What laboratory tests are required for ambulatory surgery?

Current recommendations from the 2002 ASA Task Force on Preanesthesia Evaluation are not specific to ambulatory surgery and are not based on strongly designed and adequately powered studies. Furthermore, although the ASA does not advocate routine testing or testing without indication, the guidelines for "selective" or "indicated" testing are unclear. As a result, preoperative testing in the United States is overused relative to the current ASA Task Force recommendations. Uncertainty regarding indications leads to wide variation in the use of preoperative testing across providers. There is evidence to suggest that current guidelines may recommend testing more than is necessary. Several studies reviewed in this article have shown that the elimination of routine testing and more selective use based on patient history and physical examination findings would decrease cost and increase patient satisfaction without detriment to patient care. Future studies should evaluate the effectiveness of testing in specific clinical situations, allowing for identification of clear conditions under which preoperative testing should be performed. This approach would allow the promulgation of clear guidelines, the development of which should involve surgeons (as members of a multidisciplinary team), anesthesiologists, and hospital administrators, together with governing bodies such as the ASA and American College of Surgeons that offer support for the dissemination and broad adoption of guidelines. In the future, studies should focus not only on identifying specific clinical situations whereby preoperative testing will be beneficial but also on determining current barriers to improving adherence to guidelines. Potential barriers include institutional policies for testing, physician reluctance to change practice, problems in communication between members involved in perioperative care, and legal consequences of not ordering preoperative tests. Identification of reasons for overuse of testing is the first step toward changing practice. Once clear guidelines are developed, the creation of preoperative clinics that centralize preoperative care, or promoting the use of clinical pathways and/or checklists for determining appropriate tests, may improve the adequate use of preoperative tests. It will be critical for quality improvement measures to include surgeons, anesthesiologists, hospital administrators, and governing bodies such as the ASA and American College of Surgeons to achieve success.