Hospitalists and preoperative optimization: key lessons from HM17

The annual Hospital Medicine conference in 2017 placed perioperative medicine firmly in the spotlight, with several sessions devoted to how hospitalists can reshape the surgical journey. Held at Mandalay Bay in Las Vegas from 1 to 4 May, HM17 gathered thousands of clinicians who manage acutely unwell medical patients alongside surgical teams. The theme of preoperative optimisation echoed through poster rounds, plenary talks and workshops, reinforcing that the days of surgeons alone preparing patients for the operating theatre are long behind us.

For Australian hospitalists working in tertiary centres across Sydney, Melbourne, Brisbane and Perth, the messages from HM17 align closely with national priorities outlined by the Australian and New Zealand College of Anaesthetists and the Australian Commission on Safety and Quality in Health Care. Preoperative clinics led by general physicians are already embedded in public hospitals such as Royal Prince Alfred and the Austin, but variation remains in rural and regional services. The evidence showcased at HM17 offers a roadmap for closing those gaps.

Defining the hospitalist's preoperative role

Hospitalists bring a unique skill set to preoperative optimisation, combining internal medicine expertise with the systems thinking required to coordinate multidisciplinary care. At HM17, presenters described the hospitalist as the conductor of an orchestra that includes anaesthetists, surgeons, pharmacists, dietitians and physiotherapists. The hospitalist's ability to synthesise comorbidities, medication lists and functional data into a single risk picture remains central to effective preoperative assessment.

In Australia, this model is particularly valuable in hospitals where anaesthetic preoperative clinics are overstretched. At Liverpool Hospital in Sydney, physician-led pre-admission clinics have reduced day-of-surgery cancellations by reviewing patients flagged as high risk by surgical booking teams. The conference framework, available through the main Hospital Medicine 2017 portal, offers Australian clinicians structured templates for documenting these reviews in line with local electronic medical records.

Evidence base presented at HM17

The clinical evidence highlighted at the conference drew on large registry datasets, randomised trials and quality improvement projects. Several abstracts focused on how structured preoperative programs reduce postoperative complications, length of stay and readmission rates. A recurring theme was the dose-response relationship between the number of optimisation interventions delivered before surgery and the magnitude of clinical benefit observed afterwards.

For Australian readers, the most relevant studies were those that addressed elective joint arthroplasty and colorectal resection, both of which form a substantial portion of planned surgical workload funded through Medicare. The conference findings echoed local data published by the Royal Australasian College of Surgeons, suggesting that comprehensive preoperative assessment is associated with reductions in surgical site infection and venous thromboembolism. A practical synthesis of these findings appears in a top clinical updates review compiled from the meeting.

Risk stratification tools compared

Choosing the right risk prediction tool remains one of the more contentious areas of preoperative medicine. HM17 dedicated a workshop to comparing the Revised Cardiac Risk Index, the American College of Surgeons National Surgical Quality Improvement Program calculator, and the American Society of Anaesthesiologists Physical Status classification. Each instrument offers a different lens on patient risk, and the conference emphasised that no single tool should be used in isolation.

In Australian practice, the NSQIP calculator is widely used in metropolitan hospitals, while the RCRI remains popular in regional centres where internet access during consultations can be inconsistent. Clinicians registered with the Australian Health Practitioner Regulation Agency are advised to document the rationale for tool selection in the preoperative notes.

Anaemia, nutrition and functional status

Iron deficiency anaemia was a recurrent focus at HM17, with multiple presenters advocating for early detection and intravenous iron repletion before major surgery. Patient blood management guidelines, championed by the National Blood Authority, align closely with these recommendations, particularly for patients undergoing cardiac and orthopaedic procedures. Preoperative ferritin and transferrin saturation checks, followed by iron infusions when indicated, can substantially reduce transfusion requirements.

Nutritional assessment also featured prominently, with emphasis on the Malnutrition Universal Screening Tool and the Subjective Global Assessment. Conference faculty pointed out that hypoalbuminaemia is a stronger predictor of postoperative morbidity than many traditional risk factors. For elderly patients awaiting hip fracture fixation in hospitals like the Alfred in Melbourne, a two-week preoperative nutrition window is rarely feasible, but targeted high-protein supplementation in the days leading up to surgery still confers measurable benefit.

Functional capacity, often measured in metabolic equivalents, rounded out the triad. HM17 speakers cautioned against relying on self-reported exercise tolerance alone, recommending objective tools such as the Duke Activity Status Index when feasible. Prehabilitation programs that combine resistance training, aerobic conditioning and breathing exercises are gaining ground in Brisbane's Princess Alexandra Hospital, where physiotherapists and physicians collaborate to deliver structured four-week courses before major abdominal surgery.

Anticoagulation and polypharmacy management

Perioperative management of anticoagulation remains a daily challenge for hospitalists, and HM17 devoted a full session to bridging therapy in patients with mechanical heart valves, atrial fibrillation and recent venous thromboembolism. Faculty stressed the importance of timing the last dose of direct oral anticoagulants, typically 48 hours before high-bleeding-risk procedures, and using heparin bridging selectively rather than routinely. The Therapeutic Guidelines provide an Australian framework that complements these international recommendations.

Polypharmacy, defined as the regular use of five or more medications, was identified as an independent predictor of postoperative complications. Deprescribing initiatives, including the use of the STOPP and START criteria adapted for Australian prescribing patterns, can reduce adverse drug events and improve recovery. Hospitalists at HM17 also highlighted the value of pharmacist-led medication reconciliation at the preoperative visit, a model that has been adopted successfully at Fiona Stanley Hospital in Perth.

Integration with surgical colleagues in Australian hospitals

Collaboration between hospitalists and surgical teams is not optional, and HM17 showcased several integrated care models. The Perioperative Surgical Home, developed in the United States, has local analogues in the form of the NSW Health Surgical Services Taskforce recommendations and Queensland Health's End-to-End Surgical Care framework. Both emphasise shared governance, joint ward rounds and unified documentation.

Communication was identified as the single most modifiable factor influencing patient outcomes. Standardised referral forms, multidisciplinary pre-admission meetings and shared electronic dashboards were all endorsed. At Royal Adelaide Hospital, hospitalists attend weekly colorectal multidisciplinary meetings where high-risk patients are discussed alongside anaesthetists and surgeons, a practice associated with shorter inpatient stays and lower rates of unplanned intensive care admission.

Implementation challenges and practical solutions

Embedding a robust preoperative optimisation service within existing hospital workflows is rarely straightforward, particularly in resource-constrained environments. HM17 presenters acknowledged that staffing shortages, competing clinical commitments and limited outpatient clinic space can all undermine even the most well-designed programs. The conference's emphasis on incremental change, starting with a single high-volume surgical pathway, resonated strongly with delegates from smaller regional centres.

Practical solutions included embedding preoperative screening questions into surgical booking forms, training junior medical officers to perform initial risk assessments, and using telehealth consultations for patients in remote areas of Western Australia and the Northern Territory. Automated reminders within electronic medical records, aligned with the Australian Digital Health Agency's My Health Record, can prompt clinicians to address anaemia, nutrition and anticoagulation before the day of surgery.

The evidence presented at HM17 confirms that hospitalists are central to the future of preoperative care, and the lessons translate readily to Australian practice. Clinicians interested in deepening their engagement with this field can begin by auditing one surgical pathway in their own hospital, identifying the three most common reasons for day-of-surgery cancellation, and piloting a structured optimisation checklist on the next ten patients booked through that pathway. Documenting the outcomes and presenting them at a local grand round will create the momentum needed to scale the model across the wider service.