Auditing an evolving Pre-operative Assessment Service : Completing the cycle Paul Knight, Consultant Anaesthetist Joanna 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 2002 Both 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 2004 Pilot (CRH) site only Patient viewpoint Surgical and ward staff viewpoints Anaesthetic viewpoint 1 month prospective audit elective patients

Re- audit 2004 Patients, 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 2004 Anaesthetists 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 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 patientInpatient  Day case  Was the patient admittedToday  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%)

Cancellations Pre-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 Patient questionnaire (2008): Overall quality 73% excellent 27% good 57% excellent 40% good Anaesthetic questionnaire: POA service improved? 82% better 12% same 6% worse 96% better 4% same Anaesthetic questionnaire: Time to see patients 20% Much less time 60% A little less time 20% Same time 52% Much less time 40% A little less time 8% Same time

Audit results through time: Day case and timing of admission Day case44%49%42% Same day admission 74%91%95%

Audit results through time: Medical cancellations and optimisation Cancelled: Pre-existing medical 1.0% combined 0% combined 0.5% inpatient 2.3% day case Not optimised18%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?