Offering Psychological Counseling

The first bundle intervention provides patients with the opportunity to speak with a licensed therapist who can help them manage their feelings of anxiety prior to surgery. As part of the intervention, questions were added to Epic for the preoperative evaluation team to assess patients’ anxiety several weeks before surgery. Based on the questions, the providers then ask patients who had a high anxiety score if they would like a telehealth psychology visit, which is conducted by the Max and Celia Parnes Family Psychological and Psychoeducational Services Clinic—a psychology center based at Yeshiva University in the Bronx.

The intervention is led by Matthias Eikermann, MD, PhD, Chair, Anesthesiology, Montefiore Einstein, and Francis F. Foldes Professor, Anesthesiology, Albert Einstein College of Medicine; Carina P. Himes, MD, Director, Preoperative Evaluation, Montefiore Einstein, and Assistant Professor, Anesthesiology, Albert Einstein College of Medicine; Preeti M. Anand, MD, Site Director, Anesthesia Services, Hutchinson Ambulatory Surgery Center, Montefiore Einstein, and Assistant Professor, Anesthesiology (Regional Anesthesiology & Acute Pain Medicine); along with John J. Freda, MD, Vice President, Surgical Services, Montefiore Einstein, and his Surgical Services team to address patients’ anxiety prior to surgery.

“About 60% of otolaryngology (ORL) surgery cancellations within one day of surgery at the Hutch are due to patient no-shows, which is by far the most common reason for cancellation,” Dr. Himes said. “This is due to patients changing their mind about surgery, and it’s hypothesized to be related in part to anxiety regarding surgery.”

The intervention is currently in a pilot phase for patients undergoing ORL surgery at Montefiore’s Hutchinson Ambulatory Surgery Center and will expand to patients undergoing different types of ambulatory surgeries in the coming months.

Managing Anxiety in the Ambulatory Surgery Unit

For the second intervention, the anesthesia provider will conduct an anxiety assessment of the patient while the patient is in the Ambulatory Surgery Unit (ASU) and will offer the patient a low-dose benzodiazepine to mitigate anxiety. As part of this bundle intervention, the perioperative team ensures that the anesthesia provider is available for transporting the medicated patient to the operating room (OR) and for the nursing staff to ensure a stretcher is readily available.

Philipp J. Fassbender, MD, Vice Chair, Perioperative Services, Montefiore Einstein, and Associate Professor, Anesthesiology (Transplant Anesthesiology), Albert Einstein College of Medicine, explained that prior to this intervention, providing patients with preoperative anxiolysis was not common practice at Montefiore Einstein, though it is often done at many other institutions. Instead, patients would receive an anxiolysis after being brought to the operating room and already exhibiting objective signs of anxiety, including high blood pressure and an elevated heart rate.

“The ASU setting can be very overwhelming for the patient,” Dr. Fassbender said. “They receive a lot of information about the risks of surgery, and then they typically walk into the OR, which can be stressful. So, we were thinking about how we can adjust our workflows to provide better patient-centered care and to give medication against anxiety before the patient is brought to the operating room.”

The intervention also has the potential to reduce same-day case cancellations. Tracey Straker, MD, MS, Attending Physician and Vice Chair of Clinical Operations, Chief, General Anesthesiology Division, Advanced Airway Fellowship Program Director, and Officer, Diversity, Equity and Inclusion, Anesthesiology, Montefiore Einstein, and Professor, Anesthesiology (General Anesthesiology), Albert Einstein College of Medicine, recalled a recent patient who—after walking into the operating room—decided not to go through with his surgery because of the stressful experience of seeing the OR.

“Upon our first assessment, the patient did not appear in any capacity to have anxiety,” Dr. Straker said. “However, the patient canceled his surgery after being brought to the OR, and perhaps if he was offered an anxiolysis prior, that would have made a difference in him feeling more at ease.”

Reduced Anxiety Can Improve Outcomes

Not only will this intervention reduce patient anxiety, but it also has the potential to improve patient outcomes. Research shows that patients who experience high levels of anxiety before surgery require higher levels of sedative medications and narcotics, Dr. Fassbender said.

The Department of Anesthesiology Executive Committee, together with the Ambulatory Surgery Unit nursing team, aims to improve the overall patient experience with these interventions. Providing patient-centered care and ensuring patients have positive experiences throughout the perioperative arena is of utmost importance.

“These bundle interventions are innovative solutions that complement the outstanding care we are already providing,” Dr. Eikermann said. “It is an opportunity for us to improve our patients’ experiences when they receive care at Montefiore Einstein—a health system where we prioritize patient-centered care.”