Effective preoperative assessment (POA) is best achieved with a service designed around patient requirements and run by a lead anaesthetist and nurse with support from the full inter-professional team.
The business case to fund POA will essentially revolve around the savings that can be made due to reduction in cost implications from delayed, postponed and cancelled operations.
The patient should have the opportunity to discuss his or her concerns, and to receive appropriate examination, investigation and advice from individuals who are appropriately skilled with the knowledge and experience that ensure the standard of care is of the highest level.
An effective tracking system is essential to keep the flow and ensure the patient is not ‘lost’ in the preoperative process.
Ideally, the POA service should be co-located within the outpatient department to enable patients to walk from their OPD, but a stand-alone centre can be equally functional.
Ongoing training, audit and feedback are essential to maintain and improve quality of service.
Setting the Preoperative Assessment Service
Effective preoperative assessment (POA) is best achieved with a service designed around patient requirements and run by a lead anaesthetist and nurse with support from the full inter-professional team (Woodhead et al. and Fudge, 2012).
The business case to fund POA will essentially revolve around the savings that can be made due to reduction in cost implications from delayed/postponed/cancelled operations, reducing bed days (pre- and post-operatively). POA in itself does not reduce patients’ failure to arrive for an operation; this can only be a financial business case if the POA service takes on the role of patient preparation by providing information for patients and planning the perioperative journey. Completing a final check and telephoning patients prior to hospital admission will reduce cancellations on the day of surgery.
The benefits of having a pharmacist in the POA team can be attributed to the savings made through: completed written drug charts completed in POA and ready for admission, advice to patients regarding medication to stop/commence prior to admission and appropriate referral for bridging therapy to the anticoagulation team. Where a pharmacist has completed the drug charts in POA, there will be less need for him or her to make ward visits. Drug charts completed accurately and clearly will be less likely to be subject to errors.
Important to also note in the business case is the ability within the POA service to comply with the Department of Health and with local policy by ensuring accurate completion of venous thromboembolism risk assessment (Department of Health, 2010), the Patient-Reported Outcomes Measures questionnaire (NHS England Health and Social Care Information Centre, 2011), National Joint Registry Consent (Department of Health UK, 2002), MRSA screening and smoking cessation referrals. There may be financial implications for the healthcare provider with compliance of these forms.
The task of assessing requires inter-professional teamwork alongside the anaesthetist and other health professionals such as pharmacists, cardiologists, anticoagulation team and enhanced recovery nurse specialist teams, to name but a few.
It is expected that every patient due for elective surgery will have some form of POA. This may be a triage questionnaire, telephone, face-to-face or electronic assessment. Whichever form the assessment takes, there will be the need to ensure that the outcome is checked and appropriate action taken to optimise patients prior to clearing them for admission.
The planners for a POA service will need to determine the number of patients expected to require assessment. Timings will need to be placed to the length of time required for assessor per patient.
Triage is not undertaken at all secondary care providers, but essentially takes the form of a basic identification of patients’ co-morbidities, often in the form of yes/no responses completed by patients, a yes response perhaps triggering that a patient requires a face-to-face appointment.
Face-to-face assessment is the most frequent form of assessment due to the increasing age of patients who undergo surgery. Patients may present with multiple co-morbidities which demand considerable experience and knowledge from the registered nurse (RN) for the preoperative assessment and preparation of the complex patient. In order to ensure that the experienced RN can devote maximum time to the patient with multiple health needs, the RN will require support by non-registered nurses, most often band 2 or 3 (Jackson J, and Wadsworth L, 2014).
Anaesthetic preoperative assessment sessions need to be sufficient not only to provide the review of notes for patients identified as high risk by the nursing team, but that the anaesthetist has appointments to meet the patients to discuss their health and complete an examination, investigation and advice as appropriate. The Royal College of Anaesthetists Guidelines for the Provision of Anaesthetic Services (GPAS) document 2014 (Jones K, Swart M, and Key W, 2014) recommended 1.25 programme activity (PA) session per 1000 patients attending preoperative assessment, yet rarely are sufficient sessions available within the POA services – all the more important, then, that the nursing team is skilled to provide appropriate support.
Keeping the Flow
Referral to Treatment Targets
Preoperative preparation should focus on all aspects of the patient journey commencing in primary care, transferring to secondary care and finally going back to primary care once the patient has been discharged from hospital. Current NHS referral to treatment target guidelines (Department of Health UK 2012) recommend investigation/treatment should be commenced within 2 weeks for cancer referrals and 18 weeks for non-cancer surgery. The ‘clock’ can be stopped if the patient has co-morbidities requiring optimisation.
The service should be patient-led, appropriate to the patient requirements as well as to the requirements of the healthcare provider. There needs be clear documentation, in paper or electronic format, that will form the base for the ongoing patient optimisation/treatment and be accessible by the full inter-professional team. Appropriate assessment tailored to the individual patient requirements will provide patients with the information they require to make an informed choice, involve as necessary the appropriate members of the inter-professional team and put mechanisms in place to optimise health and to minimise patient cancellations on the day of surgery. This can be achieved only through effective training and competency assessments of nurses that meet an agreed standard of care. The Preoperative Association (www.pre-op.org) is committed to identifying the standard of care that patients and staff should expect and have published an Excel sheet and PowerPoint presentation detailing the tasks associated with each band of nursing staff.
While preoperative assessment is commonly a nurse-run service, the service should be patient focussed, ensuring that timing and skills of the staff meet the requirements of the patient groups attending.
Patients should have the opportunity to discuss their concerns and to receive appropriate examination, investigation and advice by individuals who are appropriately skilled with the knowledge and experience that ensure a standard of care that is of the highest level, and that patients receive sufficient and accurate information that informed consent can be safely given. With the patients having had time to think through the outpatient advice and pending surgery, arrival at POA will often result in the assessor receiving patient queries regarding the anaesthetic and surgery, also of social requirements, during the perioperative period. It is common practice for patients to arrive at the POA appointment with Internet searches on their pending procedure and multiple questions that require direction.
The nurse in POA may become a contact point for patients during the preoperative phase of patient care, often coordinating any patient preparation prior to admission, requesting investigations, taking action on results and checking on optimisation pre-surgery, as well as liaison with the support for the individual from within both the primary and secondary care.
Any POA service should meet the Care Quality Commission 2015 (CQC) expectations, and the managerial team should ask themselves these CQC questions.
Is your POA service safe?
Is it effective?
Is the service caring?
Is the service responsive to people’s needs?
Is the service well-led?
The role of the nursing team within POA is varied. Tasks associated with the role will enhance patients’ progress during their surgical pathway and ensure clear documentation on all co-morbidities, patient investigations and optimisation completed prior to admission. This will maximise admission on the day of surgery and minimise operation cancellations on the day of surgery.
The tasks undertaken by the RN, supported by the non-RN (healthcare assistant and/or assistant practitioner), are varied and will differ according to the experience and training of the team, as well as the patient requirements (www.pre-op.org).
Potential tasks associated for the nursing team in POA:
Identify and confirm patient demographics and ensure notes/waiting list details are accurate.
Identify patient status and offer information regarding general health, smoking cessation and healthy eating.
Identify procedure and provide information of procedure.
Identify social requirements to minimise delayed discharge.
Identify past medical, surgical and anaesthetic history, exploring history and current status as appropriate.
Complete baseline observations, including manual radial pulse.
Complete ECG and spirometry as required.
Complete chest auscultation as required, sufficient to identify normal/abnormal and when to refer to anaesthetist.
Request investigations according to an agreed policy.
Determine those patients fit for admission and those requiring anaesthetic opinion.
Patient Tracking System
An effective tracking system (electronic or paper) is essential to keep the flow and to ensure the patient is not ‘lost’ in the preoperative preparation process. A tracking system should be used to track the progress of the patient along the perioperative pathway when referred to specialists for assessment and optimisation, to collate investigations and to summarise patients’ preoperative records for planning the patients’ surgical journey. An electronic preoperative assessment reporting/tracking system – perhaps using an EXCEL spreadsheet – has the additional advantages of recommending what investigations should be ordered, collating investigation results, providing medication advice for patients and recommending a perioperative plan according to patients’ co-morbidities and surgical procedure. Viewing the electronic record prior to patient admission by anaesthetists, theatres, HDU or an admissions clerk will allow patients’ surgical plans to be implemented and sharing of essential information for safe care.
Ideally the service of POA should be co-located within the outpatient department to enable patients to walk from their OPD, but a stand-alone clinic can be equally fully functional.
Extracted summary from the Francis report (2013):
Leadership and management need to focus on the provision of good patient care.
All should be responsible and accountable for their actions/inactions.
Inter-professional teamwork should be encouraged.
Openness – admitting areas of poor care/areas for improvement as well as areas of achievement.
Clinical governance is one means of monitoring agreed standards of care.
Policies should meet national levels of acceptability, with processes in place to ensure local compliance.
Staff should be appropriately trained to undertake their duties, ensuring ongoing training and competence assessments.
Performance should be measured against agreed policies.
Audit should be continually undertaken.
Actions should be taken on findings e.g. from audits, complaints.
Meeting the points as raised in the Francis recommendations and the CQC expectations requires clear policy for the POA service, a policy that the nursing and anaesthetic team have agreed and will apply consistently to ensure patient safety is maintained. Appropriate training and competency to apply the policy is required, together with audit of the outcomes of patient assessment. This will highlight potential areas for further training, and, where appropriate, the policy will be updated and cascaded through the inter-professional team at clinical governance sessions to ensure practice is updated as and when required.
Who Should Perform Preoperative Assessment?
Day and/or inpatient assessments
Complexity of patients
Speciality of surgical care
Local hospital catchment/specialism
Is the POA to be an interview face-to-face/telephone assessment/patient self-assessment?
POA teams may comprise nursing – registered and non-registered, and medical staff – foundation doctors, consultant anaesthetists, surgeons, occupational therapists, physiotherapists and pharmacists. In addition, adequate secretarial and administration support is required for the preoperative service to run efficiently.
The Guidelines for Provision of Anaesthetic Services published by the Royal College of Anaesthetists recommend the following staffing requirements for preoperative assessment based on 1000 inpatients passing through a preoperative preparation clinic.
– High-risk clinics one session per week (1.25 PAs)
– Clinical leadership for service one session per week (1.25 PAs)
Grade and experience of preoperative assessment are determined by local policies. Specially trained RNs, assistant practitioners and healthcare assistants will be efficient and effective in undertaking the tasks associated with patient preparation.
Per 1000 patients
0.6 RN and 0.3 HCA
– Staffing ratio based on 80 per cent of patients as day cases and 20 per cent as inpatients.
– Assumes nurse assessments for day-case patients have 30-minute assessments and inpatients have 45-minute assessments.
The majority of preoperative assessment in the UK is now undertaken by nurses in the preoperative assessment clinic. Nursing staff working in this specialist field undertake a varied number of tasks depending on their nurse banding levels. The Preoperative Association has published a framework of nursing skills for different band levels in preoperative assessment. The team of nurses will vary in the requirements of their skills and experiences required depending on the complexity of patients to be assessed. It is important to ensure that nurses are given the appropriate training and competency assessments to ensure that they have the skills to accurately and safely undertake the task, and that policy or protocol documentation clearly defines their role. It is unlikely that any one POA service will have a full range of Band 2–8b.
The presence of a pharmacist in the preoperative assessment clinic will reduce the nurses’ workload, reduce drug errors and provide information to patients regarding what medications should be stopped or continued on the day of surgery.
Patients attending ‘joint clinics’ in preparation for hip or knee replacement surgery benefit from having an anaesthetist/surgeon/physiotherapist/occupation therapist/nurse present at the communal session as the information provided to patients is reinforced by all members of the inter-professional team. Similarly, a ‘bariatric clinic’ may have an anaesthetist/surgeon/physician/dietician/psychologist present to discuss the appropriate treatment and management of patients being considered for bariatric surgery. Similar clinics would be effective for cataract surgery to allay any concerns of patients, relatives or carers.