Digitally managing preoperative hypertension to avoid surgical cancellations

Hypertension is the most common avoidable medical condition for postponing anaesthesia and surgery. However, ‘white coat’ syndrome is a phenomenon in which patients exhibit hypertension only during a clinical visit and so needs to be identified in order to reduce cancelled operations.

Situation

Sherwood Forest Hospital deployed telehealth as part of the preoperative assessment pathway. The aim was to monitor patients’ blood pressure in the weeks leading up to their surgery.

There were challenges with identifying patients who had white coat hypertension before the day of their surgical appointment. This caused a high number of same-day cancellations and inefficient use of time and resources.

Aspiration

To monitor patients ahead of their preoperative assessment to determine if a patient really is hypertensive, or to identify white coat hypertension. To help patients to understand how their lifestyle affects their blood pressure, and the importance of taking their antihypertensive medication, where appropriate.

Solution

Florence is a persona-based smart messaging tool which harnesses psychology to increase patient engagement and change behaviour.

The system brings a human element to remote healthcare. Friendly interactions can encourage patients to manage their health. It’s used by:

• NHS hospitals
• GPs
• mental health teams
• community teams

Sherwood Forest Hospital deployed Florence within their preoperative assessment pathway to:

• reduce the number of avoidable cancelled operations
• shorten the pathway to surgery for patients with white coat hypertension

Patients with possible hypertension are provided with the equipment to self-monitor their blood pressure from home 1 week before their preoperative assessment.

They use the Florence system to submit their readings through text message on their phone. The readings are available to clinicians through the primary care management system.

Patients are automatically informed by Florence if their submitted readings are out of the normal parameters. They are then advised by text message to follow a written action plan or to contact their clinician if appropriate.

This motivates patients and supports them to submit their blood pressure consistently. It enables continuous monitoring and accurate identification of hypertension or white coat syndrome.

Impact

Use of Florence resulted in many clinical and non-clinical benefits including an improvement in the identification of preoperative risk factors, a reduction in short-notice cancellations and an improved pathway back into primary care. Further benefits include:

• improved satisfaction with patient/nurse care
• compliance with medication and appointment reminders, reduction in DNA
• improved physical health and mental wellbeing
• a patient-led focus
• patients' lives no longer revolving around provision of services
  

Functionality

• Florence is cloud-based software for clinicians. This means it’s accessible from any web browser.
• The platform allows clinicians to build protocols for individuals or cohorts of patients. This means they can automate nudges, prompts, reminders and motivations to improve patient adherence and outcomes.
• Clinicians can choose a pre-built protocol from Florence’s library. The library contains more than 100 tried-and-tested pathways aligned to specific conditions.
• Patients interact with Florence by text messages. There are no apps to download and patients do not need a smartphone.
• The solution is totally free for patients.
• Helping patients to self-manage at home has huge impact on the clinical team’s workload. It reduces unplanned admissions.
• Florence presents clinicians with a prioritised caseload. This means they can spend more time with the patients who need more help.

The solution can also collect patient-reported readings, symptoms, or both, such as:

• blood pressure
• blood glucose
• weight
• mood
• pain

This means the solution can provide advice for the patient to act on.

The readings can also be discussed at the next face-to-face appointment as part of the treatment planning process.

Capabilities

The solution can:

• encourage patients to take responsibility for their mental and physical health
• share management of the patient as they report their symptoms and readings themselves
• improve patient engagement with medication, treatment, and lifestyle choices
• be personalised through collaboration between patients and clinicians
• improve patient health literacy and confidence to self-manage
• allow patients to be onboarded by clinical teams
• help patients enrol themselves onto protocols
• communicate with patients in their own language and dialects
• present dashboards to clinicians who can see the status of their entire caseload at a glance
• notify clinicians if patients start to deteriorate
• automatically signpost the patient to the most appropriate intervention automatically at the 1st sign of deterioration
• provide opportunity for earlier clinical intervention

Scope

Florence is used across health and social care. For example, it can help patients with healthy living and stopping smoking.

It’s also used to support patients with complex conditions, like COPD, or those who are at risk of falls.

It’s a crisis management tool which signposts patients to the most relevant place for immediate support. For example, if they have mental health problems or unstable vital signs, they will be directed to the right team.

From an acute perspective, there are a number of protocols which are designed around:

• pregnancy-induced hypertension
• pre and postoperative preparation
• outcomes reporting

Once discharged from an acute setting, the team can continue to support patients remotely via step down facilities. The team can support patients at home for as long as they need to.

Key learning points

• This intervention gives control back to patients, especially for those with mental health and long-term health conditions.
• Frequent short messages at no cost are motivating for patients.
• Therapy is more effective when patients commit to home practice between sessions. Using Florence means that patients can reconnect with what is important to them, their health, relationships, work and leisure. This reduces feelings of isolation.
• The messages stay on the patient’s phone, and they can receive messages even after treatment has ended.
• This intervention can enhance the effectiveness of therapy with little input from clinicians.
• It can enable a wide reach across the community at low cost.

Key quotes

“[Florence] prevents cancellations on the day and enables theatres to fully utilise their time.”

Kelly Crutchley, Deputy Department Leader and Nurse, Sherwood Forest Hospitals

“Everybody gains from it. I save from not having to go and wait in the doctor’s waiting room. Equally the doctors and nurses save from not having to take your blood pressure when they’ve got other people with more important issues to see.”

Bobby Blackmore, service user.

“There have been no direct trials to our knowledge exploring the impact of telemonitoring on cardiovascular outcomes, but based on previous studies of anti-hypertensive agents, blood pressure reductions of the magnitude achieved in this study would be expected to lead to a greater than 15% reduction in risk of stroke and a greater than 10% reduction in risk of coronary heart disease.”

Dr Brian McKinstry and colleagues, Scale-Up BP

“The importance of what we are trying to help teams deliver cannot be overstated. Demands on our services are continuing to increase. Utilising technology will not only enable us to shape services to suit the needs and preferences of individual patients; embracing it will also help us take on the challenges we face every day.”

Dr Ruth Chambers OBE, GP Principal, Stoke-on-Trent

“Florence is a low-cost, low-risk innovation with a strong track record.”

The Kings Fund

“The benefits Florence can deliver are wide ranging.”

The Health Foundation

“Flo has been formally evaluated, with positive results.”

Nuffield Trust

Find out more

Video of Kelly Crutchley of Sherwood Forest Hospitals talking about the benefits of Florence in managing white coat hypertension

Key contact

Kelly Crutchley, Deputy Department Leader and Nurse at Sherwood Forest Hospitals

kellycrutchley@sfh-tr.nhs.uk

John Griffiths, Head of Sales at Florence

john.griffiths@pshealthgroup.com