Auditing an evolving Pre-operative Assessment Service 2002 - 2009:

Completing the cycle

Paul Knight, Consultant AnaesthetistJoanna Gordon, ST3 Anaesthetics

Valerie Wilkinson, Clinical Governance Facilitator

Our Audits

Original Pre-op assessment process

Roll out across trust for inpatients 2007

Integrated Care Pathway introduced for inpatients in CRH 2004

Audit 2002

Audit 2004

Audit 2009

Future plans

Background

Pre-op assessment process pre-2004

Nurse & junior surgeon assessed patient approx 1wk before surgery

No formal anaesthetic support

Day cases assessed separately

Audit of original process 2002Both sites Audit (n=764) showed 26% could have benefited from

anaesthetic assessment

7% of patients were cancelled on the day of surgery 1% pre existing medical 0.5% acute medical (e.g. URTI)

18% not optimised Mix of cardiorespiratory disease, obesity, sleep apnoea etc.

The CRH Pre-op assessment pilot 2004

Nurses dedicated to pre-op assessment using integrated care pathway

Support from 3 dedicated consultant anaesthetic sessions

No need for junior doctors

Day case assessments remained separate

Our Integrated Care Pathway (ICP)

The structure of a tick-box, with the accuracy of prose

Abnormalities noted, expanded on and dealt with if necessary

A record of information given and investigations ordered

Patient history expanded on…..and action taken………

Re audit 2004Pilot (CRH) site only Patient viewpoint

Surgical and ward staff viewpoints

Anaesthetic viewpoint

1 month prospective audit elective patients

Re- audit 2004Patients, surgeons and ward staff Patients

73% excellent, 27% good

Surgeons 38% better,50% same, 12% worse

Ward staff (nurses, physios and pharmacy) 42% better, 39% same, 18% worse

Re- audit 2004Anaesthetists

Overall service better 82%, same 12%, worse 6%

Time needed to see patients Less for 80% of anaesthetists

Re-Audit 2004:1 month audit CRH: 423patients Fewer cancellations for pre existing co-morbidities

0% vs 1%

Fewer patients not optimised 9% vs 18%

More patients admitted same day 91% vs 74%

Reconfiguration of Services August 2007 CRH becomes site for

Non-complex inpatient Orthopaedics and General surgery Inpatient Gynaecology Inpatient ENT & Ophthalmology

HRI becomes site for Emergency surgery & Trauma Urology Complex major surgery and vascular surgery

Day surgery continues on both sites

Roll-out of CRH Pilot cross trust With reconfiguration inpatient pre-op

assessment standardised CRH pilot rolled out in line with audit results Time scale short. No fixed base in HRI

Process rolled out 2007 Dedicated unit 2008

Day surgery pre-op assessment remained separate

Audit 2009 - cross trust Looked at:

Patient viewpoint (2008) Anaesthetist viewpoint Timing of admission Patient pre-op optimisation Cancellations Day surgery vs Inpatient

Patient and anaesthetist viewpoint

Patients 57% excellent, 40% good, 1% fair, 2% poor

Anaesthetists 96% thought pre-op assessment service had

improved 19% thought comments from anaesthetic clinic were

occasionally useful, 42% often useful, 39% always useful

92% thought it took less time to see patients

Was the patient Inpatient Day case Was the patient admitted Today Before today  If listed as an inpatient, should they have been a day case? Yes No  If listed as a day case, should they have been an inpatient? Yes No

Did the patient go through pre operative assessment? Yes No

If NO, why not?__________________________________________________

Did the patient attend the pre-op anaesthetic clinic? Yes No  If NO, should they have done? Yes No

If they should have attended, please give details why _________________________________________________________________ Was the patient’s operation cancelled? Yes No

If YES, what was the reason?____________________________________________

How could this have been avoided ? _______________________________________

If the operation was not cancelled, could they have been better optimised? Yes No  If YES, how? ________________________________________________________

Day surgery vs inpatient, timing of admission and optimisation Overall day case 42%

Overall 95% admitted on day of surgery

10% considered not optimised Many organisational

e.g. blood results available

Cancellations (34/631 = 5%)

24%

9%

15%

41%

11%

pre-existing medicalacute medicalsurgicalorganisationalnot stated

CancellationsPre-existing medical (n=8)

75% (6/8) day case All hypertension 6/265 = 2.3%

25% (2/8) inpatients AF, Bifascicular block Hypotension & Na+

2/366 = 0.5%

Audit results through time:Patient views and anaesthetic views

  2004 2009

Patient questionnaire (2008): Overall quality

73% excellent 27% good

57% excellent40% good

Anaesthetic questionnaire: POA service improved?

82% better12% same6% worse

96% better4% same

Anaesthetic questionnaire:Time to see patients

20% Much less time60% A little less time20% Same time

52% Much less time40% A little less time8% Same time

Audit results through time:Day case and timing of admission

  2002 2004 2009

Day case 44% 49% 42%

Same day admission

74% 91% 95%

Audit results through time:Medical cancellations and optimisation

  2002 2004 2009

Cancelled:Pre-existing medical

1.0% combined

0% combined

0.5% inpatient2.3% day case

Not optimised 18% 9% 10%

Discussion

60 inpatients out of 366 identified as suitable day case 16%

2 day cases out of 265 identified as suitable inpatient 1%

Optimising Day Surgery Rates Two different pre-op pathways:

Inpatient surgery Day surgery

96% of anaesthetists were happy with inpatient assessment

84% felt all pre-op assessment should follow that same process

Incongruent system

Why does inpatient vs daycase matter?

Patient experience Environment Risk

Efficiency Bed crisis

Risk of cancellation Cost of overnight stay

Portering delays from ward to theatre

Our Plan

Unify pre assessment process based on current inpatient system Decision for inpatient made after poa, only if valid

reasons documented Dedicated area for POA in HRI to improve patient

experience Re-audit!

Further education for anaesthetists about hypertension and anaesthesia

Thank-you

Questions or

Comments?