Digital preoperative assessment triage at Chelsea and Westminster Hospital NHS Foundation Trust

Preoperative Assessment (POA) is an important step on the patients’ pathway but not all patients are required to attend an appointment for assessment.

Those with no relevant past medical history, having less complex procedures can safely bypass this step. This saves unnecessary appointments for patients who are fit and healthy, freeing up resources for those requiring more extensive POA.

Best practice dictates that patients who are at higher risk of anaesthetic complications should be assessed thoroughly a few weeks ahead of their surgery. This allows for sufficient time to optimise the patient and ensures that the risk of the procedure not being carried out on the scheduled day is minimised.

Effective communication and a team approach are vital in the pre-operative period. Complications and malpractice lawsuits are often attributable to poor preparation and failures in communication (AAGBI, 2010).

In 2019 the POA team developed a preoperative assessment triage questionnaire to identify low anaesthetic risk (ASA1) patients in the surgical clinic when they are being added to the surgical waiting list.

Situation

Following the first wave of the COVID-19 pandemic, demand for POA had increased significantly, but inefficiencies in the POA process led to delays and surgery cancellations.

On average, appointments were booked 17 days ahead of the ‘To Come In’ (TCI) surgical date, with the POA appointment taking place, 10 days prior to the TCI. Large numbers of patients had their POA appointment conducted in the week prior to their admission.

As a consequence, POA team felt they were not providing patients with a good pre-operative assessment experience.

Working with external technical partners, the Trust developed a POA pathway to enhance existing workflows by integrating and fully automating key technical functions. This application is embedded within the process of scheduling patients for surgery and enables the organisation to fast-track patients who are at low risk of surgical and anaesthetic complications.

Aspiration

• Enable remote pre-surgical pathways to allow the POA process to take place earlier in the patient journey and give patients the opportunity to avoid unnecessary hospital visits.
• Simplify the way a patient’s health status is assessed and identify patients who are low anaesthetic risk (ASA1) and thus can be fast-tracked into surgery without attending a POA appointment.
• Create a pool of patients ready to be booked for surgery at short notice.
• Create a digital workflow to better deal with demand and to maximise capacity.
• Reduce/replace the need for complex paper based administrative logistics.
• Reduce the number of ‘on-the-day’ cancellations and delays, leading to improved theatre efficiency.
• Improve the POA experience for patients and clinicians.

Solution

The Trust worked together with software developer Palantir and Isla Care to design and deploy its own solution with the ambition of delivering a product that allowed integration with the other components of the patient surgical pathway on the Care Coordination Solution (CCS).

Digital Health Questionnaire (DHQ)

As patients are added to the waiting list, the DHQ is automatically sent to all adult patients via text message with a link to an online form by Isla. A prompt to complete is sent 24 hours later, 6 days total to complete. Patients with clinical alerts (such as safeguarding) are excluded and default to standard POA pathway.

The DHQ comprises of three sections asking:

• Section 1 – if patients still require surgery
• Section 2 – 15 health related questions
• Section 3 – if patients are available at short notice

A patient who answers ‘no’ to all questions in section 2, has a BMI of less than 40 and is aged between 18 and 64 is classified as ASA1 (American Society of Anaesthesiologists grade 1). These patients can be scheduled for surgery without a POA if the procedure is not on the list of complex procedures agreed with the surgical specialities leads.

POA triage

A POA triage functionality has been introduced, allowing the team to determine which patients needs to attend a face-to-face appointment and who is fit to proceed without one.

The POA team would typically review and check triage questionnaires in approximately ten patients within 45 minutes. Analysis has shown that only 24% of patients require POA after triage.

Questionnaire is resent in 6 months if the patient is still on the waiting list.

Impact

The CCS POA module has been a success across both Chelsea and Westminster Hospital and West Middlesex University Hospital sites.

The implementation allows the Trust to fast-track patients who meet the ASA1 criteria, enabling effective decision making by optimising clinician time and improving coordination of patients along pathway.

The triage process has saved approximately 180 POA appointments of 45 minutes each (April 2022 pilot). The resources saved are being used to increase the time between POA assessment and surgery.

DHQ patient response rate:

• 86% completed the DHQ within 6 days
• 36% patients triaged as ASA1 and did not require a POA appointment
• 14% of patients that did not respond defaulted to face-to-face preoperative assessment appointment.

Patients identified as ‘Fit to Proceed (short notice)’ can be offered surgery dates on under-booked lists and also feed into the Assisted Theatre Scheduling (ATS) criteria.

Improvements to POA:

• Patients on average booked in 30 days in advance of TCI (was 17 days)
• POA appointments held on average 15 days in advance of TCI (was 10 days)
• 180 patients per month do not require POA
• 407 patients reported they no longer want or need surgery
• 7897 patients available at short notice (10 working days' notice)
• 222 patients without NHS numbers identified
• First 100 patients monitored end-to-end and no cancellations
• On-the-day theatre cancellations related to POA reduced to 1.2% (57% improvement)

Functionality

The CCS application:

• is a web-based platform integrated with the Electronic Patient Record (EPR) and other clinical systems.
• provides users to a single point of access to manage the patient pathway.
• the POA module is integrated with the management of the inpatient waitlist and supports the delivery of theatre productivity.
• there is an automated process to trigger information/questionnaires being sent to patients via SMS or email and responses are automatically integrated within the workflow.

Capabilities

The CCS POA module allows:

• a single point of access to different teams to have full visibility of patients’ surgical journey
• staff to access the application on multiple devices and securely outside the Trust network
• staff to easily action changes to the patient status that are reflected across the platform giving ‘one single version of the truth’
• near real-time information pulled from different systems and data points

Scope

This applies to all adult patients. However, information provided by patients over 65 on their health status must have an echocardiogram thus requiring POA completed by a nurse.

In future, there are plans to:

• potentially challenge the status quo to include older patients in the ASA1 cohorts
• use the same methodology for paediatric patients

Key learning points

• Engaging with key stakeholders and experienced clinicians was crucial. An internal project manager is a critical conduit between the supplier and the clinical teams.
• The application has strengthened the communication between POA teams and the different departments and provides a clear audit trail.
• The process has the unanticipated benefit of identifying patients without NHS number.
• Patients may have had surgery as an emergency or had private healthcare and still were on elective waiting list.

Digital equalities

The risk of disadvantaging patients without access to technology was considered throughout the design and development of the tool and a safety net was built in the process which automatically identifies patients who have not responded to the DHQ. These patients will be invited for a face-to-face appointment.

Key figures and quotes

Improvements to inpatient waitlists:

• 96% (18,371) of all patients on surgical pathways prioritised with clinical harm review conducted
• Waitlist reduction – 17,003 patients removed

Improvements to theatres management:

• Theatre utilisation increased by 8%
• ATS identified an average of 254 session/month valid for automated suggestions
• 577 surgeries have either been completed or have a TCI following ATS suggestion

Key contact

Digital operations team,  Chelsea and Westminster Hospital NHS Foundation Trust         

Chelwest.ccssupport@nhs.net