Challenges & Solutions of setting up an Anaesthesia Assessment Clinic Anne Kwan MBBS FHKCA FHKAM(Anaesthesiology) FANZCA FFPM ANZCA Dip Pain Mgt (HKCA) Dip Acup M Pal Care Chief of Service Department of Anaesthesia, Pain Medicine and Operating Services United Christian Hospital HONG KONG

Anaesthesia Assessment Clinic is not just Day Surgery / Same Day Admission PAC All elective cases

History  Nicole presented to BMA the results of 8988 operations on outpatients performed at the Glasgow Royal Hospital for Sick Children between 1899 and 1909  Waters opened the Down-Town Anaesthesia Clinic in Sioux City, Iowa for minor surgery and dental cases  Hertzfelt reported on more than 1000 outpatient paediatric hernia repairs performed with the use of GA  a formal ambulatory surgical programme was initiated at the University of California at LA  Federated Ambulatory Surgery Association was established  free standing ambulatory surgery centres in US

Aims of anaesthesia assessment  To assess & optimised patient’s medical condition  To explain the different types of anaesthesia which can be used for the operation  To describe the relative risks and complications of the anaesthesia chosen  To briefly explain how the intended anaesthesia is conducted  To explain to patient the available clinical studies  If patient is recruited in a clinical study, adequate explanation must be given and written consent must be obtained  To ally patient’s anxiety by adequate explanation and prescription of premedications

Aims (cont)  To remind patient to take premedications if they have been prescribed  To remind patient of fasting time  To select suitable form of postoperative analgesia for the patient  To educate patient in the use of postoperative analgesia  To warn patient of possible postoperative follow up call / visit

Benefits of Preoperative Assessment Clinic (PAC)  Ideal setting for anaesthetic assessment  Facilitate SOPD medical consultation  Decrease of inpatient length of stay (cost, hospital- acquired infection, psychological stress)  Facilitate operation scheduling  Ease immediate preoperative preparation  Reduce cancellation of operation

Essential ingredients  Anaesthetists  Anaesthetic / PAC nurses  Screening mechanism (patient/operation type, infection)  PAC protocols  Physical set up  Information technology smart  Investigation facilities on site  Fast tract consultation arrangements  Review mechanism streamline  Administrative guidelines  Audit / review

The world trend 70-90% day surgery

Definition of day surgery  9 to 6 pm  8 to 11 pm  23 hours  Round the clock as long as < 24 hours

What is the situation in Hong Kong  90% of inpatient services provided by HA  20 operating theatre suites (230 Operating Rooms)  2 day centres as there is no inpatient facilities - TWEH, HKEH  Some have limited number of inpatient beds - AHNH, OLMH, TSKH, TWH, POH  2 centres only deal with high complexity cases - GH/QMH, PWH 

HA has been monitoring day surgery or same day admission cases hoping to have benchmarking for healthcare efficiency The following data are collected regularly and displayed at the MIPO site

For those hospitals or sites with suitable cases for day surgery or same day admit, what are the barriers? Barriers:  Poor education level  Poor home environment  Patient staying alone  Patient coming from old aged home

Culture  Hospital a safer place  Some changes after SARS

Incentives for patient / family  Hospital stay around HK$100 per day all inclusive  New case consultation at SOPD - HK$100  Old case consultation HK$60  Each drug item HK$10  Consultation at AED HK$100  Community Nurse visit HK$44

Incentives for surgeons  Funding based on number of inpatient beds  Casemix model not encouraging day surgery  Hard to streamline patient care path as day cases (admission, consultation, investigation, rescheduling)

Misunderstanding / fear  Patient screening not easy  Post operative complications attract complaints / medical legal issues  Hard to overcome old habits  Respect tradition

 History of Day Surgery at UCH  April general surgical cases  Nov eye cases  July orthopaedic cases  Oct 93 - ENT cases  April 96 - O&G, dental cases  April 98 - pain cases  Same Day Admission Programme from July 97

Day Surgery Total No. of Cases Year No. of Day Surgery Cases

The UCH model - One stop approach  Surgeon consultation - anaesthesia assessment all on one day  Nurse screening and patient education before anaesthetist’s assessment  Written instruction (with DSC hotline) to take home  Patient to confirm operation within 2 weeks of operation  DSC staff to remind patient the day before  Surgeon and anaesthetist to review before operation

Challenges  Undiagnosed or unstable medical conditions: IHD, HT, DM, asthma or COAD  Anaesthetist as peri-operative physician  Fast track consultation  Cardiac - IHD - Echocardiography  COAD - Resp function test and optimization  DM, HT, Asthma - specialist anaesthetist review  Team in-charge to follow up patient until ready for operation

Others  Type and screened blood / products for every indicated cases  Bowel preparation  CMS enables communication and tracking of actions  OR Manager to approach all surgeons to promote benefits of day surgery or SDA

KPI  Cancellation rate <2%  Medical condition - URTI, menstruation; surgical condition changed - lump disappeared  Change of mind (not wanting surgery)  Social issues (family member was sick, urgent visit to Mainland)  Admission rate (<2%)  Readmission rate (<0.2%)

Nurse Call patient on day after discharge for satisfaction score and feedback

Others  In houses physician to deal with consultation  Anaesthetist or nurse manager to schedule operations (DS, SDA, IP)  Casemix funding incentives  Pain & symptom relief  Case manager to follow patient thru  ASA 1/2 Nurse Assessment Clinic

Physical facilities  Purpose built Peri-operative Centre  IT smart environment  Seamless support

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