Preoperative blood tests in elective general surgery: cost and clinical implications.
A total of [pounds sterling] 249.94 was spent on inappropriate tests, which extrapolates to [pounds sterling] 17,000 per annum for our trust, and over [pounds sterling]11 million in the UK. Conclusion: Inappropriate blood tests did not correlate with adverse outcome or impact management in our patient cohort, and represents a source of considerable financial saving for our trust and possibly others.
The purpose of performing 'routine' preoperative blood tests in patients undergoing elective surgery is to minimise the risk of perioperative morbidity and mortality from avoidable complications undetected in the history and examination (Munro et al 1997).
However, routine preoperative testing of healthy individuals prior to elective surgery is of little clinical benefit (SCTA 1991, Munro et al 1997, ASA 2002) and has been shown to be a highly cost ineffective practice (Allison et al 1996, Smetana et al 2003, Ferrando et al 2005, Chung et al 2009). In England approximately five million elective surgical procedures are performed annually (Health and Social Care Information Centre 2011 2011) at an estimated cost of around [pounds sterling]1 billion per annum (Audit Commission 2003). The annual cost for routine preoperative testing is not known but is estimated to be in the order of tens of millions (NICE 2003: Appendix 5). It is likely that inappropriate tests represent a major contribution to these costs.
In June 2003 the National Institute for Health and Clinical Excellence (NICE) published guidelines on the use of routine preoperative tests for elective surgery in order to improve the clinical and financial value of preoperative tests (NICE 2003). Recommendations were made for the use of chest radiographs, electrocardiographs, arterial blood gases, lung function tests, urine dipstick and four blood tests including full blood count (FBC), urea and electrolytes (U&Es), random glucose and coagulation. Tests were classed as appropriate, inappropriate or of uncertain value based on criteria including age, grade of surgery and medical fitness as judged according to the American Society of Anesthesiologists' (ASA) grading system. The information was made available in traffic light colour-coded 'look-up tables' (Figure 1).
[FIGURE 1 OMITTED]
ASA Grade 2: adults with comorbidity from cardiovascular disease Age (years) Test [greater than [greater than [greater or equal to] or equal to] thanor equal 16 to 40 to to] 60 to < 40 < 60 < 80 Chest X-ray Consider this Consider this Consider this test (see test (see test (see page 2) page 2) page 2) ECG Yes Yes Yes Test Test Test recommended recommended recommended Full blood Yes Yes Yes count Test Test Test recommended recommended recommended Hacmostasis Consider this Consider this Consider this test (see test (see test (see page 2) page 2) page 2) Renal Yes Yes Yes function Test Test Test recommended recommended recommended Random No No No glucose Test not Test not Test not Urine Consider this Consider this Consider this analysis test (see test (see test (see page 2) page 2) page 2) Blood gases Consider this Consider this Consider this test (see test (see test (see page 2) page 2) page 2) Lung No No No function Test not Test not Test not Age (years) Test [greater than or equal to] 80 Chest X-ray Consider this test (see page 2) ECG Yes Test recommended Full blood Yes count Test recommended Hacmostasis Consider this test (see page 2) Renal Yes function Test recommended Random No glucose Test not Urine Consider this analysis test (see page 2) Blood gases Consider this test (see page 2) Lung No function Test not ASA Grade 3: adults with comorbidity from cardiovascular disease Age (years) Test [greater than [greater than [greater or equal to] or equal to] thanor equal 16 to 40 to to] 60 to < 40 < 60 < 80 Chest X-ray Consider this Consider this Yes test (see test (see Test page 2) page 2) recommended ECG Yes Yes Yes Test Test Test recommended recommended recommended Full blood Yes Yes Yes count Test Test Test recommended recommended recommended Hacmostasis Consider this Consider this Consider this test (see test (see test (see page 2) page 2) page 2) Renal Yes Yes Yes function Test Test Test recommended recommended recommended Random No No No glucose Test not Test not Test not Urine Consider this Consider this Consider this analysis test (see test (see test (see page 2) page 2) page 2) Blood gases Consider this Consider this Consider this test (see test (see test (see page 2) page 2) page 2) Lung No No No function Test not Test not Test not Age (years) Test [greater than or equal to] 80 Chest X-ray Yes Test recommended ECG Yes Test recommended Full blood Yes count Test recommended Hacmostasis Consider this test (see page 2) Renal Yes function Test recommended Random No glucose Test not Urine Consider this analysis test (see page 2) Blood gases Consider this test (see page 2) Lung No function Test not
However, despite the clinical evidence and publication of the NICE guidelines there remains a misconception that routine preoperative testing in the absence of clinical indications is necessary to identify previously unsuspected or undiagnosed conditions. This retrospective audit assesses the current practice of routine preoperative blood testing within the general surgery department of a district general hospital against the NICE recommendations. As well as compliance, the financial and clinical implications of performing inappropriate blood tests were examined.
All patients aged 16 and over, who underwent elective colorectal, vascular or breast surgery between 1st and 31st October 2010 (31 days) at the Hillingdon Hospital NHS Trust, London were included in this retrospective observational study. The study population was obtained from the scheduled elective admission lists for the entire general surgical department in colorectal, vascular and breast surgery.
Basic demographic data (including age and gender), name of the procedure, ASA grade, indications for blood tests (if documented), complications and any changes to clinical management were obtained from patient medical records.
Every surgical procedure was graded according to the 2006 edition of the British United Provident Association (BUPA) Schedule of Procedures (BUPA 2006). The procedure was categorised into one of four grades of surgery: minor (grade 1), intermediate (grade 2), major (grade 3) and major plus (grade 4). This grading system was the same as that used in the NICE guidelines. All operations listed in the NICE guidelines had identical grades of surgery to those in BUPA, with the latter providing a more comprehensive list of operations and grades of surgery. Examples of operations and associated grades of surgery can be seen in Table 1.
Grade of surgery Example Grade 1 (Minor) Excision of skin lesion Grade 2 (Intermediate) Primary repair of inguinal hernia Grade 3 (Major) Thyroidectomy Grade 4 (Complex Anterior resection of rectum major/major+) Table 1 Grades of surgery with examples (from NICE guidelines)
Defined complications and changes in management (anaesthetic, surgical and non-clinical) associated with each blood test were taken from the NICE guidelines (NICE 2003 Appendix 1). However, details of any undefined complications and changes in management (not present in the guidelines) were also recorded, with the likelihood of an association with the result of a particular blood test being decided amongst authors GP and TE, with SD acting as arbitrator.
The results of the preoperative blood tests: FBC, U & Es, random glucose and clotting, were obtained from the trust's online pathology system, Sunquest Information Systems[R]. Trust stated reference ranges (mean [+ or -] 2 standard deviations) were used to identify results as either normal or abnormal.
Tests were categorised as appropriate or inappropriate, according to the NICE guidelines. For the purpose of this audit any test of uncertain value was placed into the former category.
Costings were obtained from the trust's pathology department, and reflect both sample analysis and staff cost. The costs per test were: [pounds sterling] 1.94 for a FBC, [pounds sterling] 1.60 for U & Es, [pounds sterling] 3.50 for a coagulation screen and [pounds sterling] 1.60 for a random glucose. All prices were inclusive of VAT.
In total, 121 patients met the inclusion criteria of this study. The medical records of 10 patients were unavailable. Of the 111 patients, 42 were male and 69 female, giving a male-to-female ratio of 1.2:2. The median (SD) age was 52 (15.4) years (range 17-84).
Thirty (27%) of the patients were classed as having an ASA grade of 1; 70 (63%) were ASA grade 2; 11 (10 %) were ASA grade 3; and none were grade 4.
Twenty-two (19.8%) patients underwent minor surgery, 41 (36.9%) intermediate, 17 (15.3%) major and 31 (28%) major plus. Fifty-nine patients (53.2%) underwent day case procedures.
A total of 273 preoperative blood investigations were performed of which 188 (68.9%) were recommended. Twenty-two (11.5%) of the recommended tests were abnormal. None of the 85 (31.1%) inappropriate tests that were performed were abnormal.
Complications occurred in 5 (4.5%) patients. Four of the five patients with complications had preoperative blood tests, all of which were recommended. In those four patients, the results of the blood tests were normal (n=3) or 'abnormal' (n=1), as according to trust stated reference ranges. Details of these cases are stated below. A summary of the audit findings can be seen in Table 2.
Test Total Appropriate Inappropriate normal abnormal normal abnormal Full blood 92 67 14 11 0 count (FBC) Urea & 92 70 7 15 0 electrolytes (U&Es) Coagulation 88 29 1 58 0 Screen Random 1 0 0 1 0 Glucose Total 273 166 22 85 0 Table 2 Total number of each blood test performed, appropriateness according to national guidelines and whether complications and/or change in management occurred.
Full blood count
Ninety-two FBCs (33.7% of total) were performed of which 81 (88%) were recommended. Fourteen (17.3%) were abnormal; 12 tests had a haemoglobin (Hb) between 11-12g/dL[L.sup.-1] and two patients had platelet counts between 500-550 x [10.sup.3]/[mu] L. There were no complications or changes in management observed in the patients with abnormal blood results.
However, in two patients with normal recommended preoperative FBCs, complications were observed. These are detailed below: An 81-year-old male was transfused with packed red blood cells (RBC) following an elective Hartmann's; day 1 post-operative Hb was 8.4g/d[L.sup.-1]. A high estimated blood loss was noted in the medical record. The preoperative FBC, which was recommended, showed a preoperative Hb of 13.4g/d[L.sup.-1]. The preoperative FBC was taken six days prior to surgery. The post-transfusion Hb was 10.0g/d[L.sup.-1]
A 62-year-old male was transfused with two units of packed RBCs following an axillo-femoral bypass procedure. A high estimated blood loss was noted in the medical record. The preoperative Hb was normal (14g/d[L.sup.-1]). The postoperative Hb was far lower (10.2g/d[L.sup.-1]), and a decision to transfuse was made on the severity of clinical signs and symptoms. Following transfusion the Hb was 12.4g/d[L.sup.-1].
Eighty-eight (32.2%) coagulation tests were performed; 58 (65.9%) were not recommended, with no written indications as to their use. Of the 30 (34.1%) appropriate tests, one was 'abnormal'. A summary of the case is stated below: A 75-year-old male had a preoperative coagulation screen (INR 1.4) four days prior to a haemorrhoidectomy. The test was both recommended and indicated; the patient was on warfarin for atrial fibrillation (AF). Subsequently the warfarin was stopped and a treatment dose of low molecular weight heparin was commenced two days prior to surgery, as per hospital protocol. The INR was 1.2 when repeated on the day of surgery. Post-haemorrhoidectomy the patient developed rectal bleeding immediately, prompting a return to theatre for control of bleeding. The operative notes stated poor haemostasis as a possible explanation.
Urea and electrolytes
Ninety-two (33.7%) samples were analysed, 77 (83.7%) were recommended. Seven (9.1%) of the recommended tests were abnormal. None of the 15 inappropriate tests were abnormal.
One patient had an inappropriate random blood glucose performed. The test was normal.
Two patients developed abscesses postoperatively. The first patient was a 71-year-old female who had had a laparoscopic cholecystectomy which was converted to open surgery. She was found to have an intra-abdominal abscess two days post-operatively. The preoperative FBC, U&E and clotting tests were all normal, and recommended. The other patient was a 34-year-old female who had had an excision of a lesion of the breast, subsequently developing a breast abscess. She did not undergo any preoperative investigations.
In total [pounds sterling]249.94 (inclusive of VAT) was spent on inappropriate blood tests (n=85) in the 111 patients included in this study. Within the trust, a total of 2201 operations are performed in colorectal, vascular and breast surgery per year. The number increases to 7578 with the inclusion of urology and orthopaedic operations. Therefore, it is estimated that between [pounds sterling]5,000 and [pounds sterling]17,000 is spent on inappropriate blood tests per annum within the Hillingdon Hospital NHS Foundation Trust, and approximately [pounds sterling]11.25 million on the five million elective operations performed in England per year.
A breakdown of the costs for each individual test in 2010 is shown in Table 3.
Test Amount ([pounds Estimated projection p.a ([pounds sterling]) spent sterling]) based on 7,578 elective, on inappropriate general surgery operations p.a. tests (inc. colorectal, vascular, breast, urology and orthopaedics) FBC 21.34 1456.80 U&Es 24 1638.48 Clotting 203 13858.86 Glucose 1.60 109 Total 249.94 17063.14 Table 3 Cost breakdown for each inappropriate blood test performed and estimated amount that can be potentially saved per year by the trust.
Routine preoperative testing of healthy individuals prior to elective surgery is of little clinical benefit (SCTA 1991, Munro et al 1997, ASA 2002). Retrospective and prospective studies have shown that routine testing seldom reveals unsuspected and undiagnosed disease in an asymptomatic patient (Turnbull & Buck 1987), surgical outcomes are rarely predicted based on the results (Johnson & Mortimer 2002, Chung et al 2009, Sarayrah & Habaiben 2009) and on the whole management is also unaffected (Johnson & Mortimer 2002, Bryson et al 2006). Furthermore testing in the absence of a clinical indication has been shown to produce a high incidence of false positive and false negative results (Macpherson 1993, Velanovich 1996, Roizen & Lichtor 2003) resulting in unnecessary and potentially harmful treatments (Lopez-Argumedo & Asua 1999) as a result of the former, and dangerous outcomes as a consequence of the latter (Eiicho 2005).
In financial terms routine testing is a highly cost ineffective practice (Allison & Bromley 1996, Smetana & Macpherson 2003, Ferrando et al 2005, Chung et al 2009) with the rationalisation of tests proven to reduce costs substantially (Ranasinghe et al 2010).
Consequently in June 2003 NICE published guidelines to improve the value of preoperative tests (NICE 2003). This retrospective audit assessed the current practice of routine preoperative blood testing within the general surgery department of a district general hospital against the NICE recommendations. Compliance, financial and clinical implications of performing inappropriate blood tests are discussed below.
Since the dissemination of its guideline, NICE conducted a single nationwide follow-up survey in 2005; national compliance was regarded to be good (NICE 2005).
More recently there have been two published studies that have examined compliance.
Putnis et al 2008 measured compliance in terms of the percentage of inappropriate tests performed. The authors reported 31 of the 178 (17.4%) tests were performed against recommendations but 13 (7.3%) of them had valid documented reasons.
Krishnamurthy et al 2007 assessed 'full compliance' with the guidelines by examining the percentage of patients that had all their recommended tests performed as well as not having had any inappropriate tests. Of a total of 125 patients, 78 (62.4%) were classed as being non-compliant. Eleven (14.1%) patients did not have certain recommended tests performed and 67 (85.9%) patients had inappropriate tests performed (n=93). The total number of tests performed was not stated.
Both studies identified the coagulation screen as the most regularly inappropriately performed test, accounting for 13 of the 31 (41.2%) inappropriate tests in the Putnis study and 45 of the 93 (48.4%) inappropriate tests in the Krishnamurthy study.
In comparison, 85 of the 273 (31.1%) routine blood tests featured in this study were inappropriate, and had no documented clinical indication. Similar to the results of the other studies, coagulation screen was the inappropriate test performed most regularly (n=58; 65.9%).
Anaesthetic, surgical and non-clinical complications and changes in management have been used as measures of the clinical impact of routine preoperative tests in numerous studies (SCTA 1991, Munro et al 1997, ASA 2002, Johnson & Mortimer 2002, Chung et al 2009, Bryson et al 2006, Sarayrah & Habaiben 2009). However, NICE has made no recommendations for the evaluation of clinical impact when auditing practice on a local level. To date, no published audit of the guideline has examined the clinical implications of performing inappropriate blood tests.
In this study five patients encountered complications. These included: an intra-abdominal collection and breast collection (n=2); blood transfusions for postoperative anaemia following intra-operative blood loss (n=2); and a return to theatre for uncontrolled bleeding (n=1). Blood tests that were performed in these patients were all recommended.
It was decided that the formation of postoperative collections (intra-abdominal and breast) could not have been predicted by any test, and so were not considered to have any association with the preoperative blood tests (performed in only one of the two patients, all recommended and normal).
The two patients that developed postoperative anaemia had recommended preoperative FBCs, the values of which were within the trust reference range (13.4g/[dL-.sup.1] and 14 g/[dL-.sup.1]). It would therefore not be possible to associate the results of the tests to the complications and changes in management that arose. Furthermore the estimated blood losses stated in the operative notes were high enough to cause the drop in Hb.
The patient that developed rectal bleeding following a haemorrhoidectomy had a preoperative coagulation screen that was both recommended and indicated; the patient was on warfarin for atrial fibrillation. It is debatable whether the preoperative INR value (1.4) could be classed as 'abnormal' given the patient's drug history. Furthermore, the INR was 1.2 (within operating parameters for the trust) on the day of the operation, following the substitution of warfarin with enoxaparin. It was therefore decided that there was no association between the rectal bleeding and the result of the preoperative coagulation screen, but rather a technical complication, as stated in the operative notes.
Possibly the more significant finding was that no complication or change in management could have been associated with the results of an inappropriate test; all 85 were normal. The results are consistent with the literature; routine testing of healthy individuals is of little, if any, clinical benefit (SCTA 1991, Munro et al 1997, ASA 2002, Johnson & Mortimer 2002, Bryson et al 2006, Chung et al 2009, Sarayrah & Habaiben 2009).
Up to an estimated [pounds sterling]17,000 per annum is spent on inappropriate preoperative blood test within our trust. This figure is based on the 7,578 operations in colorectal, vascular, breast, orthopaedic and urology operations performed in the trust per year. Based on the 5 million elective surgical procedures performed per year across the 167 NHS trusts in England and Wales, approximately [pounds sterling]11.2 million is being spent on inappropriate blood tests prior to elective surgery.
Improving adherence to guidelines
Despite the innumerable studies that have shown the practice of routine testing is inefficient, the adoption of guidelines remains problematical (Pasternak 2004, Bryson et al 2006, Krishnamurthy et al 2007). The results of this study support this. Understanding the possible reasons why clinicians continue to order tests without reason is needed in order to improve practice. These issues must be addressed if any strategies implemented are to be successful (Macpherson 1993).
Various reasons have been proposed to explain the poor compliance with preoperative blood testing (Kumar & Srivastava 2011, Power & Thackray 1999). These include the following:
1. Fear. This may range from the fear of cancellation or postponement of surgery, to the fear of litigation from not carrying out tests that may have influenced an adverse event (Power & Thackray 1999, Barazzoni et al 2002, Garcia-Miguel et al 2003Smetama & Macpherson 2003).
2. Working behaviours and the influence of others. Many junior doctors perform blood tests believing that their seniors would want them. Doctors are also influenced by the experiences of their predecessors and seniors and therefore working behaviours are passed on to them (Johnson & Mortimer 2002). A vicious cycle may emerge and it then becomes difficult to change working behaviour (Bryson 2005). There is also reluctance to challenge decisions made by a member of another discipline, such as between an anaesthetist and a surgeon (Johnson & Mortimer 2002).
3. Local policies. Although The Hillingdon Hospital has none in place, other trusts may have local policies already in place for staff to follow (MacPherson et al 2005).
In this study, the lack of awareness of the guidelines is also a possible explanation. The junior surgeons and preassessment nurses perform the majority of routine preoperative tests at The Hillingdon Hospital NHS Trust, but prior to this audit were not educated about the guidelines as part of their induction or formal teaching programme. Furthermore there were no posters, printed or electronic copies of the guidelines available on the intranet at the time of data collection. Since the findings of this study, small pocket sized versions of the guidelines and large posters have been printed and distributed to the junior doctors, preassessment nurses and around the preassessment clinics. The posters and portable guidelines incorporated the top 15 most common procedures for each specialty, making it easier for doctors and nurses to use.
To improve compliance within the trust, all members that are responsible for ordering preoperative blood tests must be included in any implementation strategies (Kumar & Srivastava 2011). These include the anaesthetists, surgeons and preoperative nurses within this trust. Furthermore the continuing education of senior staff members as well as juniors is needed (Ferrando et al 2005). Juniors especially can change rotations many times per year and so this would have to be taken into account.
The implementation strategies chosen must take into account local resources, finances, time and needs (NICE 2003). Whichever methods are chosen, it is important that the dogma that routine testing can be cost effective, improve outcome and reduce medico-legal liability must be dispelled (Kumar & Srivastava 2011), as well as taking steps to ensure that guidelines are available in places where preoperative investigations are ordered (NICE 2003). Both are needed if a significant improvement in practice is to be achieved.
Limitations of our study
As a consequence of retrospective data collection it was difficult to ascertain the accuracy of record-keeping. Potential absent documentation of preoperative history and examination findings, complications, changes in management, and indications for tests not recommended by the guidelines would have affected the quality of data obtained. An emphasis on clear and detailed documentation was made within the educational talks within our trust intervention strategies.
NICE has suggested that the evidence behind the guidelines is 'weak' (grade IV evidence, Oxford Centre for Evidence-based Medicine Levels of Evidence) and cannot be enforced. Adaptation of the guidelines to local circumstances or the incorporation of recommendations into existing local guidelines is also encouraged (NICE 2003). Guidelines consisting of higher grade evidence may exist elsewhere. However, in The Hillingdon Hospital no guidance on preoperative testing existed at the time of this audit. Therefore the implementation of NICE recommendations could only improve on current practice. This may be the case with other trusts as well.
Although the sample size in this study was comparable to other published audits (Putnis et al 2008, Krishnamurthy et al 2007) a larger cohort would have given a more accurate incidence of adverse outcomes and changes in management which resulted from an inappropriate blood test. For example, Turnbull and Buck (1985) performed a prospective study of 1010 patients, analysing 5003 blood tests, to notice a change in anaesthetic management in 17 patients. However, despite cohort size most studies, including Turnbull and Buck, suggest a low incidence of complications and changes in management, and this is comparable to the results of this study (SCTA 1991, Allison & Bromley 1996, Munro et al 1997, ASA 2002, Johnson & Mortimer 2002, Smetana & Macpherson 2003, Ferrando et al 2005, Bryson et al 2006, Chung et al 2009Sarayrah & Habaiben 2009).
The NICE guidelines have recommendations for urine testing, sickle cell screening, ECG and chest radiographs. Auditing compliance of these investigations and investigating the financial and clinical implications may also prove to be beneficial to the patient and to the NHS as a whole.
1. Trust compliance with NICE guidelines is poor. Far too many inappropriate tests are being performed with no clinical justification (31%).
2. Adherence to guidelines is therefore required, and if significant change is to arise it must occur across all general surgery departments across the UK.
3. Steps must be taken to ensure both the availability of the guidelines, and the education of all medical staff involved with the ordering of routine preoperative blood tests, for there to be considerable improvement. Educational talks, posters, and small pocket-sized guidelines as part of the intervention strategies can help raise awareness.
4. A re-audit, which is underway at the Hillingdon Hospital NHS Trust, is not only necessary to assess a change in compliance but also to help adapt the guidelines according to local needs.
Besides compliance, the aims of this audit were to assess the financial and clinical implications of performing inappropriate blood tests prior to elective surgery against NICE recommendations. Recognising poor compliance alone would not deter those responsible for ordering and performing blood tests from the practice of 'routine screening' healthy individuals. The assessment of the clinical and financial implications of performing inappropriate tests was also thought to be necessary to change working behaviour The influence of senior figures such as consultants, and dispelling the fear of litigation (from a complication where the absence of test may later be thought to be have been important) were also thought to be important factors. Our experience at a district general hospital supports the findings of innumerable studies and that of the NICE recommendations: routine testing of healthy individuals prior to elective surgery does not impact upon clinical management or correlate with adverse outcome, and represents a potential source of considerable financial saving for the NHS. We would encourage all NHS trusts to assess their practice of performing routine blood tests prior to elective surgery, and to implement strategies to improve compliance accordingly.
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by Gokulan K Phoenix, Tamara Elliott, James K Chan, Saroj K Das
Correspondence address: Dr Gokulan K Phoenix, Chelsea & Westminster Hospital, 369 Fulham Road, London, SW10 9NH. Email: email@example.com
About the authors
Gokulan K Phoenix
Core Surgical Trainee Yr 1, Chelsea & Westminster Hospital, London
FY2 Doctor, Charing Cross Hospital, London
James K Chan
MB BChir, MA, MRCS
Plastic Surgery ST3, Clinical Research Fellow, Oxford Deanery, Oxford University
Saroj K Das
Consultant Surgeon, The Hillingdon Hospitals NHS Foundation Trust, London
No competing interests declared
Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication May 2012.
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|Title Annotation:||CLINICAL FEATURE|
|Author:||Phoenix, Gokulan K; Elliott, Tamara; Chan, James K; Das, Saroj K|
|Publication:||Journal of Perioperative Practice|
|Date:||Sep 1, 2012|
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