OR Edge Morning Report | Issue 007 Guiding Every Case to Certainty and Calm

Your patients are not the same as they were five years ago.

Their medication lists are longer. Their comorbidity profiles are more complex. Their cardiac, renal, and metabolic histories are layered in ways standard intake forms were not designed to capture. And three medication classes in particular are appearing in pre-op intake right now, missed, with consequences ranging from a canceled case to an intraoperative crisis.

One of them carries a life-threatening surgical risk even when the patient's blood sugar looks completely normal.

If your center is scheduling higher acuity cases in 2026, orthopedic, spine, cardiac, or pain management procedures, this issue was written for your team

The playing field is not level. The workflow has to compensate for that gap.

The acuity gap in your intake form has not caught up to

When CMS added 271 new procedures to the ASC-covered list for 2026, the clinical conversation focused on scheduling capacity, OR time, and revenue opportunity. What received less attention was the intake implication.

Higher acuity cases mean higher acuity patients: those with more complex medication profiles, who are older, more medically managed, and more likely to be on medications that interact with surgical stress, anesthesia, and the NPO (nothing by mouth) period, requiring specific pre-op action.

Your intake form may ask about blood thinners. It may screen for diabetes medications. But if it is not asking specifically for the brand names of the three medication classes below, by the names patients actually use at home, it is creating a gap between what you know about your patient and what your anesthesia team needs to know before that patient reaches the OR.

That gap is where same-day cancellations are born.

What the floor is telling me

I have watched patients arrive at pre-op with medication reconciliation forms that look complete. Every field is filled in. The nurse who did the intake was thorough. And then the anesthesia team asks one follow-up question and discovers the patient is on a medication that nobody flagged.

Not because anyone was careless. Because the form asked about the category, and the patient did not recognize their drug by its category name. They recognized it by the name on their prescription bottle. And those two names are not always the same thing.

That gap is not a documentation failure. It is a workflow design failure. And it is preventable.

Medication Class One: SGLT-2 Inhibitors

The one that can kill a patient when blood sugar looks normal

Brand names your patients know: Jardiance (empagliflozin); Farxiga (dapagliflozin); Invokana (canagliflozin); Steglatro (ertugliflozin)

This is the medication class referenced in the Issue 006 tease. The life-threatening surgical risk is euglycemic diabetic ketoacidosis (euDKA), a form of DKA where the patient's blood sugar is completely normal or only mildly elevated. A blood glucose reading below 250 mg/dL does not rule it out.

Here is the mechanism in plain clinical language. SGLT-2 inhibitors work by causing the kidneys to excrete glucose through urine rather than reabsorbing it. This lowers blood sugar effectively, but it also shifts the body's metabolism toward burning fat for fuel, producing ketones as a byproduct. Under normal circumstances, this is manageable. In the perioperative period, where patients are fasting, physiologically stressed, and experiencing hormonal changes that further drive ketone production, the ketone load can become dangerous without the blood glucose signal that would normally alert the clinical team to check.

The patient does not look like they are in DKA. Their glucose is normal. The diagnosis is missed or delayed. The outcome can be fatal.

The FDA recommends holding canagliflozin, dapagliflozin, and empagliflozin at least 3 days before scheduled surgery; and ertugliflozin at least 4 days prior due to its longer half-life. This is a longer hold time than most other diabetes medications, which are typically held only on the day of surgery. Your intake team needs to know this distinction specifically.

This hold recommendation does not apply to patients without diabetes taking SGLT-2 inhibitors for heart failure or cardiorenal protection, as data suggest they should continue these medications. That exception matters in a higher acuity ASC population where cardiac patients are increasingly common. The decision to hold or continue requires a direct conversation with the prescribing physician, not a blanket protocol.

What your intake form needs to ask: Are you currently taking Jardiance, Farxiga, Invokana, or Steglatro? When did you last take it?

Medication Class Two: Antiplatelet Agents. Not the same as anticoagulants, and the distinction matters

Brand names your patients know: Plavix (clopidogrel); Brilinta (ticagrelor); Effient (prasugrel); aspirin

This class is the most commonly conflated with anticoagulants on intake forms. They are not the same. Antiplatelet agents prevent platelets from clumping together. Anticoagulants affect the clotting cascade. They have different mechanisms, different reversal agents, and critically, different hold times before surgery.

Per the 2024 ACC/AHA guideline on perioperative cardiovascular management, if antiplatelet drugs need to be stopped before surgery, stop prasugrel 7 days before, clopidogrel 5 days before, ticagrelor 3 days before, and aspirin 4 to 5 days before. Ticagrelor is the only reversible platelet inhibitor in this group.

The clinical danger in conflating these two classes is that a patient on clopidogrel after a coronary stent placement may have their medication held on the wrong timeline, or not flagged at all, because the intake form only asks about blood thinners and the patient does not consider Plavix a blood thinner. They consider it a heart medication.

Patients with recent coronary stent implantation should ideally postpone elective surgery during critical periods post-placement; 6 weeks for bare metal stents and 6 months for drug-eluting stents. If elective surgery cannot be postponed, dual antithrombotic therapy should be continued throughout the perioperative period.

For any patient on dual antiplatelet therapy (DAPT) after a cardiac procedure, the decision to hold or continue must involve the cardiologist. This is not a call your pre-op nurse makes independently. It is a call that your pre-op workflow should ensure gets made before the morning of surgery.

What your intake form needs to ask: Are you taking Plavix, Brilinta, or Effient? Have you had a heart stent placed? If so, when?

Medication Class Three: Corticosteroids, the one patients do not think affects surgery

Brand names your patients know: prednisone, methylprednisolone, prednisolone; dexamethasone; and inhalers or topical creams that patients often do not report at all

This is the most missed class in pre-op intake for a straightforward reason. Patients on chronic corticosteroids for rheumatoid arthritis, lupus, asthma, COPD, or inflammatory bowel disease do not connect their medication to their surgical risk. When asked about medications that might affect surgery, they report their blood pressure medication and their diabetes drugs. They do not think to mention the prednisone they have been taking every day for three years.

The surgical risk is HPA (hypothalamic-pituitary-adrenal) axis suppression. Long-term corticosteroid use signals the body to reduce its own cortisol production. Cortisol is the hormone the body releases in response to physiological stress, including the stress of surgery. A patient with a suppressed HPA axis cannot mount that cortisol response. The result can be intraoperative hemodynamic instability, refractory hypotension, and, in severe cases, adrenal crisis.

Patients who take less than 5 mg per day of prednisone equivalent or 20 mg per day for less than three weeks do not require a stress dose unless they show signs of adrenal crisis perioperatively. Patients who take the above doses or more should be assessed for stress dosing based on the level of surgical stress, as they are likely to have a suppressed HPA axis.

HPA axis suppression may persist for up to one year following a course of steroids. This means a patient who stopped their prednisone three months ago may still be at risk. Your intake form needs to ask not just what the patient is currently taking, but what they have taken in the past year.

What your intake form needs to ask: Have you taken prednisone, methylprednisolone, or any steroid medication in the past 12 months, including inhalers or skin creams? How long did you take it, and what was the dose?

The single workflow change that addresses all three

The common thread across all three medication classes is brand name recognition. Patients know their medications by the names on their pill bottles, not by the pharmacological class they belong to.

The fastest fix available to your center right now costs nothing. Add a brand name column to your medication reconciliation form alongside the generic or category column. Ask specifically:

Are you taking any of these: Jardiance, Farxiga, Invokana, Steglatro, Plavix, Brilinta, Effient, prednisone, or methylprednisolone?

That one sentence captures all three high-risk classes in language your patients will recognize. It does not require a new EHR module or a policy revision. It requires a form update and a brief team huddle to walk your pre-op nurses through why it matters.

The single workflow change that addresses all three

The common thread across all three medication classes is brand name recognition. Patients know their medications by the names on their pill bottles, not by the pharmacological class they belong to.

The fastest fix available to your center right now costs nothing. Add a brand name column to your medication reconciliation form alongside the generic or category column. Ask specifically:

Are you taking any of these: Jardiance, Farxiga, Invokana, Steglatro, Plavix, Brilinta, Effient, prednisone, or methylprednisolone?

That one sentence captures all three high-risk classes in language your patients will recognize. It does not require a new EHR module or a policy revision. It requires a form update and a brief team huddle to walk your pre-op nurses through why it matters.

What to do this week

Pull the last 10 medication reconciliation forms from recent higher acuity cases at your center. Check whether any of the three drug classes above appear by brand name in the intake documentation. If they do not, your form is not capturing the information your anesthesia team needs before the patient arrives.

You are the last line of clinical defense before that patient reaches the OR.

Not the surgeon. Not the anesthesiologist. You.

The pre-op team is where medication gaps are caught or missed. And in 2026, with a more complex patient population coming through the door, the form you use matters more than it ever has.

If this issue gave you something clinically useful, share it with one colleague who needs it. Forward it to your director of nursing or a pre-op nurse you work with. They will not find this content anywhere else written this way; from the floor, verified, and specific to the ASC environment.

Curated intelligence from the perioperative space this week.

The GLP-1 Overlap: If your intake form screens for SGLT-2 inhibitors by brand name, it should also screen for GLP-1 receptor agonists the same way. Ozempic, Wegovy, Mounjaro, and Zepbound are four different brand names for two drug classes with aspiration risk implications in the perioperative period. Most patients do not connect their weight loss or diabetes injection to their surgical safety. Your intake team is the connection point.

The Stent Timeline Question: Per the 2024 ACC/AHA guideline, patients with drug-eluting stents placed within the last 3 months carry elevated perioperative risk when antiplatelet therapy is interrupted. If your scheduling team is not asking about cardiac stent history at the point of booking, that risk assessment is arriving at pre-op on the morning of surgery, when there is no time to act on it.

The Inhaler Question: Inhaled corticosteroids at high doses can suppress the HPA axis, particularly in patients who have been using them for years. Advair, Symbicort, and Pulmicort are names your respiratory patients will recognize. Your intake form should capture inhaler use specifically, not just oral medications.

The Documentation Timing Gap: Medication reconciliation completed more than 7 days before surgery has a meaningful probability of being outdated by the time the patient arrives. Patients start and stop medications between their pre-op call and their procedure date. A secondary medication confirmation call 48 hours before surgery is one of the highest-yield pre-op interventions available to independent ASCs.

The medication forms we use were designed for a patient population that no longer exists.

They were built when the average ASC case was lower acuity; when the average patient was on fewer medications, and when the drug classes that now carry significant perioperative risk were not yet widely prescribed.

SGLT-2 inhibitors were not in widespread use a decade ago. GLP-1 receptor agonists were not a mass-market drug class. The patient coming through your door today is carrying a pharmacological complexity that your intake process may not be equipped to see.

This is not a failure of your nursing team. This is a failure of systems that have not kept pace with the patient population they serve.

You can close that gap this week. It starts with the form.

Know a perioperative nurse or ASC administrator who needs this? Forward this issue or send it directly here: oredgemorningreport.com/subscribe

Free. No fluff. Written from the floor by a perioperative RN living the same reality you are every single day.

The patient sitting in your pre-op chair right now is counting on your team to know what their prescription bottle does not say. Make sure your intake form is asking the right questions.

Build the workflow before the next case hits the board.

Brief comment before closing out this edition!

Know an ASC administrator or OR manager who needs this? Forward this issue or send it directly here: oredgemorningreport.com/subscribe Free. No fluff. Written from the floor through a Perioperative RN, who has been living the same as you every single day!

Update your medication reconciliation form this week. The patient who needs it is already on your schedule

The centers navigating 2026 are the ones that built their systems before the crisis arrived. Those that didn't are rebuilding them now, under pressure, with compromised leverage, and a full schedule on the board.

You have time right now. Use it!

What to watch in Issue 008

CMS tied the 2026 ASC payment increase directly to ASCQR (Ambulatory Surgical Center Quality Reporting) compliance. Centers that are not meeting reporting requirements are losing a portion of that update automatically, with no appeal and no recovery. Most perioperative nurses working the floor have never seen the connection between their daily documentation and their center's reimbursement rate. Issue 008 breaks down exactly which ASCQR measures are most commonly missed in independent ASCs; what the dollar impact looks like per quarter; and the one documentation habit that protects your center's full payment update starting with the next reporting period.

Forward this issue to your director of nursing or ASC administrator. They need to see this before their next case scheduling meeting.

See you Tuesday at 6:00 AM EST.

With purpose,

Yetsenia Tyson, RN.

Founder and CEO.

Haleris OR Edge Morning Report

oredgemorningreport.com

Sources and Methodology

All data cited in this issue is sourced from verifiable published references. Every statistic is verified against its source before publication.

OR Edge Morning Report maintains a strict data integrity standard. We verify every statistic against its source before publication. If you identify a discrepancy, please reply directly to this email.