a riskFitness for anaesthesia, assessed on arrival

Pre-operative assessment compressed into the days between landing and the operation, carried out by a team holding whatever records the patient brought. The standard grading is the American Society of Anesthesiologists physical status classification - the ASA grade - a single ordinal score for how much systemic disease a patient carries, assigned before an anaesthetic and recorded on the chart.

The ASA classification was introduced in 1941 and runs from ASA I, a healthy patient, to ASA VI, a declared brain-dead patient whose organs are being procured, with the letter E appended for an emergency. The current definitions were approved by the ASA House of Delegates on 15 October 2014 and last amended on 13 December 2020. ASA II is mild systemic disease and ASA III is severe systemic disease; there is no class for moderate, which is one reason two anaesthetists grade the same patient differently. Meta-analyses put its sensitivity for predicting postoperative mortality at about 0.74 (95% CI 0.73 to 0.74) and its specificity at about 0.67, with an area under the curve around 0.736 (95% CI 0.725 to 0.747). The classification "cannot be used alone to determine anesthesia or surgical risks because other factors (such as procedure invasiveness and patient frailty) also contribute to perioperative risk for poor outcomes", and age does not appear in it at all.

The grade is also a commercial boundary, and this site has one worked case of it. Bumrungrad International Hospital's knee package JOINT04, read on 17 September 2026, states that "The eligible patient who can apply this package is patient without complication and attending physician considered appropriate to this package", and lists five conditions under which a patient "will be considered as 'high risk' and will not qualify for the package": organ failure; "A patient with severe systemic disease. Examples include (but not limited to) poorly controlled DM or HTN or COPD, implanted pacemaker etc. (ASA classification III and above)"; an acute myocardial infarction within four weeks; HIV infection; and previous knee surgery unless the attending physician decides otherwise.

That list is the package model's own statement of what it prices. A fixed price holds because the case is predictable, and the hospital has said in its own words which patients it does not treat as predictable. Inference - the eligibility bar and the exclusion list do the same work from opposite ends: one removes the patient from the price, the other removes items from it.

Where the bar bites is on arrival. The Royal College of Anaesthetists asks that "Effective preoperative assessment and patient preparation, performed as early as possible in the planned patient pathway, is essential to the safety and success of day surgery" - as early as possible, because a problem found early is a problem that can be optimised or the list rearranged around. A patient graded for the first time three days before an operation they have flown to and paid a deposit on is being assessed at the latest possible point, by a team that has not seen a decade of home records, from a history taken through an interpreter.

Nobody has measured the consequence. No hospital, ministry, accreditor or research group publishes how many arriving patients are regraded on assessment, how many packages are repriced or refused at that point, or what happens to the deposit when they are.

The sequence on arrival is consultation, blood tests and imaging, an anaesthetic review and a revised price. The ASA grade is assigned at the anaesthetic review by a clinician meeting the patient for the first time, from a history the patient recounts rather than a record a system holds. Medication lists, previous anaesthetic charts, echocardiograms and the reason a drug was stopped are the things that change a grade, and they are exactly what tends not to travel.

A grade above the package's bar has three commercial outcomes rather than one: the operation proceeds off-package at itemised rates, the operation proceeds after optimisation on a later date with the extra nights billed, or the hospital declines. Which of the three applies, and what happens to money already paid, is set by the contract rather than by the grade.

Trade practice - remote pre-screening by questionnaire and uploaded reports is common before a treatment trip. It is not the same act as a pre-operative assessment clinic, it does not include an examination, and the hospital's own page reserves the decision to the attending physician on the day.

The Bumrungrad knee package's own eligibility bar — ASA III and above does not qualify — is carried on that package's price row, on the knee replacement record, rather than duplicated here.