Case Studies: Preoperative assessment

University Hospitals Bristol

Thoracic pre-operative assessment

The thoracic multidisciplinary team hold a weekly ‘complex case review meeting’ to plan the most appropriate care for high risk patients. Discussion covers the type of surgery required, the patient’s pre-op review and investigations. Morbidity scoring systems are completed. Together, these guide recommendations for prehabilitation and appropriate post-operative care.

Previd

Previd incorporates video assessment where patients are videoed introducing themselves, performing the ‘sit-stand test’ and walking a fixed distance. The sit-stand test is analysed as to the quality of the exercise, the number of repetitions and the motivation the patient shows during the test. They are then timed walking down a 20 m slope and back up. The camera is kept running after completion to see how breathless they are. This video is essential as surgeons pool patients, and therefore may not have met face to face; seeing them on screen adds additional information to numbers and scans.

Skype

Skype pre-op assessments for patients referred to our tertiary centre from out of region has improved patient experience by preventing journeys to our centre. Baseline investigations are performed at the patient’s referring hospital but the pre-op consultation with a specialist nurse and anaesthetist is done over Skype.

Newcastle upon Tyne NHS Foundation Trust

Overview

The Newcastle upon Tyne NHS Foundation Trust established its pre-assessment service in 2004. Over the years it has grown over 3 sites assessing an average of 30,000 patients per year (inclusive of Saturday working) and recently includes a community-based GP site. We provide a local service to all surgical specialties including:  Urology, Hepatobiliary, Vascular, Colorectal, Elective Orthopaedics, Ortho-Oncology, general surgery, breast, plastics, gynaecology, intra-abdominal solid organ transplantation, ENT, Head and Neck, Endoscopy and Interventional Radiology. We also provide regional assessment to transplantation and pancreatic surgery.

The team

We have a team of health care assistants, pre assessment nurses, specialist nurses and cardio pulmonary technicians who provide both booked and a one stop service to patients. 70% of the patients go through this nurse led service.  We also offer a telephone helpline run by the senior nursing team to aid patients in stopping medications appropriately before surgery.

In addition, there are a team of dedicated Consultant Perioperative Clinicians. Together, we have developed protocol driven pathways to help investigate and optimise high risk patients. These ensure that the patients are managed in collaboration with the GP minimising referral rates to other specialities to avoid unnecessary delay to patient pathways.

Initiatives 

We also run a comprehensive cardiopulmonary exercise testing service for patients undergoing major elective surgery to aid in the risk assessment process. This is run by our cardio-pulmonary technicians in conjunction with the medical team and performed over 2000 tests in 2015. This has led to some of the landmark papers in the risk assessment of patients for surgery. We are currently beneficiaries of an NIHR grant (2.5 yrs) to investigate preoperative alcohol cessation before major orthopaedic surgery and developing community based, hospital derived, habilitative exercise programmes. 

Outcomes

We are proud to have reduced our surgical cancellation rate described as ‘unfit for surgery due to inappropriate assessment’ from 9% in 2002 to <0.5% despite a significant rise in patient co morbidity, frailty, patient numbers and the addition of multiple directorates. A recent patient satisfaction (2015) carried out on over 250 patients and compared to one in 2011 showed that 98.3% of patients were very satisfied with their overall care which we had maintained despite huge increases in patient numbers.

NHS Grampian Aberdeen

In collaboration with our geriatric colleagues we have promoted the use of the 4AT for the assessment for cognitive impairment and delirium in our pre-assessment clinics and surgical wards. We have used the HIS -Health Improvement Scotland learning resources- Think Delirium to educate nursing staff and junior doctors as well as information leaflets to support patients’ families.

We have incorporated the rapid 4 AT in our pre-assessment record, to screen for cognitive impairment in all patients over 65 years of age. Cognitive impairment is a risk factor for delirium and has implications for the consent process for surgery that may necessitate Power of attorney. A score of 1-3 suggests cognitive impairment and these patients are referred back to primary care for further cognitive assessment.  In the postoperative period, we follow up with the 4AT combined assessment tool to screen for delirium in these patients. A score of >4 will initiate the TIME bundle.

Colchester General Hospital

Aims and objectives

We have introduced this ‘walk-round’ clinic to streamline and improve our pre-assessment service. All patients who are booked for surgery in clinic proceed directly to the IPA clinic. The two main objectives of the IPA are:

• To identify low risk patients having minor or intermediate surgery on the day they are booked for surgery (‘green’ patients) who can proceed directly to surgery without returning for further appointments pre-operatively
• To identify patients early who are high risk and may need multidisciplinary input in their preparation for surgery and/or optimisation of pre-existing medical conditions.

Process

All patients planned for elective surgery in a surgical outpatient clinic should receive an IPA form at their clinic appointment, which they complete and present to the IPA clinic.  Here the IPA nurse will be able to assess them, measure their BMI and observations, and perform MRSA swabs.The IPA nurse will also arrange investigations as appropriate for their medical comorbidities and the type of surgery they are due to have.  These might include blood tests and ECGs. The IPA nurse will perform a Rockwood frailty assessment for all patients over 65 years. 

On the basis of this assessment, patients will be triaged into red, amber and green groups.  ‘Green’ patients can proceed directly to surgery, ‘amber’ patient require a nurse-led pre-assessment appointment and ‘red’ patients will require a nurse-led pre-assessment with notes or face-to-face review by a Consultant Anaesthetist.

Outcome/Impact

In the first 4.5 months we have built up from one to five days per weeks, with the following results:

• 739 patients through IPA
• Total of 71 clinics in 5 months
• Mean 10.4 patients, median 11 seen per day (max 20, min 2)
• Mean wait for patient 10 mins
• Mean appointment time 13 mins  (full nurse pre-assessment time in clinic is 45 mins)

Improvements in quality of care

This has meant an improvement in quality of care through referral for optimisation at the earliest opportunity:

• All ‘red’ patients, 73, were identified as needing a Consultant Anaesthetist review (either notes review or face-to-face)
• 33 patients were identified to be hypertensive and were referred to the GP for management of this
• 43 patients were identified to be anaemic and commenced on the anaemia pathway
• 5 patients identified to have poorly controlled diabetes so referred for optimisation of diabetic control
• 6 patients were identified to have a BMI above our CCG’s threshold of 35 for joint replacement so referred back to their GP
• Some referrals of our most frail and elderly patients were made directly to our high risk pre-assessment clinic run jointly with a Consultant Anaesthetist and a Consultant Physician

Improvements in efficiency

For those green patients who now do not require a face-to-face preassessment clinic appointment just over 30mins clinic time is saved per patient. For many of these an additional trip into hospital for pre-assessment is also avoided.

Barriers and Enablers

Our enthusiastic staff with a new band 6 nurse to lead the IPA service have been fundamental to making this new service work.

Challenges include a lack of space in main outpatients to run such a busy clinic. The geography of our clinics is also a challenge; we currently are not providing this service for oral, ENT or ophthalmology as their clinics are in a different building across a road. Staffing and training new staff to run these clinics is an ongoing challenge as our service expands.

However we are optimistic that the excellent results will encourage support for this service going forward.

Manchester University Hospitals NHS Trust

The Enhanced Surgical medicines optimisation service (ESMOS) was introduced at Manchester University Hospitals Foundation Trust, a large 1200 bedded tertiary hospital within hepatopancreato-biliary (HPB), upper gastro-intestinal (GI), lower GI and vascular specialities. ESMOS is a novel model of care which has shown to improve patient outcomes in those undergoing major surgery by active and dedicated pharmacist involvement throughout the patient’s surgical journey. All pharmacists providing the service are prescribers. 

The goals of the service are aligned with the national enhanced recovery programme. The objectives are to identify high risk surgical patients once they are listed for surgery and get them in the best possible state in the pre-operative period by focusing on optimising their pre-existing co-morbidities such as hypertension and diabetes control. The ESMOS service also addresses any pre-operative anaemia. All eligible patients have their anaemia corrected pre-operatively voiding any adverse outcomes related to low haemoglobin levels.  

Patients are reviewed virtually in the pre-operative period mainly over the phone. These patients may also be reviewed by face to face contact when they attend the hospital for one of their other appointments e.g. pre-op appointment in a nurse-led clinic or attendance at surgery school. Surgery school is a multidisciplinary initiative set up to provide education to patients on what to expect during their admission for surgery and the steps patients can take to optimise their general fitness prior to surgery. 

Once high risk patients are identified, the relevant specialist ESMOS pharmacist contacts the patient by telephone to discuss: a) Current medication the patient is taking and any problems the patient may have such as compliance, adverse effects etc. b) Management of existing medical conditions to be able to identify areas for medicines optimisation c) Peri-operative drug management and provide advice on stopping drugs in this period. 

The patient’s medication is also prescribed pre-operatively reducing the incidence of missed doses post-operatively. Following admission, patients are subsequently followed up and monitored closely after their surgery with the focus on medicines optimisation to minimise the incidence of any post-operative complications. Complications such as post-operative pain, nausea and vomiting, electrolyte disturbances etc. are addressed pro-actively at the point of need with patient-centred care with patients involved in discussions around any pharmacological management. 

 
Any challenges experienced and how these have been overcome?

Some of the key challenges experienced include:
1.    Identifying patients pre-operatively once they were listed for surgery. This required engaging the admission coordinators and consultant secretaries who had their own workload to deal with
2.    Engaging other key stakeholders within the trust to include the anaesthetists, surgeons and specialist nurses. As a result, we set up an electronic referral system to receive referrals from the stakeholders which worked well. 

Outcomes and evaluation

A retrospective cohort study was undertaken between September 2017 and September 2018. Adult patients undergoing elective major general surgical procedures were included and stratified into four sub‐specialties, including HPB, upper GI, lower GI and vascular surgery. Patients undergoing emergency and day case procedures or with missing outcome data were excluded from this study. Patients' demographics, baseline co‐morbidities, high‐risk medications, ASA physical status classification, surgical procedure, post‐operative complications, length of stay and nature of pharmacist interventions were collected and reported by descriptive statistics. Length of stay was compared with the corresponding expected length of stay by the national standard. A total of 246 patients were included in the four general sub‐specialties: HPB (n = 82), upper GI (n = 17), lower GI (n = 87) and vascular (n = 60). There was a significant reduction in the median length of stay in three surgical specialties, compared with the national standard: lower GI (median reduction: −2; IQR: −4, 1.8; P = .038), HPB (median reduction: −4.5; IQR: −7, −1; P = .001) and vascular (median reduction: −2; IQR: −4, 0; P = .043). The median actual length of stay was longer than the median expected length of stay in the upper GI specialty (median reduction: 5; IQR: −3, 17; P = .055), although it was not significant. This could be due to the small number of patients in this group.

Sunderland City Hospitals NHS Foundation Trust

Type 2 diabetes mellitus is a growing health problem associated with significant adverse impact upon outcomes in the perioperative period.  The latest NHS Digital Health Survey reveals that the prevalence of type 2 diabetes has more than doubled since 1994 to approximately 8% of the adult population and expectations are for this trend to continue.  Of similar concern is the issue of the increasing number patients living with undiagnosed diabetes and prediabetes who present for scheduled surgery.

There is emerging evidence to support concerns surrounding the increased risk of major perioperative complications associated with stress hyperglycaemia in the perioperative period.  Furthermore, patients with untreated chronic hyperglycaemia who subsequently develop hyperglycaemia in the perioperative period are more prone to suffer from cardiac complications than those with treated diabetes.    Detection and careful clinical management of patients at risk of stress hyperglycaemia in advance of surgery holds significant theoretical potential to prevent avoidable perioperative complications.

The NCEPOD Highs and Low report (Dec 2018) has highlighted that satisfactory monitoring of established diabetic patients’ blood glucose levels in the perioperative period is an ongoing challenge. The historical lack of evidence of adverse outcomes associated with perioperative hyperglycaemia combined with evidence of harm from intravenous insulin infusions designed to maintain tight blood glucose control in the hospital setting has led to a less interventional approach to perioperative diabetic control.

We wished to determine the proportion of adult patients attending our preoperative clinic who presented a potential increased risk of perioperative stress hyperglycaemia (i.e. patients with known diabetes, undiagnosed diabetes and undiagnosed pre-diabetes respectively). During 2018, 12.5% of our preoperative clinic population presented with known diabetes, which is in keeping with 2018 PQIP report finding of 13%. To identify those with undiagnosed hyperglycaemia, we employed the validated University of Leicester Diabetes Risk Score screening tool in accordance with NICE guidance PH38 (to identify patients deemed at “high risk” of having or developing type 2 diabetes).

A total of 8151 patients were screened between March and December 2018 in our pre-operative clinic. 1198 (12.4 %) were found to be at “high risk” category for diabetes.  1049 of these patients accepted an offer of HBA1c testing.  7% of patients tested had an HbA1c in the diabetic range and 24% of patients had an HbA1c in the pre-diabetic range according to UK reference range. Patients diagnosed with new diabetes (at a rate of approximately 2 per week) are now postponed and stabilised prior to elective surgery. Blood glucose monitoring during the perioperative period is now recommended for all identified pre-diabetic and diabetic patients to identify the development of perioperative stress hyperglycaemia.

In summary, HbA1c testing of the highest risk category of screened patients suggests that approximately 20% of our adult population present to our preoperative clinic with either undiagnosed pre-diabetes or diabetes. Identification of such patients in the preoperative period is warranted to help prevent avoidable perioperative complications and provides an ideal opportunity to improve patients’ long term health prospects in addition to improving short term surgical outcomes.

NHS Greater Glasgow and Clyde

Local audit identified poor accuracy of drug history recording in pre-op assessment, prescribing errors on drug charts and poor communication regarding medicines to take or withhold on the day of surgery. 55% of our patients’ drug history was recorded inaccurately, 30% of drug charts contained prescribing errors. Potential perioperative optimisation issues were identified for 86% of patients including anticholinergic and polypharmacy review, drug interactions, immunosupresive drugs and more.

It was identified that Pharmacy intervention at the pre-operative assessment phase of the patient journey could help prevent potential prescribing errors and drug interactions and the formation of a perioperative medicines plan for pre, intra and post-op periods could have a positive impact.

COVID enabled the service  to explore remote means oh pharmacy review in a cohort of major surgical patients having surgery during May-August 2020. The interventions were patient centred and involved pharmacy reviews delivered remotely through telephone clinics. 

47 patients were included in the pilot. 83% of patients required amendment to the medication recording history performed at pre-op assessment thus avoiding drug errors in these patients. A perioperative medicines plan was recorded for all patients in the electronic patient record which included withholding medicines pre-operatively and post-operatively if no longer required. Plans for alternative deliver of drugs in patients who were NBM post-operatively. Individualised medicines optimisation involving patient education and shared decision making was employed in 93% of cases. MDT discussions took place with plans put in place for perioperative infusions of steroids and Octreotide. Communication was improved by alerting the MDT team of potential pharmacy issues.
Prescribing safety was improved as well as communication between staff groups. Patient education was improved including counselling about risk of delirium and other side effects. Two patients had their surgery delayed for optimisation following issues uncovered by the Pharmacist (acute thyrotoxicosis and drug toxicity). The Pharmacist also delivered smoking cessation advise and support.

Norfolk and Norwich University NHS Foundation Trust

A Consultant Anaesthetist (David Nunn) designed the electronic record fpr the preoperative assessment service with a link to the ICE system.  This searches for blood results within last 3 months and identifies haemoglobin less than 130 and HBA1C greater than 69mmol/mol.  When a patients records are opened in the theatre booking system( ORSOS) the user is alerted to the presence of anaemia or poorly controlled diabetes.

We have prepared standard letter templates to inform other medical staff including the patients GP, of presence of either anaemia or diabetes.  These letters state whether surgery can proceed, depending on urgency of procedure and advice GP what steps need to be taken to either investigate and treat anaemia or improve diabetes control. 

The alert has enabled early, consistent identification of both anaemia and poorly controlled diabetes; The letter templates enable any member of the pre op team to action the abnormal results quickly and ensure consistent management and clear communication to all involved in patient care.

Barnet Hospital, Royal Free Trust

What was the problem/issue?

High risk obstetric patients requiring anaesthetic pre assessment during pandemic, with the need to offer an alternative from face to face appointments.

How did you know there was a problem?

• Speed of pandemic and need to limit patients coming into hospital unnecessarily to reduce patient risk
• Some patients who would benefit from pre assessment were not recieiving it until in active labour

The number of patients affected?
8-10% on background of 5.5-6,000 deliveries.

With approx. 70% women receiving anaesthetic care during their delivery. So a small proportion of women are referred.

What solutions were identified?

1. Utilising digital technology (telephone calls and video calls) during pandemic to ensure good, effective and seamless anaesthetic peri-operative assessment of obstetric patients
2. Collaborative working amongst health care professionals and patients using different technology applications. Ensuring feedback was gained throughout in order to make positive tweaks and changes to the virtual clinics for a successful outcome
3. We have implemented an e-learning which covers how staff should use the platform to connect with patients. As this is new territory for a lot of staff there isn’t training in place for staff on how to get the best out of a video appointment in respect to consultation technique. We have worked closely with the undergrpointments.
4. Every medical school in the country is now teaching about remote consulting.  It’s also important to bear in mind that we are still in an 'emergency operating mode' of teaching, having had two national lockdowns and both national and local restrictions that have caused huge and rapid changes in the way that medical school teaching is delivered - to enable students to continue to learn under these circumstances - at the same time as considerable upheaval in health service delivery.  
5. Telemedicine is not new, particularly for some countries, and medical schools across the UK have been collaborating to share ideas and learn from each other over the past eight to nine months.  
6. New subjects and domains of professional behaviour are added to the curriculum all the time and incorporated into assessments. This isn’t an unusual situation in that regard; evaluation and reflection are part of the course, with programme leads to ensure there is a clear process in place for students to join in on video

Why were these solutions chosen?

• Digital technology widely utilised amongst anaesthetists and obstetric patient cohort (patient cohort tends to be young, have smart phones and are technology savvy)
• National recommendations to perform virtual clinics and avoid unnecessary patient footfall within hospitals
• Several digital platforms to use that were NHS ‘safe.’
• Prior to pandemic, NHS plan to use technology to develop stronger relationships between care givers and service users, and to develop better-integrated, team-based services and to deliver holistic, whole-person rather than narrowly bio-medical care
• Individual services are responsible for the quality of their consultations/training in the same way they would be for a face to face clinic. There shouldn’t be a distinction between the 2 because they are just as important. In the event that a video or telephone consultation is insufficient staff always have the open to use face to face clinics to complete the consultation.

What were the barriers?

• Change behaviour always takes time to create a uniform and seamless process
• Digital technology and data warehousing in the NHS (success of digital innovation often depends on what might appear to be small details such as how long it takes for health care staff or patients to log on or how hard it is to rectify a small inputting error.)
• Non face-to-face clinics can help reduce unnecessary visits to hospitals, but are still a relatively new model of care. Guidance in the current climate is changing at a rapid pace
• Small percentage of patient cohort will find using the technology difficult
• Work space: finding appropriate rooms to undertake videocalls that met appropriate social distancing requirements
• Key challenges are around equipment and internet connection largely on the Trust side as well as having a place for patients to contact much like you would have in a physical clinic.  IT are working extremely hard to upgrade the infrastructure to deal with the rapid shift to remote working.  We have implemented a virtual receptionist which greets patients and checks them in . They are also a point of contact should the patient have issues joining.

What were the enablers?

• Enthusiastic and committed staff
• Digital savvy users (Clinicians and patients)
• Able to use translator service during virtual clinic
• Less admin required compared to face to face clinics
• Overall NHS trend to move from face to face clinics to virtual clinics
• Less resources required- fewer rooms required, digital applications can be downloaded on personal mobile phones, clinic can be carried out whilst working from home
• National mandate on virtual clinics to be offered

Which disciplines were involved?     
 Anaesthetics, admin anaesthetic staff, midwives, obstetricians, managers, patients

What evidence (qualitative or quantitative) is there to demonstrate impact (either positive or negative) on:

• morbidity/mortality
• patient record outcomes
• patient experience
• process measures (e.g. reduction in referral times, hospital bed days, readmissions, cancellations etc.

Positives
Positive staff feedback and informal patient feedback
Reduced wait times by patients
Flexibility within system to allow last minute additional appointments to be booked
Less inconvenience for patients when attending virtual appointment (no need for travel, childcare, time of work)
Records are electronic- minimises risk of some records being on paper and some being recorded electronically.

Negatives
Patient DNAs still remain
Unable to physically examine patient

Dr Yohinee Rajendran (ST7 Anaesthetic registrar North Central London Deanery)
Dr Sonia Brocklesby (Consultant Anaesthetist, Deputy Regional Advisor)
Dr Sanjana Singh (Consultant Anaesthetist, Lead for Obstetric Anaesthesia)