Dr Yuhe (back row, far right) with the doctors at SGH Pre-operative Assessment Clinic

Skills and care are augmented by protocols and system of checks to make sure every patient is primed to get the best outcome from surgery 

Singapore General Hospital performs more than 100,000 surgeries every year. And for every single one of those patients, our doctors draw up a personalized peri-operative plan that details how the patient will be cared for before, during, and after surgery. 

“Did you know that we even check a patient’s teeth?” says Dr Adam Huang. As a Medical Officer at SGH’s Department of Anaesthesiology, he spends a week each month at the Pre-operative Assessment Clinic (PAC) to evaluate patients scheduled for surgery, and draw up these care plans. “If a tooth is loose, there’s a very high risk that it could fall into the lung when we place instruments in the patient’s mouth to manage the airway during general anaesthesia. This can deprive the patient of oxygen, and may lead to death.”  

Other checks include listening to the heart and lungs to ensure the patient has no heart problems or fluid in the lungs, and asking about symptoms like cough or runny nose. “When you have an upper respiratory tract infection, your airway is more sensitive. When we do anything to the airway during the surgery, there are more chances of things going wrong. For example, the patient not being able to breathe and us having problems taking out the tube. In such cases, we would delay surgery for up to two weeks to keep the patient safe,” Dr Adam explains.  

Optimising the patient for safety and best outcome

During the preoperative assessment, the doctors carefully review the patient’s medical history, allergies and medications. For example, blood thinners must be stopped ahead of surgery to reduce the risk of excessive bleeding. The doctors also review patients’ past anaesthesia experiences to determine which type of anaesthesia to use. The goal is to identify risks early and optimise the patient’s health so that every patient receives the safest possible care before, during and after their operation.  

Says Dr Ke Yuhe, Associate Consultant, SGH Anaesthesiology Department, "Surgery is like flying a plane. The most crucial part is actually the pre-flight check to ensure that everything is safe and good to go. That is what we compare the preoperative assessment to. It ensures that the patient is safe enough to undergo surgery. If we uncover areas where we can potentially optimize the patient for, then we will refer to other specialties for further evaluation, or delay the surgery so that the patient can undergo the operation under safer circumstances.”  

“For instance, if we find that the patient who’s coming for surgery has very poorly controlled diabetes, we will optimize the patient for diabetes. This means we will delay the surgery and refer the patient to the Endocrinology specialists to get his diabetes under control before doing the surgery. This way, we can potentially avoid post operative complications such as wound healing issues, as well as post operative glycemic issues, meaning when the blood glucose goes haywire.”  

Protocols for every organ system

At the PAC, which sees some 120 patients a day, doctors like Dr Adam have to formulate such detailed personalized plans after seeing each patient. To do this, the doctors are guided by more than 400 pages of perioperative guidelines. “These protocols cover nearly every organ system,” Dr Adam notes. “Depending on what we find in the examination or in investigations, the guidelines tell us what to do next so we can get the patient safely to surgery.” 

“For complex cases, coming up with a plan quickly means the patients can be referred to other specialists and scheduled for more tests.”

Dr Adam is a First Year Medical Officer at SGH Anaesthesiology Department. He aspires to specialize in Anaesthesiology and has applied for Residency.

AI as a tool with the human is in charge

To support the doctors, SGH introduced PEACH, a perioperative AI chatbot, in December 2024. The chatbot draws on SGH’s perioperative guidelines and patients’ electronic health records to suggest relevant considerations for each case.

“It cites the exact guideline it’s referring to so I can zoom into the relevant protocol without having to flip through 400 pages,” says Dr Adam. “I always review the recommendations by double-checking against the guidelines, and discussing with my consultant or peers when necessary.”  

Even without the AI, it has always been the practice for the perioperative plan drawn up by PAC to be reviewed by the anaesthesia team who will perform the surgery. “This avoids the Swiss Cheese effect,” explains Dr Yuhe. “It ensures that nothing slips through the cracks, and that the patient is truly safe for surgery.” 

To the doctors using PEACH, they are clear that it is but a tool — not a substitute for clinical judgment. Dr Yuhe, who led the development of PEACH, says, “PEACH supports routine administrative tasks so doctors can spend more time planning the safest care, but clinicians remain ultimately responsible for decisions.” 

Indeed. Thank you, PEACH, for the summary of the medical history.Could you please draft a referral letter to get the inputs of the Cardiology Department?

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