAs and NPs can't do pre-ops. It has to be one of the MDs. Not even the specialties NPs can do pre-ops (including card and surg). Which sucks for the patients that only see the NP then they have to wait weeks for an appt with a MD they have never met before to clear the for surgery.

Advanced Practice Columnist / Guide · Jun 19, 2015

At our institution, our surgical specialties receive referrals from all parts of the state for elective surgeries. Most of the time, these patients are not on our system because they see providers in the outlying communities where they live. Our surgeons, accept pre-op clearance from a provider outside of our health system so if the provider is a Nurse Practitioner working in collaboration with a Physician, then that would suffice.

However, there is an added layer to pre-op clearance once the patient is being booked for an elective surgery which is the Anesthesia Evaluation. We have a department that does that and there are NP's in that group (pretty "cush" job actually because pre-op evals is all they do). They also evaluate the patient and ask the community providers for additional medical records and/or extra testing if they feel inclined. Ultimately, they work with Anesthesiology attendings who make the decision to proceed with surgery.

automotiveRN67 · Jun 23, 2015

When I worked in cardiology, I sent surgical clearance every day from our office for elective surgeries on patients we followed.

In the hospital, if I did the consult, I would give the clearance, but run it by the cardiologist first, and put this in my note. "Case was discussed with Dr. ...... It was agreed that the patient would pose a (Low, Moderate, High) risk for the planned surgery based on the Lee's Revised Cardiac Risk Index.

Edit: Remember, you are not giving a warranty on the safety of the patient for surgery, you are giving an honest assessment of risk, and minimizing the cardiac risk. Beta blockers, antiplatelet, anticoagulation, and plan for what to do when the patient comes out of the OR dry and in A-fib. Or flooded and in CHF. Or anemic. Or all of the above, at the same time. Because you will have to help fix some of this.

Edit 2: Or anemic, dry and having dyspnea and chest pain, and someone calls a STEMI because there are ST segment depressions, and they don't know up from down. Takes me back to the good 'ol days. Good luck :).

A lot of this is art and experience, and knowing who's doing the surgery.

I didn't put the index in my note, because the surgeon didn't want to see it. But, here it is:

Lee's Revised Cardiac Risk Index

The modified cardiac index was revised by Lee and coworkers,⁵ who devised a six-point index score for assessing the risk of complications with noncardiac surgery. The Revised Cardiac Risk Index (RCRI) includes the following variables and risks:

High-risk surgery (intrathoracic, intra-abdominal. or suprainguinal vascular)
Ischemic heart disease (defined as a history of MI, pathologic Q waves on the ECG, use of nitrates, abnormal stress test, or chest pain secondary to ischemic causes)
Congestive heart failure
History of cerebrovascular disease
Diabetes requiring insulin therapy
Preoperative serum creatinine level higher than 2Ã‚ mg/dL

Each of the six risk factors was assigned one point. Patients with none, one, or two risk factor(s) were assigned to RCRI classes I, II, and III, respectively, and patients with three or more risk factors were considered class IV. The risk associated with each class was 0.4%, 1%, 7%, and 11% for patients in classes I, II, III, and IV, respectively. We recommend the use of this index because it is simple, has been extensively validated, and provides a good estimate of the preoperative risk.

Trauma Columnist · Jun 24, 2015

@automotiveNP - thanks for that update.

To be honest, all of my dialysis patients are pretty much high risk - lol